Intended for healthcare professionals

Practice What Your Patient is Thinking

Please see the whole picture of my eating disorder

BMJ 2021; 372 doi: (Published 06 January 2021) Cite this as: BMJ 2021;372:m4569
  1. James Downs
  1. @jamesldowns
  2. jamesldowns{at}

James Downs explains how the physical and psychological impacts of eating disorders need to be treated and supported through an integrated approach.

Unexplained symptoms

For many years I experienced episodes following binge eating and vomiting where I felt clammy, dizzy, and disorientated. At worst, I experienced palpitations and difficulty speaking, standing, or even staying conscious. I had reported these symptoms to GPs and eating disorders services repeatedly for more than a decade. Often, it was suspected that my potassium was low. But when my potassium levels were restored and my symptoms continued, I knew something else was going on.

Blood sugar was never mentioned to me until by chance I described my symptoms to a psychiatrist I work with. Immediately she suggested I check my blood sugar. I ordered a glucometer and took a reading the next day when I was having symptoms: 2.4 mmol/L—a diabetic emergency.

Understanding the physical impact

This revelation left me feeling angry, but also relieved that I could understand what had been happening to me for so long. With all the psycho-education, treatment, and contact with specialist services I’d had, nobody had explained the specific impacts of bulimia nervosa on my blood sugar levels. This left me with so many questions. I was also worried about the risks and long term impact of erratic sugar levels.

With a little research—and tapping information from Twitter’s medical communityI now understand how the body responds to eating vast quantities of food and then vomiting. Being able to check my blood sugar levels has changed everything. In one sense, it’s helped me to understand what’s been happening to me for such a long time. I feel empowered by this knowledge, and the fact that I can monitor my glucose in real time and respond to and prevent hypos the best I can.

Taking an integrated approach

In my experience, psychiatric conditions also have physical components. Eating disorders are rooted in, and experienced via physiological processes. Yet all too often, I felt like the component parts of my eating disorders are treated in a fragmented way. From the thinking processes that need to be addressed psychologically to the abnormal blood test results that can indicate a physical risk. This leaves me feeling frustrated or alienated at best, at significant risk of harm at worst.

To support the needs of patients with eating disorders healthcare professionals should consider how eating disorders are made up of physiological, metabolic, psychological, and social components that work in synthesis. Some elements of your patient’s difficulties you can help with, and by treating what is in your remit you can make a meaningful difference. Listening to a patient’s experiences and being curious about their symptoms, without assuming what eating disorders look like, will open the door to helping your patients understand and manage their symptoms. And with the right support, it may lead them towards recovery.

What you need to know

  • The physiological and psychological aspects of eating disorders are interconnected

  • Always consider the impact of low blood sugars on people with eating disorders

  • Informing patients of the physiological impact of eating disorders can empower them

Education in practice

  • How can you ensure you are supporting patients with both the physiological and psychological aspects of their condition?

  • What information could you share with patients to help them understand the physiological impact of their health condition?

  • Where might you find support for a patient who is struggling with an eating disorder?


  • Competing interests: none declared.

  • Provenance and peer review: commissioned; not externally peer reviewed.