Eating disorders post-pandemic – take heed of the need and use MEED.

Whilst no longer considered a public health emergency, the significant, long-term impacts of Covid -19 continue to be felt strongly by our patients, communities and economy. The masks may be off, but we remain firmly within the ‘covid decade,’ with children’s mental health arguably one of the great casualties of the pandemic. 

New data published this week in The Lancet Child and Adolescent Health highlights what many of us have seen playing out in our consulting rooms over the past few years. The study looked at the electronic health data of 9 million 10-24-year-olds and confirmed that the incidence of eating disorders and self-harm in girls was substantially higher than expected in the first two years of the pandemic. Predominantly due to increases within less deprived communities, the incidence of eating disorders in young teenage girls was a staggering 42% higher than expected based on the ten years prior.

This represents significant challenges for us in General Practice. Eating disorders are common, yet remain under-recognised and easily missed. Prompt intervention can improve recovery rates, reduce relapses and avoid admissions, but services are overwhelmed and patients face long waits for treatment. Furthermore, the signs that someone with an eating disorder is severely unwell are remarkably easy to miss, with potentially devastating consequences. These are patients who can appear healthy, with normal bloods, right up until the point of collapse. We must also remain aware of suicide risk as well as the physical risks, with 1 in 5 deaths from Anorexia nervosa due to suicide.

Thankfully, pragmatic, timely guidance from the Royal College of Psychiatrists provides a new tool in our armoury to reduce the risks in this vulnerable patient population. The Medical Emergencies in Eating Disorders (MEED) guideline replaces the MARSIPAN and Junior MARSIPAN guidance and aims to ensure we can identify which patients need urgent treatment and when. Importantly, it can be used for all ages, all types of eating disorders and across all care settings.

The MEED risk assessment framework combines history, examination and investigations alongside assessment of motivation, engagement, and, particularly for younger patients, parent or carer support. This holistic approach recognises the fact that eating disorders are multi-dimensional illnesses, represented by so much more than a BMI, and that risk assessment is fraught with difficulties.

Each ‘domain’ is rated with a traffic light system, indicating the impending risk to life. A red flag suggests a high impending risk to life, including things like recurrent syncope, bradycardia, significant ECG abnormalities, electrolyte disturbance, >2hrs/day dysfunctional exercise, moderate or high suicide risk, or poor insight and motivation. Patients with one or more red flags, or two or more amber flags, should be considered high risk, warranting urgent admission to hospital. Unlike most other traffic light systems, green flags should not be used to reassure patients (or clinicians) that the risk is low, and we should continue to emphasise the severity of the illness, the need for eating disorders service input and the importance of treatment in this group.

The guidance provides helpful advice on what to look for and measure, as well as a comprehensive assessment strategy to fall back on if we’re feeling overwhelmed. It also contains guidance on management and serves as a useful reminder of the importance of collateral information when assessing patients who may feel deeply ashamed or fearful of sharing their difficulties. I have also found the guidance incredibly helpful in facilitating discussions with secondary care colleagues and arranging admissions when I have had concerns about patients. 

The 185-page guideline is welcome, but lengthy (!) – thankfully we’ve done the hard work for you and summarised it into a beautifully colour-coded Keep It Simple Summary in our Hot Topics handbook. We will also be discussing MEED, as well as the latest SIGN and BMJ guidance on eating disorders, on our Summer 2023 GP Update this Friday 30^th June. So please do join Kate, Stephanie and Mark for a practical approach to help preventable deaths from eating disorders become a thing of the past.