Restrictive Eating Disorders in the Outpatient Setting: Assessment, Diagnosis, and Treatment - PowerPoint PPT Presentation

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Restrictive Eating Disorders in the Outpatient Setting: Assessment, Diagnosis, and Treatment

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Title: Restrictive Eating Disorders in the Outpatient Setting: Assessment, Diagnosis, and Treatment


1
Restrictive Eating Disorders in the Outpatient
Setting Assessment, Diagnosis, and Treatment
Eliana M. Perrin, MD, MPH
2
Warning
  • Scary pictures coming up

3
Bodies get extremely skeletal with anorexia
nervosa
4
Organ systems break down in the face of
starvation
  • Musculoskeletal
  • Cardiac
  • GI
  • Neuro
  • Endocrine
  • Hematological

5
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

6
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)

7
In well-child encounters, work on prevention
8
Recognize that your patients are in a push/pull
toxic food environment
9
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10
Make discussions of weight as sensitive as
possible focus on health-promoting behaviors
11
For early recognition/diagnosis, when should we
be thinking about eating disorders?
12
When there is worry from family members or friends
13
When the epidemiology makes sense
14
When the genetics makes sense
15
Specific Presentations
Any time there is weight loss in an older
patient.
16
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

17
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

18
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, amountsubjective 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)

19
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?

20
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

21
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22
Physical findings
Acrocyanosis Edema Hypercarotenemia Dull/britt
le hair/nails Lanugo
23
Bulimia Associated Features
  • Depressed mood
  • Anxiety
  • Alcohol and drug abuse
  • Low self-esteem
  • Irritability
  • Impulsive spending
  • Shoplifting
  • Sexual impulsivity
  • Concentration/memory
  • Electrolyte imbalance
  • Acid reflux
  • Ruptures of esophagus
  • Loss of enamel and dentin
  • Swollen parotid glands
  • GI complications
  • Irregular menstruation
  • Loss of normal bowel function

24
Bulimia
  • Bruises scratches on palate/ posterior pharynx
  • Subconjunctival hemorrhage
  • Salivary parotid gland enlargement
  • Dental enamel erosion (lingual)
  • Calluses on knuckles (Russell sign)

25
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)

26
Differential diagnosis
  • Gastrointestinal (malabsorption, irritable
    bowel/Crohns Disease, ulcers, tumors, achalasia,
    celiac)
  • Endocrine (hyperthyroidism, Addisons,
    hypopituitarism, diabetes mellitus, pregnancy)
  • CNS- hypothalamic tumor
  • Other malignancies/infections
  • Psychiatric (depression, OCD, drug use,
    conversion disorder, schizophrenia)

27
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

28
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 youre shooting for
  • Watch for re-feeding syndrome
  • A starving body should rest
  • Watch for cardiac pitfalls

29
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

30
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

31
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.

32
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

33
Know the weight youre shooting for
  • Figure out IBW figure out 50 BMI by
    age/gender figure out patients BMI make
    fraction or out of it.
  • Pts BMI 15
  • 50 BMI 20
  • 15/20 or 75 IBW

34
Approximate IBW
lt 60 IBW
lt 75 IBW
lt 80 IBW
35
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

36
A starving body should rest
  • Inpatient-bed rest
  • Outpatient- exercise restriction
  • Behavioral contract to be allowed to exercise
    more frequently

37
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

38
When to refer
39
When to Refer
  • When you have engaged a team approach and you
    arent 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

40
AAP Inpatient criteria-eating disorders
  • lt75 IBW, or ongoing weight loss despite
    intensive management
  • Refusal to eat
  • Body fat lt10
  • HR lt50 daytime lt45 nighttime
  • Systolic BP lt90
  • Orthostatic pulse (gt20 bpm) or BP (gt10 mm Hg)
  • Temperature lt96F
  • Arrhthymia- prolonged QTc
  • Syncope

41
AAP Inpatient Criteria- (Continued)
  • Serum K concentration lt 3.2 mmol/L
  • Serum Cl concentration lt 88 mmol/L
  • Esophageal tears
  • Cardiac arrhythmias --prolonged QTc
  • Hypothermia
  • Intractable vomiting
  • Hematemesis
  • Syncope

42
APA Inpatient Guidelines
  • For adults
  • Heart rate lt40 bpm
  • Blood pressure lt90/60 mm Hg
  • Glucose lt60 mg/dl potassium lt3 meq/L
    electrolyte imbalance
  • Temperature lt97.0 F
  • Dehydration or hepatic, renal, or
    cardiovascular organ compromise requiring acute
    treatment.

43
APA Inpatient Guidelines
  • For children and adolescents
  • Heart rate in the 40s
  • Orthostatic blood pressure changes (gt20-bpm
    increase in heart rate or gt10-20-mm Hg drop)
  • BP lt 80/50 mm Hg
  • Hypokalemia or hypophosphatemia

44
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

45
The end.
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