A PDF of this briefing can be downloaded here: University of Exeter Briefing on Eating Disorders.

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Eating disorders are complex conditions that impact upon both mental and physical health and wellbeing. It is important that students with eating disorders are able to access and engage with the most appropriate form of support, to enable engagement with academic studies and wider University life.

This briefing is written as a guidance for current and prospective students, in addition to NHS service staff and University of Exeter Wellbeing Services and Academic staff. This briefing has been prepared in consultation with the University of Exeter Student Health Centre, the University Wellbeing Services and Devon Partnership Trust NHS Community Eating Disorders Service (CEDS). It has been written in line with the current University Health and Wellbeing Support to Study (HWSS) policy and also makes reference to the Higher Education Occupational Physicians Society (HEOPS, 2013) guidance and the current National Institute for Health and Care Excellence (NICE) guidance for eating disorders (NICE, 2018).

The briefing contains the following:

1.)    Position Statement on eating disorders

2.)    Support available at the University of Exeter and within the local area

3.)    University BMI thresholds in line with HEOPS guidance

4.)    Use of Health and Wellbeing Support to Study (HWSS) policy at University of Exeter

5.)    References and Resources

6.)    Links to information which may be helpful

1.)    Position statement

The University of Exeter aims to provide a supportive, stimulating learning environment for all students. The University has a strong commitment to ensuring that students with a range of physical and mental health conditions have the opportunity to realise their academic potential and meet academic requirements associated with their programme of study.  

There are various detrimental effects of eating disorders on a students’ health and ability to study; anorexia nervosa, bulimia nervosa and related (atypical) eating disorders may have a profound impact upon psychological, social and physical functioning. Eating disorders are likely to affect a students’ ability to study and to achieve their academic potential, as well as impacting upon their ability to benefit from the broader aspects of university life. The pressures associated with university study can exacerbate an eating disorder.

In the majority of cases Wellbeing Services can offer support to students experiencing an eating disorder while at the University, supporting students to continue with their studies and engage in University life.  A small number of students attending university have a particularly severe eating disorder, mostly in the form of anorexia nervosa. These students are usually significantly underweight, physically compromised, and substantially impaired in their psychological and social functioning. Some students may continue to perform adequately academically, but at huge expense to their overall wellbeing. In some severe cases current evidence would suggest that an interruption to studies be considered to ensure that the health and wellbeing needs of the student are addressed as paramount.

The University has a duty of care to all students and it is intended that this document will offer guidance for Academic Colleges, NHS services, students at the University of Exeter and their families to best know how to seek support.

2.)    Support available at the University of Exeter and within the local area

Our position at the University of Exeter will be to support students to engage with their studies and the university experience, encouraging autonomy and guiding students towards appropriate support and care for their mental health condition.

Registering with a GP

All students at the University of Exeter are advised to register with a local GP. Students often spend significant amounts of time at home in between terms and may need to consider an arrangement whereby they keep both their home and university GP involved in their care. Students normally register at either The Student Health Centre, which is located on the University of Exeter Streatham campus, or at The Heavitree Practice, located in the Heavitree area of Exeter.  

Consideration of NHS support

The University of Exeter Wellbeing Services recommend that any students who have been under the care of NHS mental health or specialist eating disorders services in another part of the country discuss support with their current team to see what can be offered locally with Devon Partnership NHS Trust, and to discuss the referral pathway for specialist eating disorder support.  

We would suggest that students and their families view information about the local Community Eating Disorder Service (CEDS);

https://www.dpt.nhs.uk/our-services/eating-disorders/our-services/community-eating-disorder-service

HEOPS guidance suggest considering what support is available locally pre-arrival at university with the current treating team or GP. This is to ensure a smooth transition, as continuity of care is important and a change in medical team may trigger weight loss (HEOPS, 2013).

We would strongly suggest that students and their families consider making links with specialist local eating disorders services. This can happen through seeing a GP and requesting referral. At the end of this document there is a web link to information about Devon Partnership Trust NHS Services.

It is important to note that levels of service provision from the NHS varies between localities, and service provision may be different going from CAMHS to adult services across the country.  

University of Exeter Wellbeing Services support

For students with an identified eating disorder, it is likely that support from the University of Exeter Wellbeing Services alone will not be sufficient.

• A student with an eating disorder falls under the category of having a disability which is defined under the Equality Act (2010) as a physical or mental impairment that has substantial and long-term effect on the ability to carry out normal day to day activities. Higher Education institutions have a duty to provide reasonable adjustments to support a student who has disclosed their disorder. In line with this, students can declare their mental health condition to the University of Exeter Wellbeing Services and request an appointment to see a mental health advisor to consider any reasonable adjustments that can be put into place.
• University of Exeter mental health advisors can support students with a declared disability to create an Individual Learning Plan (ILP) for their time at the University of Exeter, which will outline reasonable adjustments that would be recommended to support the management of mental health and academic studies. In some cases this will include a discussion around deferment of the student’s place whilst the student engages in treatment, consideration of whether part-time studying is possible, or reasonable time off from their course to attend outpatient treatment. It is important to acknowledge that for some courses with a professional training requirement and attendance expectations, these adjustments may not be possible. 
• The University of Exeter Wellbeing Services offer a non-judgemental space for students to speak about concerns with their eating, weight and shape. There are a limited number of “eating difficulties” appointments available each term.  Please note, these appointments are not in lieu of medical treatment for an eating disorder. These appointments aim to signpost students to appropriate support and to provide relevant psycho-education including self-help resources informed by evidence-based practice.

Guidance for Academic staff members

Academic staff members who have concerns about a student should encourage the student to approach the University of Exeter Wellbeing Services and their GP. If there is an urgent concern about a person’s mental health or weight, the academic member of staff should contact University of Exeter Wellbeing Services so they can contact the student to invite them to see the University of Exeter Wellbeing Services and/or the University GP. It should be stressed that this is a supportive appointment and will be carried out in the student’s best interests. 

3.)    BMI thresholds suggested by  HEOPS (2013)

Body Mass Index (BMI) is a proxy measurement for medical risk in anorexia nervosa; whilst it is helpful to consider a student’s BMI when considering whether a student is fit to study, this is a guidance value and should not be the only criterion applied when making this decision.

BMI 17+

If a student has a BMI of 17 or above, HEOPs (2013) guidance indicates that a student may be able to continue with his/her studies. Where a student is managing their illness and keeping their BMI at 17+, reasonable adjustments can be considered to support students to continue with their academic studies. It is recommended that treatment is sought to ensure reduced risk of further damage to health.

BMI 16 to 17

HEOPs (2013) guidance recommends that students with a BMI range of 16 to 17 will need to demonstrate that they are engaging with on-going medical care with regards to their eating disorder. 

BMI <16

HEOPS guidance recommends that students with a BMI of <16 should take time out of their studies to focus on treatment and recovery. A BMI of 16 and under would indicate that there are significant health risks and there would need to be careful consideration regarding continuation of studies at this point.

4.)    Use of Health and Wellbeing Support to Study (HWSS) policy

In certain circumstances it may be necessary or appropriate to support a student through the University of Exeter’s Health and Wellbeing Support to Study (HWSS) policy, which considers the student’s ability to meet academic, social and behavioural requirements without his or her physical, mental, emotional or psychological health being negatively impacted or that of other students and/or University staff.  The aim of HWSS is that students are supported to study and manage their health, wellbeing, and current circumstances to the best of their ability, and wherever possible to meet the required learning outcomes and complete their course.

Further information about the HWSS process is available at the following link: https://www.exeter.ac.uk/wellbeing/studentwelfare/

5.)    References

Legislation.gov.uk. (2010). Equality Act 2010. [online] Available at: http://www.legislation.gov.uk/ukpga/2010/15/contents [Accessed 29 January 2019].

Higher Education Occupational Physicians Society (2013). [online] Available at: http://www.heops.org.uk/uploads/1521730766HEOPS_Guidance_Fitness_to_Study_with_Severe_Eating_Disorders_v2.pdf [Accessed 29 January 2019].

National Institute for Health and Care Excellence (2018). [online] Eating Disorders (NICE Guideline). Available at: https://www.nice.org.uk/guidance/qs175/resources/eating-disorders-pdf-75545662586821 [Accessed 29 January 2019].

6.)    Links to information which may be helpful

BEAT eating disorders charity- https://www.beateatingdisorders.org.uk/

Devon Partnership Trust, NHS - https://www.dpt.nhs.uk/our-services  

Student Health Centre - https://www.exeterstudenthealthcentre.co.uk/

Heavitree GP Practice - https://www.theheavitreepractice.co.uk/  

For some people, restricting their food and weight can be a way of controlling areas of life that feel out of their control and their body image can come to define their entire sense of self worth. Some people with the condition lose their ability to see themselves as they really are, and instead become terrified that they are fat even when they have become seriously malnourished and underweight. Others are able to see that they are thinner than most other people, but still strive to lose whatever body fat they feel remains. In many cases, they feel driven to continue to lose weight because they feel that their value as a person depends on their weight and body shape.

It can also be a way of coping with difficult emotions that may feel too complex or frightening such as pain, stress or anxiety. The amount of time and energy spent thinking about food and weight loss can leave very little room to deal with any other emotions. Anorexia nervosa can therefore act as a kind of protective barrier against the difficulties and emotional pressures of everyday life.

Bulimia nervosa is a disorder which disrupts the ability to maintain a `normal’ eating pattern. Someone with bulimia nervosa becomes increasingly unable to relate normally to food and instead develops a dependency on a chaotic cycle of bingeing and purging. Typically they alternate between the frantic activity of binge-eating and the subsequent state of panic and the need to get rid of what has just been eaten. People with bulimia nervosa either make themselves vomit or use laxatives or diuretics - or all of these - to purge themselves of the food they have consumed. Others do not purge in this way, but instead have a period of excessive fasting or exercise to compensate for their over-eating.

Bulimia is often a vicious circle. You may also think you are overweight, even though you may be at or near a normal weight for your height and build. This may encourage you to set yourself strict rules about dieting, eating or exercising, which are very hard to maintain. If you fail to keep to these strict rules, you binge on the things that you have denied yourself. After feeling guilty about binging, you purge to get rid of the calories.

Find out more.

Please also see Overcoming Bulimia Online, a low cost online course with a strong evidence base.

Body image is the perception that a person has of their physical self and the thoughts and feelings that result from that perception. It is usually defined as a person’s beliefs, thoughts, perceptions, feelings and actions about their body and appearance. Some things that body image might include or be related to are:

• Body dissatisfaction
• Weight and shape concerns
• Body distortion
• Preferred body shape/size
• Importance placed on one’s weight and shape

If you feel sad, nervous, disgusted, ashamed or overwhelmed on experiencing your body image, this is called body image distress. Others see their body differently than anyone else sees them, flaws seem more obvious or more terrible than anyone else would say, this is called body image distortion.Some focus on the difference between what we consider perfect and what we see in the mirror; comparing ourselves to an ideal, this is called body image dissatisfaction.

Binge eating involves two key features:

• Eating a very large amount of food within a relatively short period of time (e.g. within two hours)
• Feeling a sense of loss of control while eating (e.g. feeling unable to stop yourself from eating

Binge Eating Disorder can occur in people of all ages and genders, across all socioeconomic groups, and from any cultural background. A person with Binge Eating Disorder will not use compensatory behaviours, such as self-induced vomiting or over-exercising after binge eating. Many people with Binge Eating Disorder are overweight or obese.

It is not always about eating extra large portions, but eating when not hungry. Binges can be planned like a ritual and can involve ‘special’ binge food. Binge eating usually takes place in private and is often followed by feelings of guilt and disgust. People with Binge Eating Disorder are often very secretive about their eating habits.

Binge eating is a type of emotional eating. Food is used in a compulsive way to deal with uncomfortable feelings. However, no matter how much food is eaten, binging cannot deal with the feelings, whatever those feelings might be.

Some people with an eating disorder may have received a diagnosis of Eating Disorder Not Otherwise Specified (EDNOS). This category has been renamed OSFED (Other Specified Feeding or Eating Disorder). You may present with many symptoms of other eating disorders such as Anorexia Nervosa or Bulimia Nervosa.

EDNOS is not a less serious form of an eating disorder. People with EDNOS commonly present with extremely disturbed eating habits, a distorted body image and an intense fear of gaining weight. EDNOS is the most common eating disorder diagnosed for adults as well as adolescents, and affects both males and females equally.

While eating disorders are often portrayed as illnesses that only affect females, large population studies suggest that up to a quarter of people suffering with Anorexia Nervosa or Bulimia Nervosa are male, and almost an equal number of males and females suffer with Binge Eating Disorder.

We also know that under-diagnosis and cultural stigma mean that the actual proportion of males with eating disorders could be much higher.

Males also struggle with body dissatisfaction which is more commonly manifested as the pursuit of a muscular, lean physique rather than a lower body weight. For some males, heightened concerns about muscularity may become part of an eating disorder, characterised by distorted perceptions about muscle bulk, and/or distorted eating and exercise patterns.

Sociocultural influences play a role in the development of eating disorders and males are exposed to unique cultural messages that can increase their vulnerability towards developing an eating disorder. In addition, the desire not to appear weak or vulnerable has led to a stigma around mental illness that has delayed treatment and support for many males with eating disorders. This stigma has been further exacerbated by the popular misconception that eating disorders are a ‘female’s disease’.

Family and friends play an important role in the support and recovery of people with eating disorders. Family members or close friends are usually the first to intervene, as they support and encourage the person to seek help long before any therapeutic intervention is established. 

You may be working hard to support your friend, partner or family member. You may feel guilty, angry, frustrated and scared. You are not alone. 

A person with an eating disorder may deny that there is a problem. It’s often up to family and friends to notice symptoms and gently challenge them. Ultimately, the decision to ask for support and contemplate recovery is up to the individual with the eating disorder. 

It is important to understand that people with an eating disorder often feel they have no choice in their behaviours. Often they use the eating disorder as a way of coping with difficult thoughts and feelings about themselves. That is why they are very ambivalent about seeking support and recovery.