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Restrictive Eating Disorders in the Outpatient Setting: Assessment, Diagnosis, and Treatment Eliana M. Perrin, MD, MPH Warning: Scary pictures coming up Bodies get extremely skeletal with anorexia nervosa Organ systems break down in the face of starvation • • • • • • Musculoskeletal Cardiac GI Neuro Endocrine Hematological Whatever the cause... • Anorexia nervosa is the psychiatric illness with highest mortality – mortality approximately 5-10% for anorexia nervosa – 10-15% develop a chronic unremitting course – post-hospitalization relapse rates 30-50% • We know little about the mortality of bulimia – relapse rates seem to be high How can we best care for these patients? • Prevent the problem in the first place? • Screening/ early recognition /diagnosis • Outpatient Management • Inpatient Management (discussed a different time) In well-child encounters, work on prevention Recognize that your patients are in a push/pull “toxic” food environment Make discussions of weight as sensitive as possible; focus on health-promoting behaviors For early recognition/diagnosis, when should we be thinking about eating disorders? When there is worry from family members or friends When the epidemiology makes sense When the genetics makes sense Specific Presentations Any time there is weight loss in an older patient. The role of the primary care provider… • Screen patients at risk • Recognize eating disorders and rule in or out other similar presentations and reasons for weight loss • Initiate appropriate early treatment and frequent follow up • Know when you are in over your head and ask for help Take a history • Ask open-ended questions (privately, with concern, directly, and use collateral sources) – – – – – – – – – Loss of menses? Cold hands/feet? Dry skin? Constipation? Tired or fatigued? Headaches? Fainting or dizziness? Abdominal distension? Psychiatric symptoms (depressed mood, self harm ideation and behaviors, anxiety) – Substance use Ask screening questions (from AAP) • Weight history (most, least, desired) • Body image • Exercise (how much, how often, how intense, how stressed if you miss a workout) • 24 hour diet history • Calorie counting, fat gram counting, carbohydrate counting, taboo foods, skipping meals • Binge eating (frequency, amount—subjective and objective, triggers) • Purging history (or compensating for intake) • Use of diuretics, laxatives, diet pills, ipecac (elimination patterns, constipation, diarrhea) • Vomiting (how frequent, how long after meals) Another set of screening questions (from GAPS) • Are you satisfied with your eating habits? • Do you ever eat in secret? • Do you spend a lot of time thinking about ways to be thin? • In the past year, have you tried to lose weight, or control your weight by vomiting, taking diet pills or laxatives or starving yourself? Perform a physical exam • Height, weight (in a gown after voiding), BMI, % ideal body weight • Vital signs including orthostasis and temperature! (tells us medical toll of starvation or binge-purge cycle and helps rule in or rule out things on the differential) • Other key features Anorexia: Associated Features • • • • • • • • Dehydration Electrolyte imbalances Osteoporosis Lanugo hair Low body temperature Hypotension Bradycardia Growth retardation • • • • • • • • Obsessionality Cognitive impairment Depression Low self-esteem Extreme perfectionism Self-consciousness Self-absorption Ritualistic behaviors Physical findings Acrocyanosis Edema Hypercarotenemia Dull/brittle hair/nails Lanugo Bulimia: Associated Features • • • • • • • • Electrolyte imbalance Acid reflux Ruptures of esophagus Loss of enamel and dentin Swollen parotid glands GI complications Irregular menstruation Loss of normal bowel function • Depressed mood • Anxiety • Alcohol and drug • • • • • • abuse Low self-esteem Irritability Impulsive spending Shoplifting Sexual impulsivity Concentration/memory Bulimia • Bruises scratches on palate/ posterior pharynx • Subconjunctival hemorrhage • Salivary parotid gland enlargement • Dental enamel erosion (lingual) • Calluses on knuckles (Russell sign) Screening laboratory evaluation for eating disorders • • • • • • • CBC ESR T4/TSH Prolactin/FSH/LH Pregnancy test UA Stool for occult blood/LFTs/Amylase/Lipase • Chemistry panel, albumin, • EKG (including QTc) Differential diagnosis • Gastrointestinal (malabsorption, irritable bowel/Crohn’s Disease, ulcers, tumors, achalasia, celiac) • Endocrine (hyperthyroidism, Addison’s, hypopituitarism, diabetes mellitus, pregnancy) • CNS- hypothalamic tumor • Other malignancies/infections • Psychiatric (depression, OCD, drug use, conversion disorder, schizophrenia) Once you know you have a patient with an eating disorder That day (after history, PE): • Draw labs (CBC, chem 10, UA, TFTs, ESR) • Get EKG if bradycardic, syncopal, or electrolyte problems • Communicate seriousness of condition to patient and family • Draw up contract for patient? • Arrange for consultations and team approach • F/u in 3 days for longer visit, then twice weekly, then space apart if improving Basic Principles for Treatment • Be sensitive to psychiatric disease • Engage a team approach- there are parts best accomplished by people other than you • Feed the patient-- but not too fast • Monitor weight, UA, and vital signs at each visit • Help pts. gain weight--but not too fast… • ... Know the weight you’re shooting for • Watch for “re-feeding syndrome” • A starving body should rest • Watch for cardiac pitfalls Remain sensitive to the underlying psychiatric disease • Staff/ MDs should show neutral response to weighing • Do NOT discuss dieting, looks in any way--not even to say patients look better • Remember they are not trying to be manipulative Engage a team approach • • • • • • Parent Nurse Mental health professional Nutritionist Coach Specialist Your role is to assure physical safety, communicate with family and team, carefully follow up, and refer if necessary Feed the patient-- but not too fast • Be wary of the patient who is getting less than 700 calories per day-- add no more than 500 calories for first day. • Advance slowly according to sliding scale - typically you will need to increase 200-300 calories every 4 days or so. Monitor weight and vital signs • Assess height, weight, BMI, % IBW, temperature, HR, BP, orthostatics • Weight and urine protocols • Monitor patient frequently until attaining target weight Know the weight you’re shooting for • Figure out % IBW: figure out 50% BMI by age/gender & figure out patient’s BMI & make fraction or % out of it. • Pt’s BMI = 15 • 50 % BMI = 20 • 15/20 or 75% IBW Approximate % IBW < 60% IBW < 75% IBW < 80% IBW Watch for “Refeeding Syndrome” • Metabolic & physiologic consequences of the depletion, repletion, compartmental shifts and interrelationships of phos, K+, Mag, glucose metabolism, vitamin deficiency, & fluid resuscitation A starving body should rest • Inpatient-bed rest • Outpatientexercise restriction • Behavioral contract to be allowed to exercise more frequently Watch for cardiac pitfalls! • When patient is bradycardic, has significant orthostasis, syncope, or an extremely low BMI (less than or = to 13): check QTc! • Long QTc can be precursor to Toursades de points When to refer When to Refer • When you have engaged a team approach and you aren’t making progress or when the disease process is life threatening OPTIONS here at UNC: Intensive outpatient at UNC (or Duke) Partial hospitalization at UNC Inpatient pediatrics – medical complications Inpatient Eating Disorders Unit AAP Inpatient criteria-eating disorders • <75% IBW, or ongoing weight loss despite intensive management • Refusal to eat • Body fat <10% • HR <50 daytime; <45 nighttime • Systolic BP <90 • Orthostatic pulse (>20 bpm) or BP (>10 mm Hg) • Temperature <96°F • Arrhthymia- prolonged QTc • Syncope AAP Inpatient Criteria- (Continued) • • • • • • • • Serum K concentration < 3.2 mmol/L Serum Cl concentration < 88 mmol/L Esophageal tears Cardiac arrhythmias --prolonged QTc Hypothermia Intractable vomiting Hematemesis Syncope APA Inpatient Guidelines For adults: Heart rate <40 bpm Blood pressure <90/60 mm Hg Glucose <60 mg/dl; potassium <3 meq/L; electrolyte imbalance Temperature <97.0 °F Dehydration; or hepatic, renal, or cardiovascular organ compromise requiring acute treatment. APA Inpatient Guidelines For children and adolescents: Heart rate in the 40s Orthostatic blood pressure changes (>20-bpm increase in heart rate or >10-20-mm Hg drop) BP < 80/50 mm Hg Hypokalemia or hypophosphatemia Best Practices Treatment Guidelines • American Psychiatric Association • http://www.psych.org/psych_pract/treatg • American Academy of Pediatrics • Identifying and Treating Eating Disorders PEDIATRICS Vol. 111 No. 1 January 2003 • NICE guidelines (UK) • http://www.nice.org.uk The end….