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The Unbearable Lightness of BeingEating Disorders in General Practice 2021Dr Janet Bayley NQUEDS CHMHATODS

With thanks to Dr Warren WardDirector Eating Disorders ServiceRBWH and Emma Coleman NQuEDS Dietitian

ACKNOWLEDGMENT OF OUR TRADITIONAL OWNERS

We acknowledge Aboriginal people and Torres Strait Islanders as this country’s First Nations people.

We recognise First Nation people and communities as traditional and cultural custodians of the lands on which we work to provide safe and quality health services.

We pay our respect to Elders past, present and emerging.

Artwork produced for Cairns and Hinterland Hospital and Health Service

by Jedess Hudson

+Definition

DSM V Classification

Anorexia Nervosa

Avoidant/Restrictive Food Intake Disorder

Binge Eating Disorder

Bulimia Nervosa

Other Specified Feeding or Eating Disorder

PICA

Rumination Disorder

Eating disorders are characterised by disturbances of eatingbehaviours and a core psychopathology centred on food, eating andbody image concerns (RANZCP Guidelines)

Overevaluation weight and body shape

+

Small Bites

BMI no longer as important for many patients

Most people with an eating disorder have an unremarkable body weight as restraint –binge/purge cancel each other out

Increasing numbers of people are presenting with significant malnutrition with “higher BMI” AKA Atypical AN (“The Biggest Loser” Effect)

Many are told by medical professionals they “are not thin enough to have an eating disorder”

+Eating Disorders are common, and increasing in prevalence 1 in 20 Australians has an eating disorder*

Approximately 15% of Australian women experience an eating disorder during their lifetime*

The number of people in Australia with purging behaviours has doubled in past 10 years^

*www.nedc.com.au

^Hay PJ, Mond J, Buttner P, Darby A (2008) Eating Disorder Behaviors Are Increasing: Findings from Two Sequential Community Surveys in South Australia. PLoS ONE 3(2)

+High Mortality Rates10-20% for Anorexia Nervosa

The highest mortality rate of any psychiatric illness

+Causes of Death

80% due to medical causes. Bloods can be totally normal at time of death. Fatal arrhythmias Hypotension Hypoglycemia Hypokalemia Hypophosphatemia

20% Suicide Suicide rates in those with

AN 32x more likely than those without

+A Lethal Combination

I’m fine’

‘There’s nothing wrong with me’

‘I’ll eat’

‘See my bloods are fine’

‘You worry too much’

‘I’m not dead yet’

‘Everyone in my family is thin’

‘She’s medically stable’

‘Her bloods are fine’

‘Everything’s pretty normal now’

‘We’ve corrected her potassium’

‘She looks fine’

‘She’s an athlete so you’d expect her pulse to be low’

Sufferer denial Doctor Ignorance

+ What causes eating disorders?

The causes of eating disorders are complex and include… Genetic Personality Early attachment problems (trauma/abuse/neglect) Obesity Bullying and teasing The culture and media/certain subcultures Stressors Dieting Starvation syndrome

No consistent evidence of an anorexogenic familyOften adverse events within family precede development

of ED

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The Six Seductions of AnorexiaEmily T. Troscianko - A Hunger Artist

1. Anorexia as anaesthetic: Making everything else matter less

2. Anorexia as Rosetta Stone: Giving you ready made meaning

3. Anorexia as gold star: Giving you top marks in the little things .

4. Anorexia as halo: Making you feel special

5. Anorexia as hunger strike: Letting you be other than what you’re expected to be.

6. Anorexia as partial suicide: Letting you live.

+The Impact of TV on Teenage Girls

Within 3 years of introduction of TV to area in Fiji:

Eating Disorder symptoms increased 5-fold

Vomiting to control weight increased from 3% to 15%

74% felt “too big or fat”

62% dieting in past month

Favourite programs included Melrose Place, ER, Xena: Warrior Princess.

Becker et al (2002) British Journal of Psychiatry, 180, 509-514

This study done in 2002 BEFORE:

Facebook (2004)

The iPhone (2008)

Instagram (2010) Front-facing

Cameras And Selfies (2010)

Snapchat (2011)

Brain-flexible thinking

Heart-BP >90 systolic.-HR>60 -no postural changes

Bone Marrow-Neutrophils 2-8

Liver-BSL>4LFTs Normal

Ovaries-menstruatng

Bones-normal density

Weight-BMI 20-25

Intake vs output-Adequate

Electrolytes (K,Na,Hco3,P04,Mg) normal

Brain-rigid terrified thinkingNa < 125*=seizures

Heart--BP <90 systolic*-HR<50* or > 120 bpm-postural changes>20*-Potassium <3*-Phosphate below normal*

Bone Marrow-Neutrophils <1.0*

Liver-BSL<3*LFTs>500*

Ovaries-no periods

Bones-osteoporosis

Weight-BMI <14*

Intake vs output-grossly inadequate intake, out of control purging or exercise

*ADMIT

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American Journal of Clinical Pathology > Hematopathology

Bone Marrow Changes in Anorexia Nervosa

E. Abella, et al Am J Clin Pathol. 2002;118(4)

After weight loss

After re-feeding

+

The Medical Assessment•History

•Examination

•Investigations

FNQ Health Pathways

+

Red Flags

High – risk patient, or medically unstable eg electrolyte disturbance

Pregnant with low BMI and failure to gain adequate weight

Extremely underweight (eg BMI <16) or rapid weight loss

Recurrent ketoacidosis in diabetic patients

Suicide risk

+History: Suggestive Features

Unexplained disturbances in physical observations or pathology eg bradycardia, neutropenia

Rapid or unexplained wt loss

Inadequate wt gain in pregnancy

Preoccupation with

Wt, body shape, Xs exercise

Diet or GIT symptoms + low BMI

Grossly inadequate nutritional intake

Suicidal ideation, alcohol + substance use, DSH

T1DM with unexplained poor glycaemic control

Suspected misuse of medications (eg laxatives, diuretics, wt loss pills)

Disturbed eating behaviours(purge, binge, fast)

Personal or Family Hx ED

^ 6 kg

+

If you suspect an Eating Disorder, always ask what they have eaten in the last 24 hr for:Breakfast

Morning Tea

Lunch

Afternoon TeaDinner

Supper

+

Targeted History

Collateral information family etc

Weight history

Physical activity and food related behaviours

Signs and symptoms of severity

Physiological changes

Psychosocial factors

Co-morbidities and medications

+Physical examination

Weight*

Height*

BP/HR-lying and standing

Postural Tachycardia >20 BPM

Consider on spot BSL

*Body Mass Index(BMI)=Wt(kg)÷Ht(m)÷Ht(m)

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Investigations

Serum biochemistry incl Ca2+, Mg, PO4, TSH

Full Blood Count

ECGIncreased PR, 1oHB,

Bradycardia, ST-T changes, QTC prolongation

+ If patient doesn’t meet criteria for medical admission…

Should really be admitted medically if has met any of criteria in last 24 hours e.g. at G.P. or outpatients

+The Importance of the MDT

Patient

Psychiatrist

Dietitian

Psychologist CBTE

Family + Support Network

Peer Supports

GP

+ Treating Eating Disorders

Establish a therapeutic alliance

Monitor and stabilise medically

Reverse cognitive & behavioural effects of starvation

• more adaptive ways to deal with emotions• to resist cultural pressures• To identify and challenge ED thoughts

Psychotherapy – help patient learn:

+The Art of Engagement

Find common goals

Clarify non-negotiables

Educate the patient

Enhance motivation

Externalise the disorder

Involve the family

Monitor countertransference

Interdisciplinary MDT approach

Consultation

Mental Health Act

+ Enlist in evidence-based treatment

Psychotherapy: Cognitive Behaviour Therapy (CBTe), Specialist Supportive Clinical Management (SSCM), Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA), Family Based Therapy (FBT <18yrs)

Pharmacotherapy: High-dose Fluoxetine for Bulimia Nervosa, Lis-dexamphetamine for BED

Peer Support and Guided Self Help: eg Eating Disorders Qld, CBT-based Guided Self Help

1

Ensure Adequate Nutrition

2

Enquire about specifics of recent oral intake -meals/snacks/supplements (e.g. entire consumption over past 24hr)BMTLATD

3

Provide or arrange support during mealtimes

4

Consider increasing nutrition intake with liquid high calorie supplements e.g. Ensure, Sustagen, flavoured milk/soymilk drinks (e.g. Breaka, Up & Go etc)

5

Consider arranging Dietetic input to increase the nutritional adequacy of the meal plan

+GP Role

Medical Monitoring May be weekly if very unwell FBC ELFT Postural BP/HR Temp Weights ECG PRN Bone health

Referrals Dietitian, Psychology, Psychiatry

Patient Support, Education and Engagement

Family Support, Education and Engagement

+ MBS Eating Disorder Management Plan From 1 November 2019, a new suite of 64 Medicare Benefits Schedule (MBS) items will be introduced to

support a model of best practice evidence based care for patients with anorexia nervosa and other eligible patients with eating disorders.

· The listing of these new items is a result of recommendations in 2018 by the independent clinician-led Medical Benefits Schedule (MBS) Review Taskforce and the Australian Government’s response to those recommendations.

·This new item structure means eligible patients will be able to receive a Medicare rebate when eligible providers undertake the development of a Eating Disorder treatment and management plan or a review which will activate: a course of evidence based eating disorder psychological treatment services (up to a total of 40 psychological

services in a 12 month period); and

up to 20 dietetic services, in a 12 month period, depending on their treatment needs.

It is intended that the MBS services will be provided by practitioners with the knowledge, skills and experience in providing treatment to patients with eating disorders.

·Treatment provided under the Eating Disorder Psychological Treatment items are limited to the defined list of evidence based eating disorder specific treatments.

·Patients who do not fit the eligibility criteria for the MBS Eating Disorders Treatment Pathway may be eligible for treatment under the Better Access to Mental Health treatment pathway.

·There will be an evaluation of the new items after 12 months to assess if the items are operating as intended for patients, providers and the Government.

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EDTP

Review

Before or at sessions, 10, 20, 30 psychological treatmentAfter session 1 or 2 of dietetics servicesAt EDTP completion

Psychiatrist or Paediatrician review by session 20 of psychological treatment (reviewing specialist must be able to claim relevant MBS item number)

Co-morbidities or pre-existing conditions, consider if another simultaneous MBS management plan advisable

Avoidant Restrictive Food Intake Disorder Consider GP MHTP instead as not eligible for EDTP

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EDE-Q

+https://insideoutinstitute.org.au

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Encourage contact with community-based support services

Some offer online services for patients and carers and clinicians

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+Referrals NQUEDS

Routine Referral

Complete Referral Form

Contact CHMHATODS Centralised Intake Service

phone 1300 642 255 fax 07 4226 3149

Urgent need for advice

Contact NQUEDS Intake (Usually CNC or Psychiatry Registrar)

Phone 07 4226 3100

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NQUEDS REFERRAL FORM

+Optional Extra Bits

+Effects of Starvation Syndrome

Physical changes• Heart rate reduced by 25%• Heart rate and blood pressure decreased• Basal metabolic rate slowed down• Feeling cold• Fluid retention • Loss of strength/fatigue• Hair loss and dry skin •Wt loss 25%

Attitudes and behaviour relating to eating• Thinking about food all the time•Meticulous planning on meals• Eating very fast of very slowly• Increased hunger, binge-eating• Unusual food routines and rituals • Tendency to hoard • Increased use of condiments for flavour

Emotional changes•Depression • Anxiety• Irritability• Increased mood fluctuations• Intense and negative emotional reactions• Reduced motivation• Loss of interest in life

Social changes•Withdrawal and isolation• Loss of sense of humour• Feelings of social inadequacy•Neglect of personal hygiene•More critical of others• Strained relationships

Changes in thinking• Impaired concentration, judgement and decision-making• Impaired comprehension• Increased rigidity and obsessional thinking• Reduced alertness

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Cardiovascular – low PO4, K, Mg, glucose

Ventricular arrhythmia

Heart failure/pulmonary oedema

Shock

Low BP

Pulmonary – low PO4, glucose

Respiratory failure

Failure to wean

Dyspnoea

Muscular – low PO4, K

Rhabdomyolysis

Muscle pain

Myopathy

Neurologic – low PO4, K, Mg

Confusion

Paraesthesia

Weakness

Paralysis

Tetany

Haematologic – low PO4

Haemolytic anaemia

Neutrophil dysfunction

Thrombycytopaenia

Miscellaneous

Renal failure

Metabolic acidosis

Wernicke’s encephalopathy (low Thiamine, K, glucose)

Refeeding Syndrome Complications

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Benefits of Nasogastric Refeeding

Prevents hypoglycaemia due to constant supply of carbohydrates

Reduces gastric discomfort

96% of ED patients report postprandial fullness

More controlled method of renourishment

Minimise electrolyte shifts in refeeding

Reach goal nutrition more timely (less chance of not receiving nutrition)

Ensures adequate hydration (only 17% ED patients consume recommended amount)

Shortens length of stay (one study showed LOS reduced by 17 days)

Can be a relief/break for a person

When placed at admission, less likely to be seen as a punishment for poor treatment compliance

Eating disorder patients will generally fall into low-risk group for NGT insertion with pH testing for confirmation avoiding the need for chest x-ray.

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Ethical & Legal Considerations

Autonomy

Beneficence

Competence/decision-making capacity

Reversibility of starvation syndrome

Legal framework

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Recovery

“Normal Eating”Flexible and regular

Diversity of foods

Not preoccupied with avoiding food

Enjoy food

Social Meals

Family Meals

No Compensatory Behaviours

“Normal Emotions”Tolerance of distress

Experience of emotional range

Life outside of eating disorder

Self esteem

Absence shame and guilt

Mentalization ability

Variety+

Regular+

Enough

Shane Jeffrey

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Bariatric Surgery

Eating disorders and disordered eating are prevalent in the bariatric population

Patients with BED show similar patterns of weight loss post surgery cf non-BED

Problems

• Loss of control: eating pathology and weight gain

• Too much control: Anorexia Nervosa• Alcohol abuse risk increases post

bariatric surgery

+Type 1 DM: 2.4 X risk of ED

Why?

Focus on food, weight and exercise

Weight loss at onset of DM

Weight gain with insulin treatment

Availability of extra weight loss technique (insulin restriction/omission)

Need to be like peers

Need to assert control/autonomy/independence

Goebel-Fabbri. Diabetes and Eating Disorders. J Diabetes Sci Technol. 2008 May; 2(3): 530–532.

Jones JM, Lawson ML, Daneman D, Olmsted MO, Rodin G. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ. 2000 Jun 10; 320(7249): 1563–1566.

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Warning signs of ED in person with DMEDV Fact Sheet: Eating Disorders and Type 1 Diabetes

Extreme fluctuations in BGLs

Frequent DKA

High HbA1c

Fluctuations in weight

Missing or changing insulin frequently

Fear of hypoglycemia

Frequent requests to change meal plans

+Diabetes and Binge Eating

Type II DM: 6.5-9% have binge eating

Type I DM: binge eating also common

• Depression (50%)• Self-medicating other negative feelings incl remorse• Dieting/restriction• Fluctuations in blood glucose

Causes of binge eating:

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Eating Disorders in the Peripartum

Pregnancy is a time of enormous body transformation

Body and weight dissatisfaction are common in peripartum

Link between active eating disorder in pregnancy and poor maternal and neonatal outcomes Miscarriage Pre-eclampsia Postnatal depression Anaemia Low birth weight - particularly in

Anorexia Nervosa High birth weight - particularly In Binge

Eating Disorder (BED) Premature birth Poor infant attachment and maternal

bonding Feeding difficulties in infancy

+How Does Pregnancy Effect Eating Disorders?

Variable Course Negative Attitudes Window of remission for BN but window of vulnerability for new

and continuation of BED

Improve 29-78%• Maternal responsibility• Change body perception• Separate pregnancy from

ED• Increased social support• Increased DHEA • May allow Rx engagement Relapse 33%• Difficulty manage weight

gain• Difficulty managing body

changes• Loss control• Hyperemesis• Emotional dysregulation

• Child vs ED• Resentment of child• Body image distortions • Lowered self worth• Concern re baby health• Fear of failure• Judgement of others about

weight and eating• Worry about child’s shape

• Significant role of cultural and psychosocial factors

• Women with current or lifetime psychosocial adversities were at higher risk of active BN symptoms

• Role of self esteem• Life satisfaction

+Peripartum Nutritional Advice

Similar advice recommended to all pregnant mothers – goals and role of nutrition in pregnancy

Re-establishing or practicing regular eating first step

Acknowledge sometimes its difficult to know what to eat – would you like some advice around this?

Focus on safe foods (what the person is comfortable eating)

Consider a referral to a dietitian

Avoid being directive, judgmental

Steer away from warning or cautioning (weight recommendations)

NEMO Maternal Health https://www.health.qld.gov.au/nutrition/patients• Healthy eating and weight gain

during pregnancy• Antenatal and infant feeding

resources for Aboriginal and Torres Strait Islander People

• Healthy eating for breastfeeding mothersHealthy eating for vegetarian or vegan pregnant and breastfeeding methods

+Gestational diabetes

Can increase/exacerbate ED behaviours

Food monitoring

Carbohydrate counting

Treating hypo’s: sugary food and drink

Body changes during pregnancy

Consider individual treatment rather than group

Can better adjust for the eating disorder

Regular eating and general eating in pregnancy

Meal ideas vs. carbohydrate counting

‘safe’ hypo management plan

Strategies for bingeing/purging behaviours

Liaison Obstetrics + Endocrine + POSM/NQUEDS teams

+ Bone Health Assessment & Management North Queensland Eating Disorder Service Clinical Practice Guideline

DRAFT Referral Screening Investigations

General Practitioner and NQUEDS Intake to make relevant inquiries FBC, ELFT, B12, Folate, Iron, Vitamin D, TSH

Postural BP and HR Temp etc

NQUEDS Assessment

Psychiatry/Dietitian Investigate fracture history

Investigate dietary intake and evidence of malnutrition

Look for other signs high risk Osteoporosis

Fracture history

Amenorrhoea (duration)

Identification of low BMI and/or malnutrition

Restore weight and resumption of normal eating behaviours

Identification Inadequate Calcium dietary intake

Less than 1000-1200mg per day Recommend dietary enhancement of calcium

intake

Commence Calcium supplements 600mg tablets, i-ii Indefinite until adequate dietary calcium intake

Identification Vitamin D Deficiency Risk

Less than 75 nmol/L Commence Vitamin D Replacement tablets

Consider annual monitoring or more frequently if severe Vitamin D deficiency

If Vitamin D level does not increase with oral supplements

Consider IMI 600 000 units 3-6monthly.

Consider alternative causes for level not returning to normal (eg. pancreatic insufficiency)

+ Bone Health Assessment & Management 2 North Queensland Eating Disorder Service Clinical Practice Guideline

DRAFT Identification Amenorrhoea greater than

six months duration Baseline Dexa scan

Two yearly Dexa scan thereafter

Consider bone density 2-5 yearly or repeat at time of menopause.

Can consider ceasing ongoing routine surveillance if recovery eating disorder and normal bone density.

Consider hormone replacement therapy” Low BMI (<17) and amenorrhoea

Pubertal younger adult (peak bone mass is achieved in teens and this is important time to avoid hypogonadism)

Minimal trauma fracture (therefore higher risk of further minimal trauma fractures)

More severe osteoporosis (ie BMD Z score -2.5 or worse)

Poorer prognosis with eating disorder - ie chance of achieving healthy BMI is lower

Estalis Sequi patch - Until normal BMI and spontaneous recovery of hypogonadism - ienormal menses.

If topical HRT not an option second line option Oral Combined Contraceptive Pill if no contraindications"

Identification of established osteoporosis consider secondary screening Thyroid Test

Vitamin D,

Coeliac Screening (Ttg/Iga)

Parathyroid Hormone

Endocrinology Referral If minimal trauma fracture or established

osteoporosis CHHHS Medical Referral (MR Form) if Cat 1 or

external referral from GP

Yearly review of bone health for long term patients of NQUEDS