Identifying and Treating Eating Problems in Primary Care ...

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Identifying and Treating Eating Problems in Primary

Care Practice

Dr. Kathleen Pajer, M.D., M.P.H.Co-Director Project ECHO® Ontario CYMH, Psychiatrist Hub Specialist

Thursday, December 20, 2018


Faculty and/or presenter disclosure

• Presenter: Dr. Kathleen Pajer, Project ECHO® Ontario CYMH

• Relationships with commercial interests: not applicable

• Disclosure of commercial support: not applicable

• Conflict of interest: none for this session

• Mitigating potential biases: not applicable


Learning Objectives

At the end of this presentation, participants will be able to:• Describe two eating problems in infants and children.• Name one instrument that can help identify a youth with an eating disorder.• List three features of a medical work-up for a patient with a suspected eating

disorder. • Identify three interventions that a primary care provider can initiate or

participate in.


Q1. Eating Disorders in young people are associated with a slightly higher mortality rate than non-affected same age peers.

a) True

b) False

Q2. One of the best things you can say to a young person with eating problems is: "Wow! You've gained some weight!"

a) True

b) False


Joe is 3 ½ YOA; his mother brings him in because “he won’t eat”.A single mother, she says he will only eat boxed macaroni andcheese, fast food hamburgers and fries, and candy. If she tries tomake him eat regular food, he screams and throws the food ather. She is a nurse who often works double shifts. Joe is cared forby his grandmother, a total of three teenage girls at differenttimes, and visits his father for a weekend every month.

Alexa, 16 YOA who has been a patient of yours since she was born. Onher last annual check-up, she was in the 85th percentile for weight and50th percentile for height. You counseled her about the importance ofhealthy living, with good food choices and more physical activity. Thisyear, she is at the 50th percentile for height and 40th for weight. Uponquestioning, she says she lost the weight over the last three months bydoing intermittent fasting and is very happy now.

Cases


• Pica

• Rumination Disorder

• Avoidant/Restrictive Food Intake Disorder

• Anorexia Nervosa

• Bulimia Nervosa

• Binge-Eating Disorder

Feeding and Eating Disorders


25-40% of primary care practice patients have feeding problems.

3-10% of kids refusing to eat persist witheating problems.

Eating Problems in Infants and Children


Causes Examples

Structural Abnormalities

• Abnormalities of the naso-oropharynx: choanal atresia, cleft lip or palate, Pierre-Robin sequence, macroglossia, ankyloglossia

• Abnormalities of the larynx and trachea: laryngeal cleft, laryngeal cyst, subglottic stenosis, laryngo-tracheomalacia

• Abnormalities of the esophagus: tracheoesophageal fistula, congenital esophageal atresia or stenosis, esophageal stricture, vascular ring

Neurodevelopmental Disabilities

• Cerebral palsy• Arnold-Chiari malformation• Myelomeningocele • Familial dysautonomia• Muscular dystrophies and myopathies• Möbius syndrome • Congenital myotonic dystrophy • Myasthenia Gravis • Oculopharyngeal dystrophy

Behavioural Feeding Disorders

• Feeding disorder of state regulation (0-2 months) • Feeding disorder of reciprocity (2-6 months) • Infantile anorexia (6 months – 3 years) • Sensory food aversions • Feeding disorder associated with concurrent medical condition • Posttraumatic feeding disorder

Bernard-Bonnin A-C, Can Fam Physician, 2006

Causes of Early Feeding Disorders


Core Elements of Feeding Problems Assessment

1. How is the problem manifested?

2. Is the child suffering from a disease?

3. Has weight, height or other development been affected?

4. What is the emotional climate during mealtimes?

5. Are there new or major stressors in the family?


Early Childhood Feeding Problems Assessment: Details1. Medical History, including description of problem with onset, duration and conditions.

2. Physical Exam, Lab, Tests a) Swallowing problem? Look for anatomic problems. b) Recurrent pneumonia? Think aspiration. c) Vomiting, diarrhea, colic? Think GERD or food allergy. d) No specific labs for general assessment. e) Labs for specific hypotheses, e.g. celiac.

3. Psychosocial History and Exam a) Check for maternal depression. b) Ask about domestic violence, but chaos can also produce severe stress. c) Parent/sibling history of feeding/eating problems. d) Major life stressors, e.g. immigration (from where?), moves, job loss, sibling or parent

illness, divorce/marital problems. e) Observe parent-infant/child interaction in office, e.g. reciprocity, eye contact,

parental attentiveness to needs, parental discipline style.


Strategies for Behavioural Causes for Feeding Problems

Strategy Example Scheduling • Regular mealtimes; only planned snacks added.

• Mealtimes no longer than 30 minutes.• Nothing offered between meals except water.

Environment • Neutral atmosphere (no forcing of food). • Sheet under chair to catch mess.• No game playing. • Food never given as reward or present.

Procedures • Small portions.• Solids first, fluids last.• Self-feeding encouraged as much as possible. • Food removed after 10-15 minutes if child plays without eating. • Meal terminated if child throws food in anger. • Wiping child’s mouth and cleaning up occurs only after meal is

completed.

Bernard-Bonnin A-C, Can Fam Physician, 2006


Eating Disorders: Did You Know?

Lifetime prevalence, 13-18 YO = 2.7%


Eating Disorders in Older Kids: Environmental Factors


Most Common Eating Disorders in Older Kids

Diagnosis CriteriaAnorexia Nervosa

• Restriction of energy intake relative to requirements leading to significantly low weight.

• Intense fear of gaining weight or persistent behaviour that interferes with weight gain.

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

Bulimia Nervosa • Recurrent episodes of binge eating. • Recurrent inappropriate compensatory behaviours to prevent weight gain, e.g.

purging. • Self-evaluation unduly influence by body shape and weight.

Binge EatingDisorders

• Recurrent episodes of binge eating. • The binge eating is not associated with recurrent inappropriate compensatory

behaviours as in bulimia nervosa .

From: Men, Muscles & Masculinity: The General Practitioner and the Male Experience of Body Dissatisfaction, University of Sydney


Screening for Eating Disorders in Older Kids Client Name:_____________________ Client DOB: __________

Eating Disorder Screen for Primary

Care (ESP)1

YES NO

1. Are you satisfied with your eating patterns?

2. Do you ever eat in secret?

3. Does your weight affect the way you feel about yourself?

4. Have any members of your family suffered with an eating disorder?

5. Do you currently suffer with or have you ever suffered in the past with an eating disorder?

* A “no” to question 1 is considered an abnormal response.

** A “yes” to questions 2-5 are considered abnormal responses.

Any abnormal response indicates that client needs further assessment.

Please contact:

Casey Becker, LMHC Mended Wing Counseling, LLC 930 E. Brainerd St. Pensacola FL 32503 www.mendedwingcounseling.com (617)797-7949 [email protected] Client referred by :________________________ Contact number: ____________ Four Simple Questions Can Help Screen for Eating Disorders. M Cotton, C Ball, P Robinson. J Gen Intern Med. 2003 January;

18(1): 53–56. doi: 10.1046/j.15251497.2003.20374.x

Score of > 2 is positive.


If ESP is positive… DAWBA

http://dawba.info/py/dawbainfo/b1list.py?language=English


Ask about: • History of weight fluctuations; low weight/high weight, desired weight• Actions taken to maintain, control or alter weight • Dieting • Laxatives, enemas, diuretics, appetite suppressants, supplements • Vomiting• Excessive exercise • Period of binge eating or feeling a lack of control over food intake • Comfort with current weight/shape • Report of typical daily food and water intake • Exercise habits (how much? How often? Why?) • Menstrual history • Family history of eating disorders, depression, obesity, and chemical dependence

Interview Pointers


• Amenorrhea • Reflux/regurgitation• Chronic constipation• Elevated creatinine • Metabolic disturbance

• Elevated amylase • Bradycardia • Syncope• Dehydration• Hypoglycemia

Consider Eating Disorder for Patients With…


Early Identification

Medical Management

Medical Monitoring

Networking& Advocacy

From: CWEDP, Putting Eating Disorders on the Radar of Primary Care Providers, 2010


Early Identification

• Rule out other metabolic conditions.• Frequently plot growth chart data.• Provide support to child/youth, assess stress

management/coping skills.• Diagnose comorbid conditions (also use FH). Treat diagnosed

psychiatric comorbidities.• Ask parents to keep food diary. • Ask patient/family about family eating patterns and social

environment at meal times.• Develop coaching relationship with parents, children/youth.


What Do I Say?“Re-nourishment seems to have helped you think more clearly.You can talk to me if you need to.You should be proud of yourself for taking these steps.”

“It’s not your child fighting you – it’s the illness.How are you taking care of yourself? Let’s make some plans.You may have to take more control of her/his meals for a bit.”

“Wow! You’ve gained some weight!You’ll grow out of this.If you aren’t careful, you’ll wind up back in the hospital.”

“You should have brought her in sooner.People with eating disorders are very manipulative.Just try cooking foods she likes, she’ll start to eat.”


Medical Management


Medical Monitoring


Networking & Advocacy

1. PCPs can identify eating problems and disorders.

2. They can support patients/families and work to stabilize a child or youth.

3. Next level of care is to create a virtual care network. a. MHC outpatient providersb. Local hospital providersc. Tertiary care MHC providers

4. Know when and how to advocate for hospitalization.

5. Set up clear protocols with tertiary or secondary care providers for taking child/youth back into care for monitoring and management.


Indications for Hospitalization: Children and Adolescents

Adapted from Society for Adolescent Medicine Position Paper (2003) & APA Practice Guideline for the

Treatment of Patients with Eating Disorders (2006)


You explain to Joe’s mother that eating problems can sometimes be due to a child’s stress level and also due to how she reacts to his behaviour. You suggest the interventions discussed on the behavioural causes of eating problems slide, e.g., set meal times and small portions of new foods. You also suggest that she schedule time to be with him cuddling, playing, or reading every day. When they return two months later, his anger has decreased and he has tried 3 new foods.

You acknowledge that Alexa took you seriously about living at a healthier weight, but explore what she means by intermittent fasting. She doing it in a way recommended by nutritionists, but you explain effects of long-term or too frequent fasts in a week, also noting that she won’t be in a healthy weight range if her percentile drops any more. Her ESP score is 0 and you ask what her eating and activity plans are now that she is happy with her weight. You offer referral to a nutritionist and a follow-up appointment. Three months later, she returns and her weight is stable.

Cases


Q1. Eating Disorders in young people are associated with a slightly higher mortality rate than non-affected same age peers.

a) True

b) False

Q2. One of the best things you can say to a young person with eating problems is: "Wow! You've gained some weight!"

a) True

b) False

Answer is False: Eating disorders are associated with a 12 fold increase in mortality.

Answer is False: This will scare the youth and make her feel out of control, making her run back into the obsessive control of food or exercise. It is better to say something like: “Re-nourishment seems to have helped you think more clearly. You can talk to me if you need to. You should be proud of yourself for taking these steps.”


Clinical Pearls1. Infant and early childhood eating problems are common in PC practice. 2. If left untreated, they can persist.3. You should identify the causes and treat them; behavioural strategies for psychosocial causes

are effective. 4. Eating disorders in older children and teens are not uncommon and can lead to dangerous

outcomes. 5. PCPs can identify early stages of eating problems and full-blown disorders. 6. PCPs can attempt stabilization through coaching support, treating comorbidities, medical

management. 7. If secondary/tertiary care is needed, PCPs can facilitate creation of virtual networks of

providers and advocate for multi-provider care plans. 8. PCPs can take patients back for medical monitoring and coaching support after tertiary care

treatment.

Identifying and Treating Eating Problems in Primary Care ...

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