A Doctor's View

Eating Disorders and Body Image | feat. The London Centre

January 18, 2023 Dr Paul Polyvios / Dr Bryony Bamford / Christina De Beukelaar Episode 53
A Doctor's View
Eating Disorders and Body Image | feat. The London Centre
Show Notes Transcript

This episode focuses on an important topic that is becoming more and more prevalent.

An eating disorder such as anorexia nervosa and bulimia is a severe psychological eating disorder where an individual restricts their food intake to lose weight or avoid weight gain.

Recorded at The London Centre for Eating Disorders and Body Image, I’m joined by Dr Bryony Bamford, Founder and Director and Consultant Clinical Psychologist and Christina de Beukelaar, The London Centre’s Lead Dietitian.

We discuss a number of questions that surround eating disorders and the role of a clinical psychologist and dietician when treating such a difficult and debilitating illness. These include:

  •  Why eating disorders are so hard to treat.
  • The common personality traits seen in eating disorders.
  • Other specified feeding or eating disorder (OSFED).
  • The role a dietitian plays in treating eating disorders, a psychological illness.
  • What is refeeding syndrome and why is this such an important risk in eating disorder patients?
  • What an initial consultation and process with a patient looks like.
  • How treatment plans vary for different eating disorders and different ways of controlling weight such as laxatives, purging and over-exercises.
  • Treating eating disorders with patients who have strict vegan diets.
  • Thoughts on showing calories on restaurant menus.
  • How the pandemic impacted the number suffering with eating disorders.
  • How social media is contributing to the rise in eating disorders.
  • Advice for parents or people coming to terms with an eating disorder.
  • How to seek help.


Dr Bryony Bamford

Dr Bryony Bamford is a specialist eating disorder psychologist treating children adolescents and adults with eating disorders, eating problems and low body esteem. She has been treating eating disorders throughout her 20-year career. She has worked with individuals with eating disorders across a number of different treatment settings, inpatient and outpatient, and within the NHS and privately.

Early on in her career Dr Bamford worked in international research, developing psychological treatments for severe and enduring anorexia. In 2013 Dr Bamford founded The London Centre for Eating Disorders and Body Image. 

Christina de Beukelaar

Christina de Beukelaar is a specialist dietitian and has over 15 years clinical experience, her expertise spans all areas of Dietetics and Nutrition, specialising specifically in eating disorders. 

Christina’s practical and person-centred approach allows individuals to establish long term lifestyle changes. 

She works directly with clients and additionally provides education and training for their family members around food and meal times.

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[00:00:00] Dr Bryony Bamford:  I, I think above everything. Listen to that worry. You know, I think if you are a friend or a relative and you've, and you've gotta worry, you know, our gut instincts are often very, very valuable. And I think listen to that worry. Likewise, if you're worried about yourself, you know, we don't tend to be worried about ourselves for, for no reason.

So I think listen to that worry and know that there are places where you can. Support and that that support is supportive. You know, treatment isn't about doing something that's threatening or scary or unwanted. It's about finding the right support for you to enable you to live in a way that you would rather be living

So I think there's also a lot of messages in social media and the media around, um, increasing exercise and around kind of control of food. And so if you're someone that's vulnerable to disordered eating that, having that constantly kind of, um, having those messages constantly around you, you know, it would be difficult.

Yeah, it would be very difficult not to, not to listen to them.

[00:00:49] Dr Paul Polyvios: Welcome to Doctor's View with me, Dr. Oli. Join me as I discuss everyday topics in health and medicine and provide insights into everyday hospital life. Sit back and enjoy the show.[00:01:00]

Hello everyone and welcome to a Doctor's View. I'm Dr. Polyvios. Uh, for some time now, I've been wanting to publish an episode on eating disorders, but this has been met with several challenges. Firstly, as anyone has ever tried to research, Eating disorders and websites, you'll know that the information out there is infinite with thousands of articles and websites discussing various types of eating disorders, ranging from anorexia nervosa to binge eating disorders and everything in between.

So I quickly realized that whilst I have some minimal experience with eating disorder patients, I needed help. With this episode, so I'm incredibly grateful to be granted time at the London Center for Eating Disorders and Body Image with Dr. Briney Bamford, who's the founder, director, and consultant clinical psychologist.

And Christina, Deb, the London Center's lead dietician. So thank you both for joining. Thank you for having us. Thank you. Um, Brian, would you like to introduce yourself, please? 

[00:01:59] Dr Bryony Bamford: Sure. [00:02:00] I am Dr. Brian Bamford. I'm a clinical psychologist. I specialize in the treatment of, um, disordered eating and, and eating disorders.

I also am am clinic clinical director here at the London Center for Eating Disorders. So very much involved in kind of the, the, the team, um, as a whole. 

[00:02:19] Dr Paul Polyvios: Thank you and 

[00:02:20] Christina De Beukelaar: Christina? So I'm Christina De Beukelaar. I'm a dietician and I specialize in eating disorders and I've been working with Briny Yes. years and years.

Long before, uh, the London Center exists. So, um, yeah, we've been in this field for a long time. Yeah. Thanks for having us. Oh, 

[00:02:40] Dr Paul Polyvios: pleasure. I have to ask, what is the London Center and what does it. 

[00:02:45] Dr Bryony Bamford: So we, we are an outpatient treatment center. We, we specialize in, um, treatment of people, both who might meet diagnostic criteria for.

Eating disorders such as anorexia or bulimia. But we'll also see a lot of people [00:03:00] who perhaps don't quite meet diagnostic criteria, but who, um, whose relationship with food or relationship with their, with their body causes them distress or, or, um, is something that they see as, as problematic. 

[00:03:15] Dr Paul Polyvios: Okay. Okay.

And can you just describe your different roles and like different responsibilities you. , I know we've got dietician, we've got, uh, clinical psychologists, but just explain what those things mean to everyone else. Sure. 

[00:03:29] Dr Bryony Bamford: So as a psychologist, um, you know, eating disorders very much are seen as well, they are psychological disorders.

Mm-hmm. . So as a psychologist you'll be very much involved in the. Therapeutic treatment of people with eating disorders. If you look at the guidelines, um, around what treatments we know are most effective and most beneficial with disordered eating mm-hmm. , um, there are particular specialist treatment approaches that we know to be most effective.

So as a psychologist, you would be involved in, um, [00:04:00] in, well, you would be trained in, in those treatment approaches and experiencing those treatment approaches. Um, and you might then work collaboratively with, could be a dietician, but we're an m we're very much an M D T here, so we also have family therapy, we have occupational therapists, we have nutritionists.

So you would devise a a from appointment assessment, you will devise a treatment plan that meets a client's needs. Okay. And, and work with you. 

[00:04:25] Dr Paul Polyvios: It's all very personalized in the individual. Per each claim. 

[00:04:29] Dr Bryony Bamford: Yes. Yeah. So we know, um, you know, the research tells us what treatment approaches are most effective.

So we know that family-based treatment approaches are most effective for children and young people. We know that there's a good evidence-based for C B T approaches, so we know what treatment approaches are, are, um, let's say most helpful to most seating disorders of. You know, there's no one single treatment approach that's ever gonna be able to suit everybody.

Um, so as a psychologist, your role is to assess, I guess, for [00:05:00] the presence of an eating disorder, assess what sort of treatment approach you think might be most helpful and then Sure. Do deliver that treatment approach. 

[00:05:08] Christina De Beukelaar: And Christina, so I think my role as a dietician is very multifaceted. You have, um, , not one client is gonna be the same presentation or the same symptoms.

So you very much need to look at the physical wellbeing and the medical wellbeing and making sure you check those off. Um, and think about that in your assessment. But then next to that, there's also really forming a bond with the client in front of you and making sure that they feel like you're. to lots of different things in treatment, um, and making that very clear.

So it's, it's, it's very much that's a pleasure and my job is really making sure that I do both of those things, which makes it very varied. Amazing. Yeah. [00:06:00]

[00:06:00] Dr Paul Polyvios: And why are eating disorders so hard to treat? To the extent that we need a specialist center Sure, sure. For 

[00:06:08] Dr Bryony Bamford: this. I mean, there's a few reasons why they're hard to treat.

I think the most important reason is that eating disorder are the only mental health condition that is known to be egosyntonic. So what we mean by that is it's wanted by the individual. So if you think about most mental health conditions, most physical health conditions, depression, a c D, anxiety, most people don't want those.

Diagnosis. They don't want those cognition. Eating disorders are very different in that particularly when those disorders start, they're generally wanted and to some degree, at the very beginning, chosen by those individuals. And the reason for that is integral to the, the treatment of an eating disorder.

So at, at some level, an eating disorder will be functional for the. Sra, [00:07:00] it might be that, um, you know, it might be as simple as I'm not happy with my body image and therefore I want to do something about it. Generally it's more complex than that. Generally, you know, someone might be experiencing, let's say, very low mood or high levels of anxiety, and they find the eating disorder as a way of.

um, distracting or avoiding or soothing or controlling those emotions in some way. Equally, it might be that, um, people have experienced, you know, a very, very, very difficult upbringing and childhood, and they find their eating disorder as a way of communicating that. Sometimes is a way of, let's say, punishing themselves if they, if they blame themselves for some of those childhood experiences.

So, as Christina very rightly said, no. Two people are the same. You know, everyone with an eating disorder has that eating disorder [00:08:00] for a very different reason. And as a team, as a treating team, we, you know, our job is to sort of, to come alongside and, and to work out why that eating disorder is wanted and then to think about how we can help somebody to need that eating disorder.

Yeah. Less. 

[00:08:15] Dr Paul Polyvios: Is, is it fair to say that there are some, uh, people suffering with disorders that actually don't feel there's anything wrong with them at all? Sure. 

[00:08:22] Dr Bryony Bamford: Yeah. Absolutely. Yeah. And, and that again, makes it very hard to treat. If you look at the core diagnostic criteria, particularly of anorexia, you know, lack of denial and lack of.

Kind of awareness of the seriousness of the disorder is part of the diagnostic feature. So very much so often it can take quite a long time for people to present to treatment because they genuinely don't see that there's a problem and their eating disorder is very much something that is wanted. Now, of course, the other thing that makes 'em very difficult to treat is because they are so serious, you know, they are life threatening.

Disorders. There is a huge amount of medical risk [00:09:00] that goes alongside an eating disorder and as a, as a treating clinician, you have to have not only an awareness of the psychological side of the disordered eating, but also of the. medical side. And so a lot of, um, a lot of psychologists whilst they, they, they might be sort of happy to work with mild disorders, feel, start to feel quite uncomfortable working with the severe end of disorder eating Sure.

Because of that medical risk and, and, and managing both. 

[00:09:28] Dr Paul Polyvios: So where, where, at what point do you start getting, um, hospitals or gps or um, or other healthcare professionals involved, or is that right from the beginning? 

[00:09:38] Dr Bryony Bamford: Um, no, so that will vary and that will be very dependent on your initial assessment of risk.

So gps, we, we do tend to work quite closely with. Gps, of course, if, if there's, there is no risk or very, very minimal risk, it might be that we don't need to get a GP involved at all. If there is, um, you know, if someone's presenting with a, with slightly [00:10:00] higher levels of risk, then you will very much want the GP to be involved in, um, medically assessing a medically monitoring the safety of of, of that person.

And then again, as risk kind of continues down the spectrum, you might want a consult. , um, psychiatrist or a consultant, pediatrician involved. And of course you, you know, at, at the most severe end it might be the outpatient treatment becomes something that isn't really possible for people to utilize or isn't safe for people to utilize.

And that's the point at which you might be thinking about, um, more intensive treatment 

[00:10:36] Dr Paul Polyvios: options. And at what point do patients tend to present to you? Is it at, um, The early stages of having an eating tour, is it much later on and do they typically self-refer or is is that someone you know? 

[00:10:52] Dr Bryony Bamford: Um, I'd say it really varies.

I say sometimes yes, people present relatively early on. Um, sometimes [00:11:00] it'll be years. Um, I think there was some research done that suggested that it was usually about seven years. Of having experience in eating sort of before mm-hmm. , um, a lot of people will present for treatment, so sometimes, you know, and sometimes people will never present for treatment, for various, for various reasons.

Um, with children and young people, you tend to see them presenting for treatment slightly earlier, cuz of course you've got the influence. Of parents and, and parents picking up on, on changes that they're, that they're seeing and, and their concern might often, um, be what's, what sort of motivates the, the initial referral, whereas, um, adults it can, it can be, it can be a little bit longer.

Sure. A lot of people partly cuz of the, um, the denial of the illness or, or you know, when we talked about them sort of wanting that, wanting that illness, wanting or as wanting, certainly wanting aspects of. Illness, it will mean that they do put off accessing [00:12:00] treatment for, for some time until the balance tips and it becomes something that they see as no longer helpful to them.

[00:12:05] Dr Paul Polyvios: see. And uh, question for both of you actually. What, what, uh, what, what's the most common question that patients, when they first come to you, what do they say or what do they ask? 

[00:12:19] Dr Bryony Bamford: Um, I don't, I don't know that there is a question per se. I think that what a lot of people, um, what a lot of people come with is a, is a fear or an uncertainty over what to expect and what's gonna happen.

I think that often, um, often people have been met with. Kind of a lack of awareness over eating disorders or even a sort of, I guess, a fear of eating disorders. So it might be that the people that they've spoken to thus far, be it a friend or a family member or a gp mm-hmm. that they, um, That those people don't sort of know what, [00:13:00] what to, what to say or what to do or, or what or what to make of it.

And so I think often they can be quite fearful over what is this psychologist or what's this dietician gonna do? Are they gonna, um, you know, are they just gonna take this eating sort away from me and, and make me lots of foods that, you know, that's certainly a fear that a lot of people come with. And as Christina said earlier, A, a huge part of our role is forming that relationship and, and creating a safe environment for people in which they can start to make the changes that really are very terrifying for them often.

[00:13:35] Christina De Beukelaar: I guess one thing I would add to that is, Thinking about the time it takes to get better. And very often people can come to us and think, okay, in a couple of months I walk out of here and I'm better. Um, and during treatment they realize that's just not gonna happen. And I think those, [00:14:00] that distorted view of.

What is the work that I actually need to put in here? What is, what do my parents need to put into this to support me or my partner, or whatever? I think those are things that are really. , I feel come up a lot. Yeah. Yeah. 

[00:14:18] Dr Bryony Bamford: It's a, it's definitely a common question we get asked by, by parents, isn't it? How long is it gonna, how many sessions will she need?

Or how many sessions will he need? How long is it gonna take? And, and, you know, let to Sandra, that's how long is a piece of string, it's a very difficult question to, to answer. Do you find, 

[00:14:32] Dr Paul Polyvios: um, an understandably, you obviously want your child or your relative to get better as. Possible. And do you sometimes find there might be a somewhat unrealistic expectation?

[00:14:43] Dr Bryony Bamford: There can be. Yeah, there definitely can be. I think there's a hope that you'll be able to wave a magic wand and, and, you know, in two weeks time there won't be a eating 

[00:14:52] Dr Paul Polyvios: disorder there. I, I say that cuz it's, it's the same in the hospital when people say, how, how long do I have to stay in the hospital for?

And they think it's gonna be one, one [00:15:00] day and it's unfortunately a bit longer. So I. Wondering the same. And I, I guess 

[00:15:04] Christina De Beukelaar: one key thing to this is the sooner you find support mm-hmm. the better. Yeah. Really. Yeah. 

[00:15:12] Dr Paul Polyvios: Sure. And Ronnie, what are the most common personality traits you see in eating disorder patients?


[00:15:20] Dr Bryony Bamford: Um, in some ways it's hard to say because I hate to pigeonhole people, and I think it's really important to recognize that no one is a immune from an eating disorder. Mm-hmm. , you know, and, and you can't say, oh, you are this personality type, so you are at risk, or you are, you are not this personality type, so you are not at risk.

I think certainly I could say that. Um, there are a lot of people who experience anorexia who perhaps are more perfectionist, um, are a little more kind of rigid or con controlling over their, um, kind of e emotional. worlds. Mm-hmm. , um, perhaps more anxious, whereas in comparison, some people with [00:16:00] bulimia will tend to be a little bit more impulsive, maybe a little, a little bit more emotional.

Yeah. Um, so there's, there definitely are differences, but, but there not so clear cut that you can, you know, that you can say everyone with this personality desire type would have anorexia, of course not bulimia, of course, of. 

[00:16:19] Dr Paul Polyvios: And so do, do you notice there are actually some different personal types between the different eating disorders as well actually?

So say an song with anorexia may have this, this type of personality, whereas I know like you say, you can't pigeon in hall, but just as a generalization. Yes. Yeah. 

[00:16:37] Dr Bryony Bamford: Yeah. So I would say, I dunno if you'd agree with this, Christina, but I would say that, um, the more restrictive disorders mm-hmm. , so kind of restrictive anorexia, um, Those are often the people with more perfectionist Okay.

Traits. Okay. Um, if people are binging or purging or using, [00:17:00] um, a lot of sort of compensation behaviors, often those compensatory behaviors are there as a way of regulating emotions. So they may, may maybe be people that are a little bit more emotionally dysregulated. I 

[00:17:15] Dr Paul Polyvios: see. And I came across, um, offset, which is other specified eating disorder.

And please correct me if that's wrong. Eating disorder. Yes. Yes. And um, and since is apparently the most common eating disorder from my initial research. And I was just wondering how does that differ from anorexia and you know, what other common eating disorders you mentioned bulimia. , there seems to be like a wide range of spectrum for this.


[00:17:42] Dr Bryony Bamford: aved is kind of the, the catchall in a sense, like an umbrella. So it's so Well, no. So a aved, you were diagnosed if people didn't quite meet the criteria for anorexia or olima or another eating disorder. So for example, you might meet, um, most of the criteria for anorexia, but [00:18:00] you are, you might be a healthy weight range.

So you would then diagnose atypical anorexia, which. I see a, a form of osfa or you might, um, meet the criteria for bulimia, but not be binging quite as frequently as is required. So to meet diagnostic criteria, you have to be binging weekly. So it might be that you're binging fortnightly, so you've got all of those facets of the eating disorder, but it just doesn't quite meet diagnostic criteria.

So afad is the term that you would use if there's very clearly. DISORDERED eating present and eating disorder present that, that someone is eating in a way that is causing them distress and is, um, un unhealthy or un unhelpful to them, but they don't quite meet. Mm-hmm. criteria. Um, you've also got binge eating disorder and um, AD is a relatively new diagnostic term as well.

Avoidant, restrictive food intake disorder, which. , um, a, [00:19:00] a re a restrictive form of eating disorder. But the reasons why you are restricting aren't as a way of, um, controlling weight or shape, but there's another reason why you are restricting your food. Okay? 

[00:19:12] Dr Paul Polyvios: Intake disorder. So it's, it's less of a body dysmorphia.

[00:19:16] Dr Bryony Bamford: Height? Yes. It's less about body image. Okay. It's, it's, it's, you're not, um, restricting your food because you want to change your body shape and size. You're restricting your food perhaps cuz you have a, a lack of interest in food perhaps because you have, um, there's a feared consequence around eating. So it might be that you have a fear of choking or something like that.

Fear of vomiting or it might be because, and we see this a lot with as s d presentations, it might be because the sensory component of eating is very, um, distress. Okay. To an individual. So there's essentially another reason other than shape and weight, why you are restricting your food intake. Okay. 

[00:19:54] Dr Paul Polyvios: Um, Christina, I have to ask cuz anorexia comes from the Greek [00:20:00] word.

An orex is, which literally means, you know, without appetite when you've got someone who's not eating. The role of a dietician, it's slightly paradoxical in a way, uh, because we tend to associate, at least in the hospital setting, you know, um, some people that are taking intravenous feeds or having parenteral nutrition, and you are in control of that.

But when you've got someone who's literally not. Eating. What's your role in that? How do you go about this? 

[00:20:30] Christina De Beukelaar: So obviously it's, it's not just the fear of it, but it's also a fear of a normal body weight. It's the psychological thoughts around it. And even though obviously therapy seems like it's something, obviously they need, dietetics is very much something they need as well for a.

Different reason. Um, it's for education. It's making sure that they understand why [00:21:00] they need certain nutri. because they've made rules in their head of why or how they lose weight. For instance, the, let's cut this out, let's do this. Um, and along the way, they've forgotten how they ate before. So I guess that is my job.

It's my job to reintroduce that to, to make them feel safe with the choices that I'm asking them to make. Mm-hmm. , um, Doing it step by step, having having someone that they can feel accountable to. Yeah, 

[00:21:32] Dr Paul Polyvios: yeah, yeah. I see. And at what point in the diagnosis do you get involved? Is it right early on? Is it a little bit later on or?

is it once, uh, the, the psychological aspect of it's been initially confirmed, and then do you step in? 

[00:21:49] Christina De Beukelaar: It varies so much. Um, I can definitely assess. I wouldn't diagnose, but I can assess and, and, and find out what's been going on, what the history is, [00:22:00] um, what they might need out of treatment. Um, but. Working together in an mdt, as we've said, is so important.

You're never alone in it. You really need the other members of your team with you. May I ask 

[00:22:15] Dr Paul Polyvios: how often you have MDTs for, for it? Uh, is it, is it once a week, twice a week or so to vary? 

[00:22:22] Dr Bryony Bamford: Yeah, so, so we will make a decision usually fairly on after assessment over about who? Be who it might be beneficial to get.

I see. Involved, sometimes you won't make that decision early on. Sometimes it will be that, you know, a lot of therapy is required to get someone to the point where they're able to use dietetics. Mm-hmm. equally. Sometimes people might not feel able to engage in therapy at all. They might. What they might want is the, the much more kind of, um, , practical kind of here and now focused approach that, that Christina can, can do [00:23:00] and, and almost she gets them to a point where they can then access.

Therapy. So there's no sort of one direction that it, that it goes. But having the ability to work alongside a dietician, I'd say is completely invaluable. Yeah. To me as a psychologist, um, be it because, you know, Christina has a, an extra, an extra level of knowledge around. Um, the psychoeducation of nutrition and, and eating and, and what's required, but also often there's so much to do in a therapy session and you've only got often one session a week, sometimes two sessions a week.

There's so much to do that actually being able to say, well, you know, all these thoughts, all these fears, all these questions, all this uncertainty that you've got around food, you know, that's what your session with Christina is for. And then I'm here to think about the emotional side of things and, and, um, the slightly kind of.

um, I suppose the more psychological reasons why someone is presenting Yeah. With an eating disorder. So it's really invaluable to be able to, so 

[00:23:58] Dr Paul Polyvios: there is, there is some [00:24:00] overlap actually between your role as a, as a dietician actually with regarding the, the psychological side of things as you're saying.

You know, the, the way that foods associated and the different fears, and 

[00:24:10] Christina De Beukelaar: I think there really is, however you really do, I try and manage. , the anxiety that comes up. Um, and I try and really put it into motion instead of really thinking it through and where is this come from and why is this here? I leave that to therapy, but I will be like, okay, I understand this, but let's see this as an experiment.

Let's try to do this in a slightly different way than what you've. For instance, restriction. Let's try this and let's see what your weight does and, and, and, and let's come together with this. It's 

[00:24:47] Dr Paul Polyvios: a, it's a compromise between patient Definitely. The patient and what you want them to, to be doing. 

[00:24:52] Christina De Beukelaar: Yeah.

Because I, I will have probably much higher expectations and they can do, and they will [00:25:00]probably say, I can't do anything, so we need to try and find a middle ground. Yeah. 

[00:25:04] Dr Paul Polyvios: What, what's the, um, key thing that the, the thing that. Most looking for in the history when you're trying to come up with a diet plan or trying to come up with a, a, a treatment plan?

[00:25:14] Christina De Beukelaar: I think the onset of where, where it all started, what, why was it something that you felt you needed to take to this extreme? Mm-hmm. , but also the family history. I, I find incredibly invaluable because seeing a child who's actually never. Had a lot of family around them to eat, to teach them what a plate looks like, to have home cooked meals, or to have someone who actually did really well up until they were 16, 17, and then all of a sudden there was an incident.

So there's so many different things that will actually help me so much to know how to educate [00:26:00] them around food. 

[00:26:02] Dr Paul Polyvios: So it's, it's actually. Not just as simple. It can take a couple, maybe a couple of sessions in order to come up with, with a plan itself then, is that fair to say? Or by the time you've got all of this 

[00:26:13] Christina De Beukelaar: information, I guess I quite like working with, with within a routine of seeing me quite often because if you really wanna change the idea around food and how you food and how you challenge yourself.

I'm not gonna be able to do that in a couple of sessions. Some people are very good at that and they take it away and they run with it. But someone who's quite entrenched will find that very difficult. Um, and 

[00:26:40] Dr Bryony Bamford: for example, you know, often people. Might actually know what they need to eat. They know what healthy eating looks like.

They know what normal eating looks like, so it's not a case of just giving them a plan and saying, go away and eat this out, would be hugely overwhelming to people. It's about that regular support and understanding, encouragement, [00:27:00] managing or helping a client to manage the anxiety that these small changes and, and making tweaks to the meal plan kind of as you go, as you.

[00:27:09] Dr Paul Polyvios: So is, is this constantly, it's a dynamic management plan, really. Is that fair to say? Yeah, 

[00:27:14] Dr Bryony Bamford: it can be. I mean, again, you know, that's what Christina would work out in assessment and, and if, if a client has been assessed by psychology and then referred to dietetics, you know, we'll have an idea of what we think might be needed or might be helpful.

So we can also feed into that as well. And 

[00:27:31] Dr Paul Polyvios: the world's been a very interesting place the last couple of years. Yeah. Um, have you found the pandemic to. impacting eating disorders. Did you find an increase, uh, decrease

[00:27:42] Dr Bryony Bamford: or, yeah, a huge increase? You know, I think it's well reported and recognized now that the pandemic has had a really, really detrimental impact on eating disorders.

I think, um, across all eating disorder services, you've seen huge rises in. , um, written referral rates. Mm-hmm. across [00:28:00] all ages, you know, particularly child and adolescents. I think that's, that's well reported and, and sort of well recognized, but actually across all ages, I think, um, people who I do believe without Covid wouldn't have developed an eating disorder or people who, um, were in recovery who then relapsed, um, due to the impact of, of Covid.

So yeah, it's had a really, it's had a really, really detrimental impact. 

[00:28:25] Dr Paul Polyvios: Do you think there's, um, Part of it is being at home and being able to manifest these, these thoughts, um, without the distractions of the outside world. And or is it also the accessibility because of being in lockdown, just. People not being able to get to the health 

[00:28:42] Dr Bryony Bamford: service?

I think it's both. I think it's, I think it's lots of things that have, that have happened. I think, you know, mental health has been really impacted as a whole through covid. So you've got, um, you know, I've got, you've got a huge increase in anxiety, in stress levels, in, um, deterioration in [00:29:00] mood, and for a lot of people.

when you pair that with their sort of support systems and their safety mechanisms being much less available. You know, so people weren't able to just go and meet up with friends or, or do the things that might have improved their mood or taken the edge of their anxiety in the same way you've got a, you know, a recipe for emerging mental health conditions.

Equally, you know, people were at home where food was available and accessible and you know, the vast majority of people emotionally eat to some degree. So you've also got, um, you know, you've got availability of. Of food that has an impact on that. Um, diet and, and exercise was really one of the only things that we could control during Covid.

Right. There was very, very little control Yes. That we had over, over anything. And yes. And for people who really need a certain level of. Control actually gaining that [00:30:00] sense of control through restriction or, or through dieting or through over exercising was, was one of the only ways that they could achieve that.

[00:30:08] Dr Paul Polyvios: I guess we, we associate eating sources with, with. Losing weight and, and people who are need to eat more, but it can also be the other way round as well. So, uh, yeah, please forget to think about the people sitting at home doing very little exercise or just eating more and, uh, drinking more. And, you know, binge 

[00:30:29] Dr Bryony Bamford: eating disorder is, is, um, A much more common disorder actually than, than anorexia and binging, um, binging on food as an emotional soothing tool or emotional comfort tool.

Um, you know, when that was needed, all the more because people were going through, you know, living through these fairly, fairly traumatic covid times, plus the availability of food and the unavailability of other, um, Coping mechanisms [00:31:00] or, or you know, things that, that would, that may have, that people may have used to help them tolerate stress or distress ordinarily was kind of a recipe for an eating disorder in, in many 

[00:31:11] Dr Paul Polyvios: cases.

Yeah. It's just sitting at home manifesting your thoughts and uh, and carrying on feeling a little bit sorry for yourself sometimes. And, um, yeah, without that outlet that we have going to the, the park or. Pub or some, whatever these things are, so, 

[00:31:25] Dr Bryony Bamford: yeah. Yeah. And there was a huge focus, if you remember, in Covid, on, on kind of exercise.

And that was one of the only things that people were kind of allowed to do at one point. But a lot of people kind of, um, through social media or, or, or what, whatever, um, or whatever it, it was, would, um, focus on kind of. Exercise targets or fitness targets or health targets or diet targets. So I think there's also a lot of messages in social media and the media around, um, increasing exercise and around kind of control of food.

And so if you're someone that's vulnerable to disordered [00:32:00] eating that, having that constantly kind of, um, having those messages constantly around you, you know, it would be difficult. Yeah. It would be very difficult not to, not to listen to them. Yes.

[00:32:10] Dr Paul Polyvios: Uh, I, I wanted to actually ask what your thoughts are. On social media, just as over the years, it's, it's, it's increased in popularity.

Um, now with TikTok, with reels, with all these, all these things, how you found that impacting, uh, eating disorders as a whole? 

[00:32:26] Dr Bryony Bamford: It certainly plays its part, I would say. I think it's never the whole picture, you know, people don't develop eating disorders because social media exists. But what social media does give you is an almost.

Constant opportunity to make comparisons to idealized others. And that is something that can, um, increase vulnerability to disordered eating. So if you have, you know, constant access on your, on your phone to people who are, um, portraying a version of themselves that maybe isn't [00:33:00]necessarily an accurate version of themselves because.

Most people tend to present the kind of the best version of themselves, if you like. Um, a lot of people with eating disorders will make social comparisons with others that they perceive. better than them in some way. And social media is a tool that, you know, enables us to do that constantly. So it does, it does play its part.

And often it might be something that, you know, certainly not in the early stages of treatment, but it might be something that people do need to think about and address at some stage in treatment is. is their social media use and whether they can, um, reduce it or, or change 

[00:33:34] Dr Paul Polyvios: it in some way because it just sort of feed the competitive nature within us when you are doing the comparison between.

[00:33:40] Dr Bryony Bamford: Yeah, and I just think there's also so many unhelpful messages out there on social media. Right. I, I, you know, I can't tell you the number of times you, I, I hear people talk about sort of gaining so much understanding and nutrition from Instagram and you think, well, yes. Okay. There's some there, you know, there are some.

That, you know, are very highly trained and experienced that do use [00:34:00] Instagram, but there's also a lot of people that are very, very unqualified. Yes. You know, and I know that cuz we treat a lot of them as well, that, that they're using Instagram to, um, to give kind of education around nutrition and, and, and you just don't know the level of qualifications of people when you're looking at Instagram.

And that's part of the reason why it's a 

[00:34:19] Dr Paul Polyvios: problem. I actually, I wanted to ask. Christina, when you, if, if you see on social media, all the, all the different things that people come up with, um, in terms of you must eat this or this, this food's particularly bad, is there times where you look at it as a dietician to think this is absolutely rubbish?

You know, and I can't believe this is out there and these people have got big followings, or, 

[00:34:39] Christina De Beukelaar: well, I th I think my thoughts are this is not true. This is, this can't really be, or the what I eat in a day type of thing. Um, . I think there are very helpful things out there as well, but it's really trying to figure out, this is why it's [00:35:00] difficult for someone with an eating disorder to.

To know, they think black and white. They can't really see that there is a gray area there. And that's, that's very often the problem. Mm-hmm. . Yeah. Yeah. 

[00:35:14] Dr Paul Polyvios: That's fair. Um, and what's Refeeding syndrome, because we talk about this in the hospital. quite a bit, uh, when, when the dietician's involved, and one of the things they're always looking for is re-feeding syndrome.

Can you just 

[00:35:27] Christina De Beukelaar: explain what that is? Yeah, so it's an imbalance in fluid and electrolytes that happens when you give food or you re-feed too quickly when someone has been more nourished for a prolonged period of time. And this will could be detrimental to certain things. Um, Heart, lungs, muscles, things like that.

So it's something that we need to monitor. We would tend to monitor at least once a week with bloods. Be very involved with psychiatry [00:36:00] with a gp, have multivitamins. Yeah. Um, thymine, I think this sound okay. That we would prescribe as well. So there, there's, there's very clear guidelines around how we would measure that.

Um, the way you refeed is very important as well. You can't just say, oh, just eat whatever. It's really making sure over a per like 10, 14, That you every other day increase a little bit. And that would be very much part of my role of, of making sure that that's done in a regulated way, in a safe way. Mm-hmm.


[00:36:39] Dr Paul Polyvios: And when you've got someone who is, uh, bulimic or some, someone that's purging often, and in the dietician side of things, I know we mentioned getting rid of the, the fear rather than actually the, the different types of foods, uh, that they eat, but. How do you deal with that from a, from, [00:37:00] do you make sure that they get more nutrients at the times that they are eating and not, not purging or do, does your diet plan change for it or is it mainly more the psychological side of things for that?

So I 

[00:37:11] Christina De Beukelaar: think someone who's purging, it's all about the food. Um, it's the reaction. The protein is the reaction. Okay. So, , it's rethinking are they having too much that they feel that they need to purge, and how can we slow that down? Can we implement support for them after a meal up until about two hours after to make sure they can't purge?

So it's, I think, finding a way with. to think about how can we really make sure that this doesn't happen? Because obviously there again, it's, it's quite dangerous if, if purging is, is there very often. Mm-hmm. , yeah. It's 

[00:37:53] Dr Bryony Bamford: usually a compensation for food eaten. It can also have an emotional regulating [00:38:00] sort of, um, benefit to it.

So people, people can sometimes purge if they're feeling overwhelmed and it's a. A bit like self-harm, I guess it's a release of emotions. It's a, it's a can, can be, um, experienced as a seething behavior, but usually in eating disorders it's there as a form of compensation. So you very much need to help people feel safe with the food that they're eating, such that they don't feel the need to purge.

So yeah, you absolutely might do things like, um, think about how people can resist. Purging. Think about bringing in, um, uh, you know, if it's a young person, it might be parents sit with them for a while after, after eating and help them to sort of work through those emotions. But essentially if people can start to feel safe with the food that they're eating, such that they recognize that that food is healthy and necessary and isn't gonna lead to, um, Kind of excessive, unwanted weight gain [00:39:00] then that need those urges to purge will before.


[00:39:04] Dr Paul Polyvios: And, and do you find, um, anorexic patients that try and control their diet, not just through, not through lack of eating per se, but actually just with laxatives or exercise and these things, what, how does this impact you? Cuz obviously, um, for your management plan, you've gotta take that into account.

How do you go about this? Because I've just been quite interested in, in what I've been reading up on, it's just been seen so much to consider, so I guess. 

[00:39:35] Christina De Beukelaar: It's something that we'll know quite a lot in our assessment, what's been going on, um, and what behaviors they might have used in the past. But everyone will fluctuate between one or the other.

And maybe they're trying to eat a little bit more, but then they start over exercising bit more. So I think it's, again, finding that balance of. Not too much. [00:40:00] Making sure we hit certain goals. Mm-hmm. , but not create another behavior out of that. 

[00:40:06] Dr Paul Polyvios: And can you adapt the eating plans for say, vegan diets, vegetarian diets, um, that have its own challenges and, um, you know, 

[00:40:15] Christina De Beukelaar: trickiness?

Yeah. So we will see many and many clients who. intolerances who are vegan, who are vegetarian. But then when you go back into their history, were they like this? Were they eating like this five, 10 years ago before the illness? Mm-hmm. or has it developed? And I guess it's quite easy saying, I'm gonna cut out some sugar, or I'm gonna cut out this or that.

But to then be in a social environment, it's much easier to say, oh, sorry, I'm, I'm dairy free. I, I, I'm lactose intolerant. So almost you start to believe it. Yeah. Um, so out of that, I guess my question would be, do you really need, do you [00:41:00] need to be. doing, doing these types of diets. Is this, is this what, this what you really need?

Yeah. Yeah. Because you can gain weight on a vegan diet, you're gonna have to eat lots and lots. You can do it, but do you need to 

[00:41:16] Dr Paul Polyvios: mm-hmm. , yeah. So it's often, uh, something that might have been acquired as a consequence of all the, everything going on, the eating disorder going on, and then, uh, forms. Can't form an excuse, like you say, social setting.

Um, what's the biggest fear that patients may have? Is it, is it the eating of the food or is it the fear of losing the control of their diet? 

[00:41:43] Christina De Beukelaar: I think both of those for sure. Um, very big, but one that I feel. Is almost more overwhelming is once they get to a certain weight that we would call a healthy weight.

And that's something that's a big debate obviously, [00:42:00] is will I be able to eat normally? Will I be able to eat everything I'm eating now on a weight gain plan or on this type of plan that you've put me on mm-hmm. or am I gonna have to change this? Because that will be really difficult. So it's, it's figuring out.

what weight they actually need to be, to be behavior free. That's the only way you can be free of the thoughts and move away from 

[00:42:28] Dr Paul Polyvios: the illness. Yeah. And a question for both actually. I, I was interested, what do you think about calories on restaurant menus? Cause uh, it's become mandatory now, I believe, and I've seen even in, in Starbucks or.

You know, coffee shops, you, you see the calories and there's been times where I have to admit, after going to, um, having a, a nice burger, that I look at the menus and I'm quite shocked by. . It's, I think that's, that's my entire daily [00:43:00] catastrophic intake. Um, so it's, it's interesting from my perspective, it's interesting and it's useful to know because I think, uh, we see a lot of obesity in the hospital and in patients.

So I think it's, it's useful that if people know what a calorie is and know how much they should be having, that they have an idea of, of, of what they're eating. But, I guess in this setting, um, what do you 

[00:43:24] Dr Bryony Bamford: think about it? Yeah, I think it's, I think it's fairly safe to say it's very problematic from our perspective.

Yes. You know, we spend a lot of our, a lot of our time encouraging people not to calorie cow and thinking about flexibility with, with eating and, and paying less attention to, um, to, to things like calories and, and to have it there, you know, un unavoidable is, you know, it's, it's, yeah, it's definitely something that's really problematic from.

From our perspective, and, you know, I would question how helpful it is actually to, yeah. To, to most people. You know, I, I, I think that, that most people [00:44:00] who are struggling with obesity probably aren't, um, too worried about that. Hugely benefiting from, from knowing, knowing what calories are. Um, 

[00:44:09] Christina De Beukelaar: I think it's about the education.

You can put the, the numbers out there, but if you don't really know what to do with. . Yeah. Then how, how do you use them? It's, it's nutrients you're eating. It's not calories, and it's how do you, how do you, you need to teach people what foods, what different foods are and what a plate would look like. But also I think lots of the obese people have about 30% has disordered eating, so they've been struggling massively.

So then putting that extra pressure on. Will not benefit them at all. 

[00:44:48] Dr Paul Polyvios: Yeah. It, it feels to some extent, a way of going, there's this big crisis, we don't know quite what to do. Let's do this. Uh, this is doing something. Yes, putting calories on menus [00:45:00] will, will be, like I said, I found it very, very interesting to see, um, just how.

Rich. Some things are, and you think, my goodness. Yeah. That's why it's so nice, you know, but, but, um, I can see it's 

[00:45:12] Christina De Beukelaar: not, I think another really important part is those calories don't get used in calories in our body. We, we use them very differently than the number on, on there. And you need to take it with pinch of salts.

Okay. Um, so. , luckily, . Fair enough. Otherwise we can't go out for burgers. Right. Yeah. , 

[00:45:35] Dr Paul Polyvios: it doesn't work that way. Okay. That's good to know. Actually, , um, 

[00:45:38] Dr Bryony Bamford: but you know, no, that, that knowledge is, is, is not well known, you know? No, I, I, I, I think it's a, um, I, you know, I think there will be, very little evidence that putting calories on menu knees is, is a helpful way of combating obesity.


[00:45:56] Dr Paul Polyvios: that's fair. Um, Do patients, [00:46:00] um, they can come and ask for a consultation here at any time. How does, how does the referral process work when you, 

[00:46:07] Dr Bryony Bamford: so most, most clients will self refer mm-hmm. . Um, some of course will be referred by their GP or referred by, um, a psychiatrist. Um, but a lot, a lot self-refer.

And, um, there will be a kind of initial intake, um, uh, Questionnaire that they complete just to, to make sure that it's sort of, um, just so we have their details and, um, and have some, um, some information about them. And then usually the first person they would see would be a clinical or counseling psychologist.

Not always. Um, sometimes they might specifically ask me with a dietician initially, or sometimes, um, it might be very difficult to get an appointment. Clinical psychologist. And so we might suggest an appointment, an initial appointment with a dietician. Um, but there will always be an, an assessment, [00:47:00] which would be an assessment of what's going on for that client, an assessment of risk.

Um, you know, cuz of course if there's, if there's high risk, then we need to think about how we are responding to that level of. Risk and what we're putting in place to make sure that a client is safe. And then the development of a, a treatment plan, which might be just psychology or just dietetics, or it might be, you know, full m d t approach.

So it might be psychology plus dietetics, plus some family work, plus occupational therapy. So it, it will depend on, um, you know, that that initial assessment appointment and what you say occupational. . 

[00:47:36] Dr Paul Polyvios: Um, can I ask what, what, what they, because again, from a hospital Yeah. What background? Uh, that, that, that sounds surprising to me.

Sorry. Just, uh, what, what does the role of the OT do, uh, in, in this? So, so 

[00:47:48] Dr Bryony Bamford: OTs, you know, a specialist eating disorder, ot Okay. Will be very highly trained in. Working with eating disorders. Sure. So they will, um, likely have a, a lot [00:48:00] of, you know, so our, our wonderful OT here, um, is also trained in C B T and D B T and lots of therapeutic mm-hmm.

approaches. Mm-hmm. . But essentially it's a bit more of a kind of practical here and now approach. So if what someone needs is support and help with, um, Shopping, you know, food shopping or, um, cooking independently or even, you know, some here and now approach with anxiety management or, um, emotional coping tools.

It's, it, it, it's a very sort of, um, practical approach, practical supportive approach I guess. Whereas therapy often is, you know, a little bit more, digs a little bit. Deeply. Sure. Um, so OT can be incredibly valuable and it's something that often people won't consider as an as 

[00:48:53] Dr Paul Polyvios: available approach. Not something I would ever have, have thought as a, you know, to be dealing with, with eating disorders, but yeah.

Fair [00:49:00] enough. That makes, makes sense. So, . Um, and what, what advice do you have, uh, both of you for, for anyone listening who's worried either themselves or a parent or relative or friend, um, they, they're worried about someone with an eating disorder. What's your initial advice for them? 

[00:49:19] Dr Bryony Bamford: I, I think above everything.

Listen to that worry. You know, I think if you are a friend or a relative and you've, and you've gotta worry, you know, our gut instincts are often very, very valuable. And I think listen to that worry. Likewise, if you're worried about yourself, you know, we don't tend to be worried about ourselves for, for no reason.

So I think listen to that worry and know that there are places where you can. Support and that that support is supportive. You know, treatment isn't about doing something that's threatening or scary or unwanted. It's about finding the right support for you to enable you to live in a way that you would rather be living.[00:50:00]

[00:50:00] Dr Paul Polyvios: And, uh, what would you do? Um, so say you're a parent, worried about your child, and. You do raise it with, with them, but, um, sadly, there's. Conflict when that, when that happens and denial. Uh, it's as, it's something we, we've, we see in medicine quite a lot. Um, sometimes even with, with your elderly relatives or you want them to go to hospital and they, or you want them to cc help and they're, they're in completely di in denial about, uh, certain things and.

It can be hard and I dunno what you would do in a situation like that. 

[00:50:37] Dr Bryony Bamford: Um, I think that it's really useful to think about the way in which you're talking to people when you are talking to them, where you are talking to them, and I think to be very kind of considerate of picking the right. moments. Um, and not to be put off if there is a kind of un unwanted reaction, um, but to [00:51:00] keep trying to gently have that conversation.

I think also making sure that you are talking to them, not just about, let's say the food, but also thinking with them about, you know, h how are. feeling and how, you know, how are thing, how are they experiencing things? Cuz as I said, that eating disorder is always there as a response to something. Mm-hmm.

So people may be more willing to talk about stress or distress than they are to think about the food. Behaviors that they're, that they're using. 

[00:51:32] Dr Paul Polyvios: So not, not, not sitting someone down and be like, eat this. You know this. 

[00:51:36] Dr Bryony Bamford: Right, exactly. So I think it's really important to have those conversations really sensitively.

You know, not to, not to criticize, not to, um, not to attack or not to, not to go in sort of angrily. Um, but equally, I think it's, it is really important not to. You know, and, and lots of clients that I have seen will say things like, you know, no one, no one mentioned it. No one raised any [00:52:00]concerns. So I didn't think that it was a problem.

And, and the message that not expressing worry gives can be very damaging. So having those conversations, even if they're really difficult ones, even if they're painful ones, is really important. Doing your research, so, you know, where to get help and what that help might look like and how to access that help so that you can go with some ideas is also, 

[00:52:26] Dr Paul Polyvios: yeah, really helpful.

And Christina, what would you, uh, look for in, in a household? For example, say if, if you are worried. parent or relative or or friend, and you start noticing certain habits about someone or even yourself as a, as a patient, what, what the initial things that you would start to pick up on in terms of eating habits.

[00:52:50] Christina De Beukelaar: So I think cutting things out, saying, I'm not gonna have sugary stuff, or I'm not gonna have carbs, or skipping dinner [00:53:00] or, Noticing weight loss or noticing certain other behaviors? Um, I think again, there're making sure you talk about it. You sit next to them in the evening and just have a chat about stuff and, and try and open up some conversation.

But then again, not ignoring the fact that actually the food, the longer it goes. The harder it's gonna get. Um, and to almost say, can, can we work on a plan? Can we, can we think about something that I can support you with and I'll be home for this or that? Or do you want to try this? Um, do you wanna sit together at dinner time?

We haven't had dinners together for, for a long time. You know, they're, they're not gonna want to do that, but, , if you're there and you're around and you're there, 

[00:53:56] Dr Paul Polyvios: yeah. Is does the family dinner table, [00:54:00] which is becoming, dare I say, slightly rarer as time's going on, have you found that? Is this a, does this make a big difference to, um, the demographic or is it not really a thing?

[00:54:13] Dr Bryony Bamford: I, I think from a treatment perspective, Family involvement and family support, especially for children and young people. Is hugely, hugely, hugely beneficial and important. You know, children can't do this on their own. They're, they're overcoming a, an incredibly powerful phobia and, and, you know, mental health condition, you know, it's not something that children can or should be expected to do on their own.

So at that point, yeah, family, family involvement, family support, family dinners are, are really, are really important. Yeah, 

[00:54:46] Dr Paul Polyvios: no, fair enough. Um, and where can people find, Information about eating disorders. They've got concerns, where can we, uh, send them to? 

[00:54:55] Dr Bryony Bamford: There's a really good, um, national eating disorders charity called beat, which has a [00:55:00] lot of information, um, on their website.

There's also lots of really, really good local eating disorder charity. So I always think that's a really good place, um, to start all. Um, All gps should be aware of kind of what the local NHS provision is. But, um, most trust there will be a specialist eating disorder team. Of course, we all know that the waiting lists are very, um, you know, very, very long at the moment.

But, um, but certainly an initial conversation with the GP is a, is a really good place to start as well. Or, um, you know, or, or private clinics like, like our. Um, just doing some research into what, what's available around 

[00:55:43] Dr Paul Polyvios: you. Amazing. Thank you very much. And, uh, so Bryony and Christina, thank you and thank you all for listening.

Please do check the podcast description for links to the London Center. And if you are worried about needing sorter, please do ensure you seek medical help as soon as possible from your GP or family [00:56:00] doctor. And if you're enjoying the show, please don't forget to follow the feedback on your podcasting platform.

And as always, please look after yourself. I'm Dr. Polyvios. Goodbye. 

[00:56:09] Christina De Beukelaar: Thank 

[00:56:09] Dr Bryony Bamford: you. Thank you.