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Managing eating disorders

Professor Janet Treasure and Dr Geoffrey Wolff offer practical tips for GPs

Eating disorders are common in young women, affecting up to 10 per cent of people. The individual may not complain directly of symptoms; however, people with binge eating problems seek information about diets, and family and friends will be concerned about the weight loss of anorexia nervosa.

An exploration of eating and weight or shape concerns is usually sufficient to suggest an eating disorder diagnosis.

Symptoms of starvation are pathognomic of anorexia nervosa, and include sensitivity to cold, amenorrhoea, hair loss and dry skin.

However, depression and vague abdominal symptoms can occur. The differential diagnosis includes endocrine or inflammatory bowel disease or brain pathology.

The most useful differentiation of subtypes of eating disorder is to establish what physical risk may be present, such as:

• significant starvation

• metabolic disruption.

And whether extreme personality traits are present, for example:

• compulsive features, such as rituals

• impulsive dysregulated features, such as substance abuse, antisocial behaviours.

Practical tips for diagnosis

• Anorexia nervosa is likely if the individual is unconcerned about weight loss and

has increased energy and application for

exercise or academic pursuits.

• A normal ESR is a useful screen.

• Uncontrolled eating bouts are characteristic of binge eating disorders.

• People with bulimia nervosa use a variety of behaviours to compensate for eating, such as vomiting, laxatives and diet pills.

Monitoring patients

A simple guide to monitoring cases of eating disorder is available in the professional section of the Institute of Psychiatry website at eatingresearch.com. A BMI risk chart can

also be downloaded.

Key features associated with acute risk are highlighted in table 1.

Long-term risks

Most medical problems (involving all organs of the body) resolve following weight restoration. Osteoporosis can cause long-term disability. There is also concern about transgenerational transmission of eating disorders.

GP management

Engagement

People with eating disorders are ambivalent about treatment. Building an alliance can be difficult. It is important to acknowledge their mixed feelings about change and build a discrepancy between their shrunken quality of life (medical problems are a valuable hook) and any perceived benefits for their behaviours.

Family involvement

Involving families in the management is particularly helpful when anorexia nervosa is present. Living with someone who has

bulimia nervosa is particularly distressing and carers may need support themselves.

There is a tendency for families to become overprotective and to fall in with the rules and controls of eating symptoms and behaviour. Helping them to step back and provide a compassionate platform is valuable.

Information-guided help

A variety of books written for and by professionals, carers and/or people with eating disorders are available (see useful reading). New forms of resources using web-based information and DVDs are being developed.

Individual management

Individual management should be tailored to medical risk and other clinical features.

• High risk – an urgent referral for assessment for possible inpatient care and, in some cases, the use of the Mental Health Act is warranted.

• Moderate risk – an urgent referral for

specialist assessment and treatment.

• Low risk – regular review to observe response to minimal intervention-guided self-care (with the support of materials related to eating disorders or allied areas, such as perfectionism) is recommended as a first stage of treatment in the NICE guidelines; however watchful waiting should be time limited as the chance of recovery decreases the longer the illness persists.

People with additional personality difficulties (obsessive compulsive or borderline), medical problems (diabetes) or who are pregnant may require specialist management.

Nutritional restoration

In order to gain 1kg in weight an extra 7,000kcal on top of basal requirements are needed. A multivitamin and mineral supplement is recommended for people with a BMI of 15 or lower. In addition to eating a sufficient amount to attain a healthy BMI, the goal is to introduce variety and restore meals as a social event.

Medication

Poor acceptability and an unfavourable balance between risk (patients have a prolonged QT interval) and benefits mean that medication is rarely useful for anorexia.

Antidepressants, especially SSRIs, can compliment psychological help for bulimia nervosa. The place of new drugs, such as topiramate and sibutramine for obese binge eating, is uncertain.

Janet Treasure is a director of the Eating Disorder Unit at South London and Maudsley Hospital NHS Trust and professor of psychiatry at King's College London

Competing interests None declared

Geoffrey Wolff is a consultant psychiatrist at

the Eating Disorder Unit, South London and Maudsley Hospital NHS Trust, and honorary senior lecturer, Institute of Pyschiatry, London

Competing interests None declared

key points

• Living with an individual with an eating disorder is stressful, and carers benefit from information and support (see useful reading). Families can be a resource to foster change.

• Screening for nutritional risk includes BMI, cardiovascular function (blood pressure, heart rate, peripheral circulation), temperature and limb girdle strength.

• Monitor for dehydration (postural drop in blood pressure) and metabolic risk (low potassium and glucose in particular), particularly if extreme compensatory behaviours are present.

• In moderate-risk cases, a trial of guided self-care is warranted.

• High-risk cases should be referred immediately.

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