Transcript Eating Disorders in Primary Care

Eating Disorders in
Primary Care
Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating
Disorder (BED)
Consider evaluating for an eating disorder if:
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Precipitous weight changes or fluctuations
Sudden changes in eating behaviors (new vegetarianism/veganism, elimination of
certain foods or food groups, etc)
Sudden changes in exercise patterns, excessive or extreme exercise regimens
Body image concerns
Abdominal complaints in the context of dieting
Electrolyte abnormalities (especially hypokalemia, hypochloremia, or elevated CO2,)
Hypoglycemia
Bradycardia
Amenorrhea or menstrual irregularities
Unexplained infertility
Type 1 diabetes mellitus with poor glucose control or recurrent DKA
Inappropriate use of appetite suppressants, caffeine, diuretics, laxatives, enemas,
ipecac, artificial sweeteners, sugar-free gum, prescription medications that affect weight
(insulin, thyroid medications, psychostimulants, or street drugs) or nutritional
supplements marketed for weight loss
DSM-5 Diagnostic Criteria for Anorexia Nervosa
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in
the context of age, sex, developmental trajectory, and physical health. Significantly low weight is
defined as a weight that is less than minimally normal or, for children and adolescents, less than
that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight
gain, even though at a significantly low weight.
C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of
body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the
current low body weight.
Specify:
Restricting type
Binge-eating/purging type
Severity:
Mild: BMI ≥ 17 kg/m2
Moderate: BMI 16–16.99 kg/m2
Severe: BMI 15–15.99 kg/m2
Extreme: BMI < 15 kg/m2
Remission:
Partial: Used to have all three, now just B (intense fear of weight gain) and/or C (perceptual
disturbance)
Full: Used to have all three, now none
DSM-5 Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is
definitely larger than what most individuals would eat in a similar period of time under similar
circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced
vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a
week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Type:
Purging: during current episode, the person has regularly engaged in self-induced vomiting or misuse of laxatives, diuretics,
or enemas
Nonpurging: during current episode, the person has used inappropriate compensatory behaviors, such as fasting or
excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
Severity:
Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.
Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week.
Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week.
Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.
Remission:
Partial: Used to have all, now only some criteria still met
Full: Used to have all, now no criterial still met
From Harrington BC, Jimerson M, Haxton C, Jimerson DC Initial evaluation, diagnosis, and treatment of anorexia
nervosa and bulimia nervosa. Am Fam Physician. 2015 Jan 1;91(1):46-52. PubMed PMID: 25591200.
http://www.aafp.org/afp/2015/0101/p46.html
DSM-5 Diagnostic Criteria for Binge-Eating Disorder
A. Recurrent episodes of binge eating (same as bulimia nervosa)
B. Binge eating episodes are associated with three (or more) of the following
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of embarrassment.
5. Feeling disgusted with oneself, depressed, or very guilty after overeating.
C. Marked distress regarding binge eating is present.
D. At least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate
compensatory behavior, and does not occur exclusively during the course
Anorexia Nervosa, Bulimia Nervosa, or Avoidant/Restrictive Food Intake
Disorder.
Binge Eating Disorder and Morbid Obesity
Adults with BED are more likely to have morbid obesity (body
mass index > 40 kg/m2) compared to adults without any eating
disorder (odds ratio 4.9, 95% CI 2.2-11); nearly one third of these
patients meet diagnostic criteria for BED.1
Only 3% of these formally diagnosed.
1. Ivezaj V, White MA, Grilo CM. Examining binge-eating disorder and food addiction in adults with
overweight and obesity. Obesity (Silver Spring). 2016 Oct;24(10):2064-9.
2. Cossrow N, Pawaskar M, Witt EA, Ming EE, Victor TW, Herman BK, Wadden TA, Erder MH. Estimating
the Prevalence of Binge Eating Disorder in a Community Sample From the United States: Comparing DSMIV-TR and DSM-5 Criteria. J Clin Psychiatry. 2016 Aug;77(8):e968-74.
Evidence for Eating Disorder Treatment Modalities
Anorexia
Bulimia
BED
Antidepressants
Mgmt of comorbid
anxiety/depression; limited
evidence for effect on sx/weight
gain1
Other meds
atypical antipsychotics (new
limited evidence)1,5
topiramate, naltrexone, odansetron (new
limited evidence)2,6
topiramate, naltrexone, orlistat
(new limited evidence)6
Therapy
CBTª and IPT† equivalent to
supportive clinical
management.3
CBT is most effective at reducing symptoms;
no effect on weight.4
Limited evidence supporting
similar efficacy of CBT.5
Therapy+med
s
Self-guided
therapy
No evidence for enhanced
effect5
Not
appropriate5
Clinical improvement RR* = 0.63 (95% CI Similar to bulimia; unclear effect
0.55-0.74); NNT (mean 9 weeks) = 4 (95%
on weight loss (consider
2
CI 3-6). Buproprion contraindicated.
buproprion).6
36% pooled remission rate for psychological
Likely similar to bulimia, orlistat
tx compared to 49% for both;
and topiramate may enhance
NNT (mean 15 weeks) = 8 (95% CI =
weight loss6
2
4;320).
Limited evidence to suggest improvement in
functioning but not remission of
binge/purging.5
May be more successful than
for bulimia5
*Clinical improvement defined as a reduction of 50% or more in binge episodes.
ªCognitive behavioral therapy, CBT
†Interpersonal psychotherapy, IPT
1.
Claudino AM, Silva de Lima M, Hay PPJ, Bacaltchuk J, Schmidt UUS, Treasure J. Antidepressants for anorexia nervosa. Cochrane Database of Systematic Reviews
2006, Issue 1. Art. No.: CD004365.
2.
Hay PPJ, Claudino AM, Kaio MH. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database of Systematic
Reviews 2001, Issue 4. Art. No.: CD003385.
3.
Carter FA, Jordan J, McIntosh, VVW, Luty SE, McKenzie JM, Frampton CMA, Bulik CM and Joyce PR. The long-term efficacy of three psychotherapies for anorexia
nervosa: A randomized, controlled trial. Int. J. Eat. Disord., 2011 44: 647–654.
4.
Hay PPJ, Bacaltchuk J, Stefano S, Kashyap P. Psychological treatments for bulimia nervosa and binging. Cochrane Database of Systematic Reviews 2009, Issue 4.
Art. No.: CD000562.
5.
Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. Am Fam Physician. 2008 Jan 15;77(2):187-95. Review. PubMed PMID: 18246888.
6.
McElroy SL, Guerdjikova AI, Mori N, O’Melia AM. Pharmacological management of binge eating disorder: current and emerging treatment options. Therapeutics and
Clinical Risk Management. 2012;8:219-241. doi:10.2147/TCRM.S25574.
AAFP treatment recommendations
From Harrington BC, Jimerson M, Haxton C, Jimerson DC Initial evaluation, diagnosis, and treatment of anorexia
nervosa and bulimia nervosa. Am Fam Physician. 2015 Jan 1;91(1):46-52. PubMed PMID: 25591200.
http://www.aafp.org/afp/2015/0101/p46.html
Guided Self-Help for Bulimia Nervosa
and Binge-Eating Disorder
From Harrington BC, Jimerson M, Haxton C, Jimerson DC Initial evaluation, diagnosis, and treatment of anorexia
nervosa and bulimia nervosa. Am Fam Physician. 2015 Jan 1;91(1):46-52. PubMed PMID: 25591200.
http://www.aafp.org/afp/2015/0101/p46.html
Overeater’s Anonymous
www.oa.org
https://www.oa.org/pdfs/is_food_a_problem_for_you.pdf
A Plan of Eating
A plan of eating helps us abstain from compulsive
eating. This tool helps us deal with the physical
aspects of our disease and achieve physical recovery.
Sponsorship
We ask a sponsor to help us through our program of
recovery on all three levels, physical, emotional, and
spiritual.
Meetings
Meetings give us an opportunity to identify our common
problems, confirm our common solution through the
Twelve Steps, and share the gifts we receive through
this program. In addition to face-to-face meetings, OA
has telephone and online meetings.
Telephone
Many members call, text, or email their sponsors and
other OA members daily. Telephone or electronic
contact also provides an immediate outlet for those
hard-to-handle highs and lows we may experience.
Writing
Writing helps us to better understand our actions and
reactions in a way that is often not revealed to us by
simply thinking or talking about them.
Literature
We read OA approved books, pamphlets, and Lifeline
Magazine. Reading literature daily reinforces how to
live the Twelve Steps and Twelve Traditions.
Action Plan
An action plan is the process of identifying and
implementing attainable actions that are necessary to
support our individual abstinence. Just like our plan of
eating, it may vary widely among members and may
need to be adjusted to bring structure, balance, and
manageability into our lives.
Anonymity
Anonymity guarantees we will place principles before
personalities.
Service
Any form of service that helps a reach fellow sufferer
adds to the quality of our own recovery.
Food Addicts Anonymous
http://www.foodaddictsanonymous.org/
“Food Addicts Anonymous is an organization that believes that Food Addiction is a biochemical disorder that
occurs at a cellular level and therefore cannot be cured by willpower or by therapy alone. We feel that food
addiction is not a moral or character issue. This Twelve Step program believes that food addiction can be
managed by abstaining from (eliminating) addictive foods, following a program of sound nutrition (a food
plan), and working the Twelve Steps of the program. After we have gone through a process of withdrawal
from addictive foods many of us have experienced miraculous life-style changes.”
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Have I tried and failed to
control my eating before?
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Do I binge-eat, especially when
I’m feeling angry or sad?
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Do I hide food?
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Do I feel guilty when I’m done
eating?
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Do I think about eating even
when I’m not hungry?
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Do I eat until I feel sick?
From Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. Am Fam Physician. 2008
Jan 15;77(2):187-95. Review. PubMed PMID: 18246888.
Don’t forget…
1. Patients with EDs may not acknowledge that they are ill, and/or they may be ambivalent
about accepting treatment. This is a symptom of their illness. Patients may minimize,
rationalize, or hide ED symptoms and/or behaviors. Their persuasive rationality and
competence in other areas of life can disguise the severity of their illness. Outside support and
assistance with decision-making will likely be necessary regardless of age.
2. Parents/guardians are the frontline help-seekers for children, adolescents, and young
adults with EDs. Trust their concerns. Even a single consultation about a child’s eating
behavior or weight/shape concerns is a strong predictor of the presence or potential
development of an ED.
3. Diffuse blame. Help families understand that they did not cause the illness; neither did their
child/family member choose to have it.
4. Monitor physical health including vital signs and laboratory tests. Clinicians need to
remember that physical exam and laboratory tests may be normal even in the presence of a
life-threatening ED.
5. Psychiatric risk. Always assess for psychiatric risk, including suicidal and self-harm thoughts,
plans and/or intent. Up to 1/2 of deaths related to EDs are due to suicide.
From the Academy for Eating Disorders’ A Guide to Medical Care
http://www.aedweb.org/images//2016MCSGV3.pdf
Resources About Eating Disorders
Academy for Eating Disorders
http://www.aedweb.org
American Academy of Family Physicians
http://familydoctor.org/familydoctor/en/diseases-conditions/eating-disorders.html
American Academy of Pediatrics
http://www.aap.org/en-us/search/pages/results.aspx?k=eating%20disorders
American Psychiatric Association
http://www.psychiatry.org/mental-health/eating-disorders
Centers for Disease Control and Prevention (growth charts)
http://www.cdc.gov/growthcharts/charts.htm
Families Empowered and Supporting Treatment of Eating Disorders
http://feast-ed.site-ym.com/
National Association of Anorexia Nervosa and Associated Disorders
http://www.anad.org
National Eating Disorders Association
http://www.nationaleatingdisorders.org
National Institute of Mental Health
http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml
Society for Adolescent Health and Medicine
http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Eating-Disorders-and-Nutrition.aspx