Eating Disorders In A General Practice Population (Psychological Medicine Supplements)
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Treatment generally involves a team approach that includes you, your family, your primary care provider, a mental health professional and a dietitian experienced in treating eating disorders. You may have a case manager to coordinate your care.
Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with eating disorders. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications.
Usually, when people turn to alternative or complementary medicine it's to improve their health. But dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be unsafe and abused by people with eating disorders. Such products can have potentially dangerous interactions with other medications.
Although the lifetime prevalence of BN has been shown to be roughly double of that of AN (0.5% vs 0.3%) in males in the general population,21 we found an IR ratio closer to 1 for diagnosed BN and AN in this study. This might suggest that males are not being diagnosed with BN in general practice in the UK.
The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.
The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.
The objective of this project was to develop recommendations and clinical considerations to guide clinicians in the management of people experiencing eating disorders who also have higher weight. A Guideline Development Group was formed containing members with academic and/or clinical expertise and people with a lived experience of eating disorder. The guideline was not only informed by reviews of the scientific literature but also clinical expertise and lived expertise. This guideline has undergone extensive review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical, academic and/or lived expertise. The guideline outlines a set of recommendations for clinical practice including the strong recommendation for psychological treatment to be offered as the first treatment for an eating disorder in people who are of higher weight. Considerations in clinical practice including weight stigma, care by professionals from disparate disciplines, and cultural considerations are also discussed. The Guideline Development Group acknowledges a lack of available research evidence specific to people experiencing an eating disorder who are also of higher weight and consequently some recommendations relied on consensus of group members taking into account the expert reviews. The Group also identified areas where additional research is necessary such as research evaluating weigh-neutral and other more recent approached in the field.
Eating disorders are serious, complex and potentially life-threatening mental illnesses. While historically, eating disorders have been conceptualised as disorders of people of low body weightFootnote 1 there is now substantive evidence that this is inaccurate. The most common eating disorders are binge-eating disorder, other specified feeding or eating disorder (OSFED) and bulimia nervosa, and these occur in people across a broad range of body types . Eating disorders are common and increasing in prevalence. This is particularly true for people with eating disorders who are of higher weight. This population comprises more than half of all people with an eating disorder in Australia with rates of eating disorders increasing most in people with higher weight .
A key rationale for this guideline (see Box 1) is that despite the high prevalence, eating disorders in people with higher weight have been consistently under-recognised and under-treated. People with a lived experience of an eating disorder who are of higher weight report being misdiagnosed, dismissed by health professionals and sidelined or excluded from eating disorder treatment services. This population is also often absent from eating disorders research, with the exception of binge-eating disorder. Weight stigma is a major factor contributing to these shortfalls and is addressed in this guideline. This guideline aims to promote weight-inclusive practice and provide advice on how to avoid weight stigmatising practices for people with an eating disorder who are of higher weight.
This guideline is intended for all health care professionals and does not present specialist information for any specific discipline. It does not aim to provide recommendations on prevention or detection but does provide advice on assessment. The guideline addresses treatment and/or management recommendations, specifically for people with an eating disorder who are of higher weight. This encompasses, but is not limited to psychological, pharmacological, nutritional, medical, family and activity interventions. Management should address all aspects of an eating disorder, thus interprofessional collaborative practice (ICP) is recommended, with each clinician practicing within the scope of their profession. Readers are referred to other literature for management of specific medical and other psychological disorders that are often experienced by people who have an eating disorder and are of higher weight.
This guideline was developed within the Australian context and thus includes reference to Aboriginal and Torres Strait Islander peoples. However, it is anticipated to be relevant more widely as representing current knowledge and best health practice broadly. For this reason we have chosen to publish in international literature where it comes under scrutiny with international review. As the focus of this guideline is on the management of eating disorders, the outcomes considered are those relevant to the eating disorder. General physical and mental health-related quality of life are relevant as secondary outcomes. A reduction in body weight, or stabilisation of fluctuating body weight in itself is not an outcome or goal of treatment of an eating disorder experienced by people with higher weight. Further, it is possible that attempts at weight loss may exacerbate eating pathology and therefore may be contraindicated in some people (see Box 2).
Eating disorders are common and increasing in prevalence. There is a lifetime estimated prevalence of 8.4% for women and 2.2% for men . In Australia, the 3-month point prevalence is around 0.5% for low weight anorexia nervosa, 1% for bulimia nervosa and 1.5% for BED (broadly defined with ICD-criteria) and 3.2% for OSFED [including anorexia nervosa (without low weight) prevalence of 2.5%]. Furthermore, around 10% of people have recurrent binge eating  with rates of binge eating increasing most in people with higher weight . A recent meta-analysis suggested lower rates of eating disorders but this may be accounted for by 25% of included studies being from China with large samples and generally low identification of eating disorders in these studies other than anorexia nervosa .
Eating disorders are also prevalent in diverse populations including men , across sexual and gender minority identities , all levels of socioeconomic status  and, migrant status . Whilst more prevalent among adolescents and young people, they can affect people at any age including middle-aged and older adults [35, 37]. There is limited research on the experience of eating disorders in Aboriginal and Torres Strait Islander peoples. However, emerging research suggests that eating disorders are more common in Aboriginal and Torres Strait Islander adults and youth compared with non-Indigenous people .
Exercise and its management in general eating disorder populations (largely focusing on bulimia nervosa and low weight anorexia nervosa) is mainly targeted at reducing compulsive overexercise . These interventions typically include structured physical activity under supervision (often in a group setting) and individual psychotherapy, and demonstrate improvements in depressive symptoms, skeletal muscle mass and quality of life [80, 81]. Interestingly, effects on exercise compulsion have been mixed . Dittmer et al.  found a significant reduction in compulsive exercise in their intervention for inpatients with low weight anorexia nervosa, whilst Mathisen et al.  and Zeeck et al. , found no significant reductions compared with control groups. In contrast, Ng et al.  and Moola et al.  found that compared to a control group, people with low weight anorexia nervosa undertaking prescribed exercise reduced eating disorder symptoms, including disordered beliefs about food and exercise, and enhanced quality of life.
The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders for people who are of higher weight. The focus is on the treatment of the eating disorder, with consideration of higher weight. The aim is not to address weight loss or treatment of obesity. The guideline provides guidance on providing treatment for people currently with higher weight whether or not the eating disorder developed when the person was of a higher weight.
It is important to note that binge eating, loss of control, grazing or emotional eating are not the only or even predominant eating behaviours experienced among people with higher weight [2, 122]. Dietary restriction and other disordered behaviours (e.g., use of laxatives, purging, driven or compulsive exercise, dietary supplements use or abuse) are also frequently present among people with higher weight . Not