Restrictive Eating Disorders in the Restrictive Eating Disorders in the Outpatient Setting: Assessment, Outpatient Setting: Assessment,

Diagnosis, and TreatmentDiagnosis, and Treatment

Eliana M. Perrin, MD, MPHEliana M. Perrin, MD, MPH

Warning:Warning:

Scary pictures coming Scary pictures coming upup

Bodies get extremely skeletal with Bodies get extremely skeletal with anorexia nervosaanorexia nervosa

Organ systems break down in Organ systems break down in the face of starvation the face of starvation

• MusculoskeletalMusculoskeletal• CardiacCardiac• GIGI• NeuroNeuro• Endocrine Endocrine • Hematological Hematological

Whatever the cause...Whatever the cause...

• Anorexia nervosa is the psychiatric Anorexia nervosa is the psychiatric illness with highest mortalityillness with highest mortality– mortality approximately 5-10% for anorexia mortality approximately 5-10% for anorexia

nervosanervosa

– 10-15% develop a chronic unremitting course10-15% develop a chronic unremitting course

– post-hospitalization relapse rates 30-50%post-hospitalization relapse rates 30-50%

• We know little about the mortality of We know little about the mortality of bulimiabulimia– relapse rates seem to be highrelapse rates seem to be high

How can we best care for these How can we best care for these patients? patients?

• Prevent the problem in the first Prevent the problem in the first place?place?

• Screening/ early recognition Screening/ early recognition /diagnosis/diagnosis

• Outpatient Management Outpatient Management

• Inpatient Management (discussed Inpatient Management (discussed a different time)a different time)

In well-child encounters, work on In well-child encounters, work on preventionprevention

Recognize that your patients are in a push/pull Recognize that your patients are in a push/pull “toxic” food environment“toxic” food environment

Make discussions of weight as Make discussions of weight as sensitive as possible; focus on sensitive as possible; focus on

health-promoting behaviorshealth-promoting behaviors

For early recognition/diagnosis, For early recognition/diagnosis, when should we be thinking about when should we be thinking about

eating disorders?eating disorders?

When there is worry from family When there is worry from family members or friendsmembers or friends

When the epidemiology makes When the epidemiology makes sensesense

When the genetics makes senseWhen the genetics makes sense

Specific PresentationsSpecific Presentations

Any time there is weight loss in an

older patient.

The role of the primary care The role of the primary care provider…provider…

• Screen patients at riskScreen patients at risk• Recognize eating disorders and rule Recognize eating disorders and rule

in or out other similar presentations in or out other similar presentations and reasons for weight lossand reasons for weight loss

• Initiate appropriate early treatment Initiate appropriate early treatment and frequent follow upand frequent follow up

• Know when you are in over your Know when you are in over your head and ask for helphead and ask for help

Take a historyTake a history

• Ask open-ended questions (privately, with Ask open-ended questions (privately, with concern, directly, and use collateral sources)concern, directly, and use collateral sources)– Loss of menses?Loss of menses?– Cold hands/feet?Cold hands/feet?– Dry skin?Dry skin?– Constipation?Constipation?– Tired or fatigued?Tired or fatigued?– Headaches?Headaches?– Fainting or dizziness?Fainting or dizziness?– Abdominal distension?Abdominal distension?– Psychiatric symptoms (depressed mood, self harm Psychiatric symptoms (depressed mood, self harm

ideation and behaviors, anxiety)ideation and behaviors, anxiety)– Substance useSubstance use

Ask screening questions Ask screening questions (from AAP)(from AAP)

• Weight history (most, least, Weight history (most, least, desireddesired))• Body imageBody image• Exercise (how much, how often, how intense, Exercise (how much, how often, how intense,

how stressed if you miss a workout)how stressed if you miss a workout)• 24 hour diet history24 hour diet history• Calorie counting, fat gram counting, Calorie counting, fat gram counting,

carbohydrate counting, taboo foods, skipping carbohydrate counting, taboo foods, skipping mealsmeals

• Binge eating (frequency, amount—subjective Binge eating (frequency, amount—subjective and objective, triggers)and objective, triggers)

• Purging history (or compensating for intake)Purging history (or compensating for intake)• Use of diuretics, laxatives, diet pills, ipecac Use of diuretics, laxatives, diet pills, ipecac

(elimination patterns, constipation, diarrhea)(elimination patterns, constipation, diarrhea)• Vomiting (how frequent, how long after meals)Vomiting (how frequent, how long after meals)

Another set of screening questions Another set of screening questions (from GAPS)(from GAPS)

• Are you satisfied with your eating Are you satisfied with your eating habits?habits?

• Do you ever eat in secret?Do you ever eat in secret?• Do you spend a lot of time thinking Do you spend a lot of time thinking

about ways to be thin?about ways to be thin?• In the past year, have you tried to In the past year, have you tried to

lose weight, or control your weight lose weight, or control your weight by vomiting, taking diet pills or by vomiting, taking diet pills or laxatives or starving yourself?laxatives or starving yourself?

Perform a physical examPerform a physical exam

• Height, weight (in a gown after Height, weight (in a gown after voiding), BMI, % ideal body weightvoiding), BMI, % ideal body weight

• Vital signs including orthostasis Vital signs including orthostasis and temperature! (tells us medical and temperature! (tells us medical toll of starvation or binge-purge toll of starvation or binge-purge cycle and helps rule in or rule out cycle and helps rule in or rule out things on the differential)things on the differential)

• Other key featuresOther key features

Anorexia: Associated FeaturesAnorexia: 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 findingsPhysical findings

Acrocyanosis

Edema

Hypercarotenemia

Dull/brittle hair/nails

Lanugo

Bulimia: Associated FeaturesBulimia: Associated Features

• Electrolyte imbalanceElectrolyte imbalance

• Acid refluxAcid reflux

• Ruptures of esophagusRuptures of esophagus

• Loss of enamel and Loss of enamel and dentindentin

• Swollen parotid glandsSwollen parotid glands

• GI complicationsGI complications

• Irregular menstruationIrregular menstruation

• Loss of normal bowel Loss of normal bowel functionfunction

• Depressed moodDepressed mood

• AnxietyAnxiety

• Alcohol and drug Alcohol and drug abuseabuse

• Low self-esteemLow self-esteem

• IrritabilityIrritability

• Impulsive spendingImpulsive spending

• ShopliftingShoplifting

• Sexual impulsivitySexual impulsivity

• Concentration/memoryConcentration/memory

BulimiaBulimia

• Bruises scratches Bruises scratches on palate/ posterior on palate/ posterior pharynxpharynx

• Subconjunctival Subconjunctival hemorrhagehemorrhage

• Salivary parotid Salivary parotid gland enlargementgland enlargement

• Dental enamel Dental enamel erosion (lingual)erosion (lingual)

• Calluses on Calluses on knuckles (Russell knuckles (Russell sign)sign)

Screening laboratory evaluation for Screening laboratory evaluation for eating disorderseating disorders

• CBCCBC• ESRESR• T4/TSHT4/TSH• Prolactin/FSH/LHProlactin/FSH/LH• Pregnancy testPregnancy test• UAUA• Stool for occult Stool for occult

blood/LFTs/Amylase/Lipaseblood/LFTs/Amylase/Lipase• Chemistry panel, albumin, Chemistry panel, albumin, • EKG (including QTc)EKG (including QTc)

Differential diagnosisDifferential diagnosis

• Gastrointestinal (malabsorption, Gastrointestinal (malabsorption, irritable bowel/Crohn’s Disease, ulcers, irritable bowel/Crohn’s Disease, ulcers, tumors, achalasia, celiac)tumors, achalasia, celiac)

• Endocrine (hyperthyroidism, Addison’s, Endocrine (hyperthyroidism, Addison’s, hypopituitarism, diabetes mellitus, hypopituitarism, diabetes mellitus, pregnancy)pregnancy)

• CNS- hypothalamic tumorCNS- hypothalamic tumor• Other malignancies/infectionsOther malignancies/infections• Psychiatric (depression, OCD, drug use, Psychiatric (depression, OCD, drug use,

conversion disorder, schizophrenia) conversion disorder, schizophrenia)

Once you know you have a patient Once you know you have a patient with an eating disorderwith an eating disorder

That day (after history, PE):That day (after history, PE):• Draw labs (CBC, chem 10, UA, TFTs, ESR) Draw labs (CBC, chem 10, UA, TFTs, ESR) • Get EKG if bradycardic, syncopal, or Get EKG if bradycardic, syncopal, or

electrolyte problemselectrolyte problems• Communicate seriousness of condition to Communicate seriousness of condition to

patient and familypatient and family• Draw up contract for patient?Draw up contract for patient?• Arrange for consultations and team approachArrange for consultations and team approach• F/u in 3 days for longer visit, then twice F/u in 3 days for longer visit, then twice

weekly, then space apart if improving weekly, then space apart if improving

Basic Principles for TreatmentBasic Principles for Treatment

• Be sensitive to psychiatric diseaseBe sensitive to psychiatric disease• Engage a team approach- there are parts best Engage a team approach- there are parts best

accomplished by people other than youaccomplished by people other than you• Feed the patient-- but not too fast Feed the patient-- but not too fast • Monitor weight, UA, and vital signs at each Monitor weight, UA, and vital signs at each

visitvisit• Help pts. gain weight--but not too fast…Help pts. gain weight--but not too fast…• ... Know the weight you’re shooting for ... Know the weight you’re shooting for • Watch for “re-feeding syndrome”Watch for “re-feeding syndrome”• A starving body should rest A starving body should rest • Watch for cardiac pitfallsWatch for cardiac pitfalls

Remain sensitive to the Remain sensitive to the underlying psychiatric diseaseunderlying psychiatric disease

• Staff/ MDs should Staff/ MDs should show neutral show neutral response to weighingresponse to weighing

• Do NOT discuss Do NOT discuss dieting, looks in any dieting, looks in any way--not even to say way--not even to say patients look betterpatients look better

• Remember they are Remember they are not trying to be not trying to be manipulativemanipulative

Engage a team approachEngage a team approach

• ParentParent• NurseNurse• Mental health professionalMental health professional• NutritionistNutritionist• CoachCoach• SpecialistSpecialist

Your role is to assure physical safety, Your role is to assure physical safety, communicate with family and team, communicate with family and team, carefully follow up, and refer if carefully follow up, and refer if necessarynecessary

Feed the patient-- but not too Feed the patient-- but not too fastfast

• Be wary of the patient Be wary of the patient who is getting less than who is getting less than 700 calories per day-- 700 calories per day-- add no more than 500 add no more than 500 calories for first day.calories for first day.

• Advance slowly Advance slowly according to sliding according to sliding scale - typically you will scale - typically you will need to increase 200-need to increase 200-300 calories every 4 300 calories every 4 days or so.days or so.

Monitor weight and vital signsMonitor weight and vital signs

• Assess height, weight, BMI, % Assess height, weight, BMI, % IBW, temperature, HR, BP, IBW, temperature, HR, BP, orthostaticsorthostatics

• Weight and urine protocolsWeight and urine protocols

• Monitor patient frequently until Monitor patient frequently until attaining target weightattaining target weight

Know the weight you’re Know the weight you’re shooting forshooting for

• Figure out % IBW: Figure out % IBW: figure out 50% BMI figure out 50% BMI by age/gender & by age/gender & figure out patient’s figure out patient’s BMI & make fraction BMI & make fraction or % out of it.or % out of it.

• Pt’s BMI = 15Pt’s BMI = 15

• 50 % BMI = 2050 % BMI = 20

• 15/20 or 75% IBW 15/20 or 75% IBW

Approximate % IBWApproximate % IBW

< 60% IBW < 75% IBW < 80% IBW

Watch for “Refeeding Watch for “Refeeding Syndrome”Syndrome”

• Metabolic & Metabolic & physiologic physiologic consequences of the consequences of the depletion, repletion, depletion, repletion, compartmental shifts compartmental shifts and and interrelationships of interrelationships of phos, K+, Mag, phos, K+, Mag, glucose metabolism, glucose metabolism, vitamin deficiency, & vitamin deficiency, & fluid resuscitationfluid resuscitation

A starving body should restA starving body should rest

• Inpatient-bed restInpatient-bed rest• Outpatient- Outpatient-

exercise exercise restrictionrestriction

• Behavioral Behavioral contract to be contract to be allowed to allowed to exercise more exercise more frequentlyfrequently

Watch for cardiac pitfalls!Watch for cardiac pitfalls!

• When patient is When patient is bradycardic, has bradycardic, has significant significant orthostasis, orthostasis, syncope, or an syncope, or an extremely low BMI extremely low BMI (less than or = to 13): (less than or = to 13): check QTc!check QTc!

• Long QTc can be Long QTc can be precursor to precursor to Toursades de pointsToursades de points

When to referWhen to refer

When to ReferWhen to Refer

• When you have engaged a team approach When you have engaged a team approach and you aren’t making progress or when and you aren’t making progress or when the disease process is life threatening the disease process is life threatening

OPTIONS here at UNC:OPTIONS here at UNC:

Intensive outpatient at UNC (or Duke)Intensive outpatient at UNC (or Duke)

Partial hospitalization at UNCPartial hospitalization at UNC

Inpatient pediatrics – medical complicationsInpatient pediatrics – medical complications

Inpatient Eating Disorders Unit Inpatient Eating Disorders Unit

AAP Inpatient criteria-eating AAP Inpatient criteria-eating disorders disorders

• <75% IBW, or ongoing weight loss despite <75% IBW, or ongoing weight loss despite intensive managementintensive management

• Refusal to eatRefusal to eat• Body fat <10%Body fat <10%• HR <50 daytime; <45 nighttimeHR <50 daytime; <45 nighttime• Systolic BP <90Systolic BP <90• Orthostatic pulse (>20 bpm) or BP (>10 mm Hg)Orthostatic pulse (>20 bpm) or BP (>10 mm Hg)• Temperature <96°FTemperature <96°F• Arrhthymia- prolonged QTcArrhthymia- prolonged QTc• SyncopeSyncope

AAP Inpatient Criteria- (Continued)AAP Inpatient Criteria- (Continued)

• Serum K concentration < 3.2 mmol/LSerum K concentration < 3.2 mmol/L• Serum Cl concentration < 88 mmol/LSerum Cl concentration < 88 mmol/L• Esophageal tearsEsophageal tears• Cardiac arrhythmias --prolonged QTcCardiac arrhythmias --prolonged QTc• HypothermiaHypothermia• Intractable vomitingIntractable vomiting• HematemesisHematemesis• SyncopeSyncope

APA Inpatient Guidelines APA Inpatient Guidelines

For adults:For adults:

Heart rate <40 bpmHeart rate <40 bpm

Blood pressure <90/60 mm HgBlood pressure <90/60 mm Hg

Glucose <60 mg/dl; potassium <3 Glucose <60 mg/dl; potassium <3 meq/L; electrolyte imbalancemeq/L; electrolyte imbalance

Temperature <97.0 °FTemperature <97.0 °F

Dehydration; or hepatic, renal, or Dehydration; or hepatic, renal, or cardiovascular organ compromise cardiovascular organ compromise requiring acute treatment. requiring acute treatment.

APA Inpatient GuidelinesAPA Inpatient Guidelines

For children and adolescents: For children and adolescents:

Heart rate in the 40sHeart rate in the 40s

Orthostatic blood pressure Orthostatic blood pressure changes (>20-bpm increase in changes (>20-bpm increase in heart rate or >10-20-mm Hg drop)heart rate or >10-20-mm Hg drop)

BP < 80/50 mm HgBP < 80/50 mm Hg

Hypokalemia or Hypokalemia or hypophosphatemiahypophosphatemia

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….The end….