Download Eating Disorders A Guide for Primary Care

Eating Disorders
A Guide
for
Primary Care
Tier 3
Specialist Eating Disorders Service
Maindiff Court Hospital
Abergavenny
NP7 8NF
Tel: 01873 735546
1
Introduction
The Welsh Assembly Government launched the ‘Eating
Disorders Framework for Wales’ in 2009.
This document describes services that should be
provided to eating disorder sufferers and their carers
across all Tiers of service see fig1. The document also
includes 5 standards to guide implementation.
1. Role of GP and primary care teams in identification,
assessment and treatment of people with an ED.
2. Role of local CMHS in provision of advice and support
to primary care staff and community groups.
3. Role of local CMHS in provision of assessment and
care planning.
4. Role of local CMHS in the provision of direct treatment
interventions.
5. Provision of a range of acute and general medical
treatment and service.
This leaflet is offered as a resource to guide and support
the implementation of standard 1 and 2 for Primary Care
at Tier 1.
2
Fig 1
In patient Eating
disorders Unit 6 beds for
Wales Marloborough
TIER
4
Specialist ED Team
Referrals from CMHT’s
Specialist Interventions
Gatekeeper for Tier 4
TIER 3
Tier 2 CMHTs
Designated Eating
Disorders contacts in
each CMHT for advice
TIER 2
Screening Assessing
Information
joint working
Annual health Checks
Counselling
TIER 1
PRIMARY CARE
.
Estimated rates of clinically significant eating
disorders
LHB
Gwent
(Pop.
550k)
Total New
Cases Per
Year
(incidence)
Estimated caseload within each tier
(prevalence)
Tier 1 Tier 2 Tier 3 Tier 4
194
637
145
91
16
Source: National Public Health Service for Wales, October 2008
3
What is an Eating Disorder?
The main features of an eating disorder are:

Abnormal eating behaviours such as starving, overeating, binge-eating

Other abnormal compensatory behaviours such as
inducing vomiting, abuse of laxatives or other weight
control drugs, excessive exercising

Physical health problems resulting from the above
behaviours

Extreme concerns about weight, shape and eating
control
The Eating Disorders are:
Anorexia Nervosa (AN) – where sufferers starve themselves,
lose weight to 15% or more below normal, are terrified of
weight gain, and have a loss of sexual interest (man) or loss of
periods (women) although this may not be present (e.g. with
women on the contraceptive pill) and is not a necessary
requirement for diagnosis. Some people with AN also binge
and purge.
Bulimia Nervosa (BN) – where sufferers binge-eat and then
induce vomiting, abuse laxative or other weight control drug,
exercise excessively or starve in odder to compensate for the
binging. Sufferers are very concerned about weight and
shape, but stay within the normal weight range.
Binge Eating Disorder (BED) – where sufferers binge-eat but
do not carry out any compensatory behaviours their weight
may increase to above the normal range (NB obesity is not
categorized as an eating disorder).
Atypical Eating Disorder (AED) (or Eating Disorders Not
Otherwise Specified EDNOS) – where sufferers have many
of the above symptoms but do not quite meet the criteria for
AN, BN or BED.
4
More information
 Eating Disorders can cause severe and chronic physical
and psychiatric morbidity and occasional death.
Intervention in the early stages of the illness is more
likely to be successful

Men, children and older women can also have an eating
disorder

People with an eating disorder become over concerned
with body shape and weight, but have underlying
problems of very low self-esteem and difficulties relating
with people

An eating disorder can be caused and maintained by
many different factors, but it usually starts with dieting.

People who have low self-esteem, and tend to be
perfectionist, are particularly vulnerable.

They rarely see themselves as ill and try to avoid
discovery of their secret behaviour.

Weight loss is seen as the only way to feel better and ‘in
control’ of life, so people with an eating disorder
generally do not seek help.

Eating disorders cause, physical, psychological and
social suffering, and can also have a damaging effect on
the lives of carers, who are often the first to identify the
problem.

Eating disorders usually last several years and don’t
tend to improve without help.
5

What are the effects of an Eating Disorder?
The physical consequences can affect almost every part
of the body, and are potentially fatal if there is severe
weight loss, vomiting or laxative abuse.
Physical effects can include:
 Circulatory problems
 Electrolyte imbalance
 Epileptic fits
 Gastric problems
 Bowel damage
 Stunted growth
 Infertility
 Kidney failure
 Heart failure
 Osteoporosis
 Dental enamel erosion
The psychological consequences often include:
 Impaired cognitive functioning
 Reduced capacity to make informed decisions
 Depression
 Anxiety obsessional behaviour
 Drug abuse
 Self harm
Social effects can include:
 Erratic behaviour
 Social withdrawal
 Debt
 Shoplifting
 Damage to relationships (including feeding and growth
problems in the children of mothers with an eating
disorder).
6
Identifying the person with an Eating Disorder
The person with an Eating Disorder usually keeps the
behaviour secret and may deny the problem if confronted.
However, eventually someone may notice or the person
realises they need help. This might take months or years.
They often remain ambivalent regarding receiving help
and changing their behaviour, because the disorder
becomes a way of coping with stress.
People often visit their GP several times before gaining
courage to discuss the real problem. They can present
with various symptoms including:
Gynaecological problems
 Amenorrhoea, delayed menarche, infertility.
 Pre-menstrual syndrome, irregular periods.
Digestive problems
 Abdominal bloating and pain
 Indigestion, diarrhoea, nausea
 Constipation (including requests for laxatives)
Other problems
 Psycho-sexual or mental health problems
 Fluid retention
 Sore throat (as a result of vomiting)
 Difficulties sleeping or concentrating
 Weight loss or failure to thrive in children
 Generally feeling unwell, weak and tired, anaemia.
 Wanting to lose weight when normal or under weight
 Food allergies
7
Screening and Assessment in Primary Health Care
Nice Guidance (2004) recommends screening high risk groups
as follows:
 young women with low body mass index compared with
age norms,

those consulting with weight concerns who are not
overweight,

women with menstrual disturbances or amenorrhea,

people with gastrointestinal symptoms,

people with physical signs of starvation or repeated
vomiting

children with poor growth

people with a family history of an Eating Disorder,

those with Type 1 Diabetes,

people who were previously overweight

those in a high risk occupation in terms of overevaluation of body weight – e.g. athlete, dancer, model

Also screen when parents express concerns about a
child or adolescent.
Enquiring about eating habits and worries about weight
gives the person the opportunity to be more open and can
take very little time to rule out an eating disorder (bearing
in mind the possibility of denial).
People with eating disorders are extremely sensitive and
can easily be put off pursuing help. However, careful
assessment and respect for the views of the patient and
their carers makes change possible.
8
The following SCOFF screening tool (Luck et al 2002)
can be used to identify people with a possible eating
disorder:
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone in a 3 month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that Food dominates your life?





Score one point for every "yes” a score of 2 or more indicates a likely
case of ED
Ask questions about:
 Eating patterns (diet, regularity, amount)
 Amount and frequency of purging behaviour (vomiting,
laxatives, diuretics, exercise).
 Attitude and aims regarding weight (including previous
variation).
 Menstrual history (the contraceptive pill can mask
amenorrhoea).
 Substance abuse (alcohol, amphetamines, diet pills,
cannabis, caffeine).
 Mental state (depression, self harm, anxiety, obsessional
behaviour).
Weight and measure and calculate Body Mass Index (weight in
KGs ÷ height in metres²) or percentile on Tanner scales for
child:
BMI DESCRIPTION
20-25
17.5 20
15 75
13.5 15
1213.5
<12
Normal weight range
Underweight: Irregular or absent menstruation. Ovulation failure
Anorexia Nervosa: Amenorrhoea. Loss of substance from all body
organs and structure.
Severe Anorexia Nervosa: All organ systems compromised; bone,
heart; muscle; brain. Metabolism reduced by 50%
Critical Anorexia Nervosa: Inpatient treatment recommended.
Organs begin to fail: muscle bone marrow: heart.
Life threatening anorexia nervosa
9
SYSTEM
Nutrition
Circulation
Test or Investigation
BMI
Weight loss per week
Skin Breakdown
Purpuric rash
Systolic BP
Concern
Alert
<14
>0.5kg
>0.1cm
<90
<12
>1.0kg
>0.2cm
+
<80
Diastolic BP
<70
<60
Postural drop (sit –stand)
>10
>20
Pulse Rate
<50
Extremities
Musculo-skeletal
(squat Test and
Sit up test)
Unable to get up without using arms for
balance
Unable to get up without using arms as
leverage
Unable to sit up without using arms as
leverage
Unable to sit up at all
Temperature
Bone Marrow
Salt /water
Balance
Liver
Nutrition
Differential
Diagnosis
ECG
<40
Drk blue
cold
WWC
Neutrophil count
Hb
Acute Hb drop
(MCV and MCH raised – no acute risk
Platlets
K+
Na+
Mg++
PO4-Urea
Bilirubin
Alkpase
AsT
ALT
GGT
Albumin
Creatinine Kinase
Glucose
TFT
+
+
+
<35C
<98.0F
<4.0
<1.5
<11
+
<34.5
<97.0F
<2
<1.0
<9.0
<130
<3.5
<135
<0.5-0.7
<0.5-0.8
>7
>20
>110
>40
>45
>45
<35
>170
<3.5
<110
<3.0
<130
<0.5
<0.5
>10
>40
>200
>80
>90
>90
<32
>250
<2.5
<50
<40
>450 msec
+
ESR
Pulse rate
Corrected QT intervals (QTC)
Arrythmias
+
10
Initial Treatment in Primary Health Care

Provide information about the effects of eating disorders.
This can increase motivation to change behaviour,
especially in the early stages. Don’t try to shock, but use
your knowledge of the body to explain things in a matter
of fact way (e.g. energy balance, the effects of
starvation, vomiting and laxative abuse, the risk of
osteoporosis).

Suggest they monitor their eating, behaviour, emotions
and thoughts by keeping a diary.

See the person regularly, monitoring their weight and
reviewing their progress (don’t praise the weight gain,
ask how they feel).

Consider referral to:
 Primary Care Counsellor for guided self help,
motivational work and/or brief therapy
 Dietitian for nutritional assessment and advice
 Practice nurse for regular weighing and blood
monitoring.

The book prescription scheme has a range of useful self
help books included in the following list:
E.g. for Bulimia Nervosa and Binge Eating Disorder:

Getting Better Bit(e) by Bit(e) by Ulrike Schmidt and Janet
Treasure. Psychology Press.

Overcoming Binge Eating by Christopher Fairburn, The Guilford
press.

Bulimia Nervosa – A guide to recovery, by Peter Cooper. Robinson
Publishing.
E.g. for Anorexia Nervosa:

Anorexia Nervosa the wish to change by A. Crisp, N. Joughin, C.
Halek and C. Bowyer. Psychology press.

Anorexia Nervosa – A survival guide for Families, Friends and
Sufferers by Janet Treasure. Psychology press.

Provide advice regarding adequate nutrition and the dangers and
ineffectiveness of dieting.
11
When to Refer to your Local Mental Health Service
Clinical management and treatment within primary health
care might be sufficient help for many people with less
severe eating disorders.
However, early referral is advisable for patients who do
not respond rapidly to help in primary care.
For consultation and advice please contact your
Designated Eating Disorders Contact (see page 13)
Referrals to your local mental health team should include
as much detail as possible particularly about assessed
risk. Primary care should continue physical monitoring
and support during the process of referral and may be
required to share care with Tier 2 e.g. medical monitoring.
In the case of suspected high risk i.e. alert in Test or
Investigation table, Contact the Tier 3 specialist
Eating Disorders Team for consultation and advice.
If the presentation is clearly medically urgent ward
4/2 at Nevill Hall hospital hosts Aneurin Bevan LHB’s
specialist bed for medical management of high risk
eating disorders for example during re-feeding from
extreme low weight.
N.B. Please contact the Tier 3 Specialist Eating
Disorder Service to alert them to the planned/urgent
admission.
Tier 3 Specialist Eating Disorders Team contact
details on Page 14
12
Tier 2 – Adult Community Mental Health Teams
Designated Eating Disorders Contacts
North Monmouthshire
Gayle Thomas
Tel: 01873 735500
South Monmouthshire
Alex Price
Tel: 01291 636700
Blaenau Gwent
Sharon Probert
Tel: 01495 363259
Newport
Wendy Rees/
Becky Lowther
Tel: 01633 786000
North Caerphilly
Ruth Dodd
Tel: 01685 846444
South Caerphilly
Torfaen
Mike Larner
Tel: 01495 765729
South Powys
Cath Arnold
Tel: 01874 615050
Tel: 02920 855020
13
Tier 3 – Contact Details
Tier 3 Specialist Eating Disorders Service
Maindiff Court Hospital
Ross Road, Abergavenny
Monmouthshire NP7 8NF
Tel:
Fax:
Email:
01873 735546
01873 735542
[email protected]
Tier 3 Clinical Lead
Clinical Specialist
Consultant Psychiatrist
Specialist Clinician
(Occupational Therapy)
Specialist Dietitian
Specialist Practitioner
Admin Support
Gerrard McCullagh
Emma Hagerty
Dr Irene Jones
Beverley Williams
Claire McCluskey
Clair Loft
Caroline Davies
Further information can be found on the ABUHB Intranet
site at:
http://howis.wales.nhs.uk/sitesplus/866/page/47636
About the Tier 3 Service
 Consultation advice and joint working with Tier 1, 2 & 4 and
acute medical services.
 Direct and joint assessment of eating disorders
 A range of individual, group and family therapies
 Care pathways that have been developed by Tier 3 SEDS
and are delivered jointly between Tier 3 and involved Tier 2
and Tier 1 clinicians.
 A gate keeping role for those patients whose level of risk
and complexity are such that they would require Tier 4
intensity of treatment.
 Supervision and training for Tiers 1 and 2 staff.
14
 Research and audit.
RESOURCES FOR TIER 1, 2 AND 3
B-eat is a national charity (Registered Charity No. 801343)
based in the UK providing information, help and support for
people affected by eating disorders and, in particular,
anorexia and bulimia nervosa. https://www.b-eat.co.uk
A RANGE OF TREATMENT MANUALS FOR EATING
DISORDERS CAN BE DOWNLOADED FREE OF CHARGE FROM
www.cci.health.wa.gov.au
www.aedweb.org/newwebsite/index.htm
www.eatingresearch.com
15
Centre for Clinical Interventions
Academy for Eating Disorders
Institute of Psychiatry