People with eating disorders in England denied help as ‘BMI not low enough’

Growing numbers of women and men in England with eating disorders are being denied support because they are not considered to be thin enough to warrant it, a leading psychiatrist and other experts have warned in a briefing shared with ministers.

Against the backdrop of a fourfold rise in people admitted to hospital with eating disorders during the Covid pandemic, doctors said body mass index (BMI) was too often used as a blunt measure to decide whether someone should get treatment.

In some cases, women have not received an eating disorder diagnosis despite their periods stopping due to overexercising or restrictive eating.

BMI uses height and weight to calculate a healthy weight score. A normal body weight is considered to be between 18.5 and 24.9, and some doctors consider anything below this a signifier of an eating disorder.

Dr Agnes Ayton, the chair of the Royal College of Psychiatrists eating disorders faculty, and the mental health campaigner Hope Virgo shared a briefing paper with the Department of Health and Social Care (DHSC) urging funding to meet demand and “as a direct result of an increase in the number and severity” of patients during the pandemic. The paper, seen by the Guardian, said there had been a significant increase in eating disorders among ethnic minorities and men.

Concern has been raised about “a state of emergency” for eating disorders, the briefing paper said. Hospital admissions have seen a fourfold increase in the last year without extra investment in specialist eating disorder inpatient services during this time, it added.

Ayton said BMI was “not an appropriate measure for eating disorders” but “simply a way to monitor the physical symptoms of this mental illness”. “Unfortunately, it is not uncommon that patients are excluded from chronically underfunded services based on their BMI. This puts desperate patients in a life-threatening position to reduce more weight in order to meet the threshold to gain help,” she said.

Renee McGregor, a sports dietician specialising in eating disorders, who has treated 300 women since August, said many “have generally been told they can’t get help through [the] NHS”.

She added: “We get a large number of women who come to our clinic. When you calculate their BMI they are within the normal range, however, none of them has regular periods. Many have had years of [this] amenorrhoea, perhaps through a previous history of restrictive eating and/or being physically very active.

“They have often tried to seek support regarding their lack of period and most are either told that it is normal because they are so active or that the only option is to go on the [contraceptive] pill to help kickstart their reproductive system.”

Periods can stop due to natural causes such as pregnancy and menopause but lifestyle factors can also affect them, including excessive exercise and stress. Having too little or too much body fat, as well as hormonal imbalances, may also delay or stop menstruation.

“When we work with these women, we are looking at them holistically, taking into account their energy availability, their training load, their body composition and also the composition of their diet as these all have an impact on the reproductive system, even if you are a normal weight,” said McGregor.

Virgo said: “Over the last year we have seen more people presenting with eating disorders but because their BMI isn’t seemingly low enough they are unable to get the support they really need. Not only does this perpetuate the myth that eating disorders are all about weight and you can’t have one unless you weigh a certain amount, but it also fuels the eating disorder, the competition, the shame, and guilt that an individual feels.” She said “turning people away because of their BMI” is “dangerous and costing lives”.

An NHS spokesperson said: “NHS community eating disorder services continue to step up through the pandemic and have treated 1,700 more children and young people since last year, while funding for community mental health services continues to rise year on year.”

A DHSC spokesperson said the National Institute for Health and Care Excellence guidance is clear: “People should not be rejected for treatment solely on the grounds of weight or BMI – and we expect commissioners and providers to follow this guidance.” NHS England is launching early intervention services for young people with eating disorders which means they could begin treatment within two weeks, they added.