eating disorders - medicine for psychiatrists · 2017-05-30 · epiphyses, advised to lose weight...

EATING DISORDERSMedical Assessment & Management

Dr Raewyn Gavin

Dr Louise Webster

Auckland - March 2015

Review Definition and Epidemiology

Medical Complications

Medical Risk Assessment

Children vs Adults

Psychiatric Comorbidity

Cases

OVERVIEW

Persistent restriction of energy intake leading

to significantly low body weight.

Intense fear of gaining weight or persistent

behaviour that interferes with weight gain.

Disturbance in the way one's body weight or

shape is experienced

Subtypes:

- Restricting type

- Binge-eating/purging type

DSM V - AN

Recurrent episodes of binge eating.

Recurrent inappropriate compensatory behaviour to prevent weight gain (self-induced vomiting, laxative abuse, diuretics, enemas, exercise etc.)

Behaviours both occur, on average, at least once a week for three months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

DSM V - BN

Disordered eating behaviour which does not

meet all criteria for AN or BN

Not less severe

Biggest group

EDNOS

AN 0.3% (0.4% teenage girls)

Lifetime 1.4 – 2.2%

~33% will receive care for AN

BN 1%

Lifetime 4 - 7%

~6% will receive care for BN

EDNOS 2.3% of young females

PREVALENCE (UK)

Re-feeding syndrome

Renal

Haematological

Cardiac

GI

Bones

Gynaecological

Endocrine

Cognitive & psychological

Other

MEDICAL COMPLICATIONS AN

Starvation:

↓ carbohydrate intake

↓ insulin secretion

Energy from fat & protein catabolism

Intracellular loss of electrolytes

Intracellular phosphate can be low despite normal serum phosphate

Re-feeding:

Shift to carbohydrate metabolism

↑ insulin secretion

Phosphate moves from serum into cells

Can cause rapid ↓ serum phosphate

RE-FEEDING SYNDROME

Phosphate needed for crucial phosphorylation reactions – e.g. generating ATP from ADP etc.

Early signs often subtle

Occurs within 4-7 days re-feeding

As well as low phosphate may get:

↓ magnesium

↓ potassium

↓ glucose (most likely if long periods between meals)

RE-FEEDING SYNDROME

Rhabdomyolysis

Oedema

Respiratory failure

Cardiac failure

Arrhythmias

Hypotension

Delirium

Seizures

Coma

Sudden death

EFFECTS OF SEVERE ↓PO4

Prophylactic phosphate supplement if planning to significantly increase intake(Phosphate sandoz – one tablet twice daily)

Reintroduce feeds at approximately half expected daily requirement

Monitor bloods closely in 1st week

Can increase feeds quickly to 100% if monitoring closely (beware under-feeding)

Consider thiamine 50 mg bd (or multivitamin containing thiamine) if long history

PREVENTING RE-FEEDING SYNDROME

Dehydration → pre-renal

Nephrocalcinosis (risk of kidney stones)

Polyuria (↓ ability to concentrate urine)

Usually resolve with improved nutrition

NB: Expect creatinine to be low because of ↓ muscle mass

RENAL COMPLICATIONS

Haematological: Anaemia (often macrocytic)

Neutropenia – 25%

Thrombocytopenia - 5%

Due to bone marrow atrophy with deposition of gelatinous material.

Cardiac: Arrhythmia due to electrolyte imbalance

Bradycardia

Prolonged QT interval

↓ ventricular mass

Mitral valve prolapse

COMPLICATIONS

CTR 35%

Constipation (very common) – supervised treatment

Intestinal dilatation & delayed gastric emptying (↓ gut motility) – feeling of gastric fullness very common.

Abnormal liver function (AST, ALT)

Gall stones

Pancreatitis

GI COMPLICATIONS

↓ bone density 2° to:

↓ oestrogen

↑ cortisol

malnutrition

1/3 bone mass achieved during puberty

↑ risk osteoporosis later – esp if delayed recovery

30-50% have osteopenia >10 years later despite full recovery

BONE HEALTH

Total Body

Lumbar Spine

Z score

Osteopenia = -1.0 - -2.5

Osteoporosis = <-2.5

Body Composition

(% body fat)

BONE DENSITY SCAN

Z score -2.9

Important to aim for recovery by age 18 -20, the

years of maximal bone density accrual.

Best treatment of low bone density in younger

age group is weight restoration (body fat)

Remember Vitamin D

Hormone supplements controversial

Nutritional improvement preferred

Variable response in bone density

BONE HEALTH CONTD;

Gynae / Fertility:

Delayed menarche

2° amenorrhoea (regular menses never return in ~25%)

↑ risk pregnancy complications (miscarriage, LBW, etc.)

↓ response to fertility treatment

Endocrine:

↑ Cortisol

Sick euthyroid with low T3

Abnormal insulin secretion

COMPLICATIONS

Cognitive: Cortical atrophy & ↑ ventricle size

Significant long term deficits if remain amenorrhoeic

Weight & oestrogen have independent effects on brain.

Short term memory, focus and attention, spatial skills & cognitive flexibility

Are they fit to drive?

Psychological: 50-75% depression or low mood

60% anxiety

- ? secondary to weight loss (reverses with weight gain)

- ? pre-existing

Loss of ‘personality’ & sense of humour

COMPLICATIONS

Hair Loss – non-essential use of protein

Lanugo hair

Dry skin

Carotenaemia

Hypercholesterolaemia

Patulous eustachian tube

Parotid swelling (purging)

Dental erosions (purging)

OTHER

Average duration of illness = 5-6 years

~50% full recovery (all ages). Up to 80% adolescents

Adolescents with AN (US study)

At 3.5 years :

75% excellent or much improved

Mean weight = 94% IBW

79% females menstruating

Most = good social & educational functioning

PROGNOSIS AN

Mortality ~5%

Highest mortality of all psychiatric disorders

Predictors of mortality (adults) BMI < 13 (BMI < 11 = risk)

Prolonged QT interval

Low serum albumin

Long duration illness

Poor social adjustment

↑ risk suicide (22% make at least one attempt)

~50% from medical complications

~50% suicide

Death is usually sudden, can look well

MORTALITY

Higher risk rapid medical deterioration

Risk of potentially irreversible effects on

physical and emotional development

BMI less useful, can be normal

Linear Growth

Pubertal Delay

Better prognosis (unless onset < 10 years)

CHILDREN vs ADULTS

Ideal weight is a

moving target.

Especially if still

growing but even if

not.

BMI naturally

increases with age .

GROWTH

Weight

Height BMI

Eating Disorder symptoms and behaviour

Weight information

Medical parameters

Bloods

Re-feeding risk

Ongoing risk monitoring

Long term risk

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MEDICAL RISK ASSESSMENT

Good information - weight & growth history

Calculator and BMI centile chart

Good clear communication with GP who will

be monitoring your patient.

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WHAT YOU NEED

Medical Risk Increased if:

Low weight and purging

Multiple forms of purging (laxatives and diuretics)

Excessive exercise

Look for inconsistency between history and objective evidence

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ED SYMPTOMS AND BEHAVIOUR

Medical Risk Increased if :

Rapid weight loss > 4kg in 6 weeks

Loss 15-20% of body weight in 3 months,

regardless of BMI

<2nd percentile BMI,<80% wt for ht

Lower BMI usually means more risk but depends

on rapidity of loss and other medical factors

Height gain but no weight increase

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WEIGHT INFORMATION

Weight/height/BMI

Blood pressure lying and then standing

Pulse rate lying and standing

Temperature

Hydration

Muscle strength

Duration of amenorrhoea

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MEDICAL PARAMETERS

Hypotension: BP less than 80mmHg systolic < than 75mmHg (adults)

Postural drop in blood pressure > 20mmHg (take BP lying and then after standing for 2 min)

Bradycardia = HR < 50 beats per minute < 40/min (adults)

Increased heart rate of more than 20-30 beats per minute on standing after lying down

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BLOOD PRESSURE AND PULSE

Arrhythmia/palpitations

Fainting

Dizziness

Chest pain

Consider ECG if bradycardic or other cardiac

symptoms. Check QTc and PR interval. If ECG

abnormal needs medical review

Helpful tips about ECGs can be found online at ‘ECGpedia’ http://en.ecgpedia.org/wiki/Main_Page

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OTHER CARDIAC SYMPTOMS

Hypothermia: body temperature taken orally less than 35.5 C

less than 35.0 (adults)

Severe dehydration – dry lips, mouth, skin,

sunken eyes, difficulty taking blood

Inability to rise from chair or squatting

position without use of hands (or SUSS test)

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TEMPERATURE, HYDRATION, MUSCLE

STRENGTH

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Full blood count

Electrolytes: Na, K, Mg, Phosphate, Calcium, bicarbonate

Kidney function tests, creatinine and urea

Glucose

Liver function tests including albumin

Thyroid function tests

Hormonal levels (oestradiol most useful)

Iron, Vit B12 and red cell folate

Vitamin D

INITIAL BLOOD TESTS

Potassium (K+) low due to vomiting and laxative use.

If below 3.0 mmol/l need urgent medical review

If below 2.5 mmol/l especially with ECG changes; can be life threatening.

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POTASSIUM

Low sodium can indicate water loading

Low Magnesium - risk of arrhythmias

If Mg low - always indicates deficiency. Often due to

vomiting, laxative/diuretic use.

Low Phosphate – indicator of re-feeding syndrome,

need to treat and consider hospital referral.

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SODIUM, MAGNESIUM, PHOSPHATE

Significantly elevated levels of bicarbonate

(more than 35 mmol/l) are often correlated

with purging

Monitor potassium closely if bicarbonate

elevated and vomiting or laxative use

suspected

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BICARBONATE

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Quick Reference Table (<18 years)

Body

System

Test or measure Warning

Parameter

Intervention if Within the Warning Parameter

Circulation Systolic BP (top number) <80 Monitor, check postural drop, assess hydration

Postural drop (lying-stand) >20 Check hydration, consider admission

Pulse rate <50 bpm get ECG and consider hospital admission

Temperature Oral if possible < 35.5

degrees

Need to keep warm, and increase food intake, restrict activity levels

and outings

Blood result Potassium <3.0

<2.5

Ask about vomiting and laxative use, ECG, medical review

Urgent medical review, hospital admission needed

Sodium < 135 Check for potential water loading, ask parents to monitor this

Magnesium < 0.75 Ask about vomiting or laxative use, needs treatment

Bicarbonate >31mmol Check for purging especially if > 35

Phosphate <0.7 Treat. Monitor regularly, if refeeding may need daily checks, refer

Creatinine Upper range of

normal or

>90

Suggests renal impairment, dehydration and/or muscle

wasting/weight loss

Quick Reference

Guide (Adults)

Assess ED behaviour change weekly

Assess weight weekly - if dropping need to check bloods (frequency depends on rate of loss and BMI%)

If at high risk of re-feeding consider hospital admission for medical stabilisation

Check medical monitoring is occurring and providing the information you need

Think about – should they be at school, playing sport, driving, travelling overseas?

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ONGOING MONITORING

WHAT FACTORS CAN OBSCURE AN EATING

DISORDER?

Prior obesity with rapid weight loss

Other comorbid psychiatric disorders

Other comorbid medical disorders

Family and patient denial

14 YEAR OLD

Presented with a history of:

40 kg weight loss over 2 years

Restricted food intake

Excessive exercising

Low irritable mood.

Secondary amenorrhea for 1 year

Medically unstable:

Pulse rate below 38/min

Hypotensive

Peripherally shut down

Weight = 63 kg

PAST 3 YEARS

2012 aged 12 years, surgery for slipped femoral

epiphyses, advised to lose weight (weight = 103 kg)

Multiple appointments for myringoplasties

Recurrent presentations 2013 to GP with collapses

Investigated by Cardiology Service 2014 after a

collapse, heart rate down to 38/min on Holter

monitor

Diagnosed Fe deficiency and Vasovagal syncope

(weight = 78 kg)

WEIGHT PERCENTILE FOR AGE

HEIGHT PERCENTILE FOR AGE

BMI PERCENTILE FOR AGE

PSYCHIATRIC COMORBIDITY

Depression

Anxiety

Borderline Personality Disorder

Drug and alcohol abuse

Somatoform disorders

18 YEAR OLD

Long history of low mood, social phobia, mood

instability and deliberate self harm

Trials of SSRIs, CBT, attending a DBT group

Presented after seeing GP for a chest infection and

GP noted weight loss

No record of weights in treating mental health

services.

Disclosed 2-3 year history of vomiting and food

restriction, initially as part of attempted affect

regulation

13 year old girl

Identical twin

Born prematurely

Onset of symptoms 12yrs

Teased about pre-adolescent chubbiness

Healthy eating

Rep netball team

School council

Twin issues

CASE PRESENTATION - LS

Weight 1 year prior = 68kg

As weight ↓, more & more driven and obsessed by weight.

Last 4 months low mood, low energy, anxious

Weight loss 23.5 kg in 1 year (35% of body wt)

No periods last 2 months (?more)

Exercising 1-2 hours per day

No purging

Fluid restricting

LS

GROWTH CHART - WEIGHT

GROWTH CHART - HEIGHT

GROWTH CHART - BMI

OBSERVATIONS

Temp = 35.4

Heart Rate = 38/min

BP lying = 138/92

BP standing = 96/55

Dehydrated

ELECTROLYTES

FULL BLOOD COUNT

16 years old

Age 9 meningitis → chronic headaches

(Topiramate)

Last 2 years – chronic abdominal pain

Extensive investigation

Seen by several specialists

GP prescribed multiple alternative therapies

Tried various exclusion diets

Weight loss of 20kg in 1 year

HC

2 admissions to hospital

Evidence of laxative abuse

3rd admission Xmas Eve

Pitting oedema to knees

Heart Rate = 33/min

BP and temp normal

Rapid fluctuations in weight

Hyponatraemia

Abnormal liver function tests

HC

Nutritional supplements

Alternative therapies

Liquorice tea!

Athletes

BE AWARE OF:

SUPPLEMENTS

Is there any side effects?

Garcinia Cambogia is very well tolerated by the body.

CDC Weight, height and BMI centile charts

http://www.cdc.gov/growthcharts/clinical_charts.htm#Set2

Starship Clinical Guidelines

https://www.starship.org.nz/for -health-professionals/starship -cl inical -guidel ines/a/anorexia /

Marsipan Guidelines (UK – 2nd edition Oct 2014)

http://www.rcpsych.ac.uk/pdf/CR189_a.pdf

Junior Marsipan Guideline

http://www.rcpsych.ac.uk/files/pdfversion/CR168nov14.pdf

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ONLINE RESOURCES

“FOOD IS AN IMPORTANT PART OF A

BALANCED DIET”- FRAN LEBOWITZ