Background

Assessment

1. Identification and Screening

   • Early identification and treatment of patients with an eating disorder is hugely valuable and makes a real difference in outcome. Patients in this group have the highest mortality of any psychiatric disorder. 
     • Eating Disorders can be difficult to detect in primary care
     • They will often be identified in educational settings via the school nurse or a teacher or from parental concerns
     • Individuals are often presented by parents/caregivers rather than present themselves
     • Routine psychological assessment is probably the best way to pick up an eating disorder, and this can be done via a quick HEEADSSS assessment (see screening tools box)
     • Target groups for screening

       Young women with low BMI compared with the age norm	Patients consulting with weight concerns who are not overweight
       Women with menstrual disturbances or amenorrhea	Patients with gastro-intestinal symptoms, i.e. constipation, bloating, reflux
       Patients with physical signs of starvation or repeated vomiting	Children with poor growth
       Young people with type I diabetes and poor treatment adherence	Patients that present with dental problems eg gingivitis or toothache, may raise concerns if vomiting repeatedly

     • Higher risk groups for anorexia: young people who diet (x5 with moderate dieting, x18 with severe dieting), overweight people who suddenly lose a lot of weight, boys who are into extreme exercise or body building.
     • Useful questions
       • "Does your weight affect the way you feel about yourself?"
       • "Are you satisfied with your eating patterns?
       • "What do you think about your current weight and shape?
       • "Have you cut out any food groups recently?"
       • "Have you ever had anorexia?"
       • "Has anybody ever suspected you have an eating disorder?"
       • "Have you ever vomited or used laxatives, diuretics or enemas for weight loss or weight control?"
     • Use the  SCOFF
       • 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 > 1 stone (6.3kg) in a three-month period?
       • Do you believe yourself to be Fat when others say you are too thin?
       • Would you say that Food dominates your life?  

       (One point should be given for every “yes” answer; a score of ≥2 indicates a likelihood of anorexia nervosa or bulimia nervosa) 

       questionnaire to help clarify any suspicion of an eating disorder – this is not a diagnostic tool but a guide.

2. Screening tools

   • HEEADSSS- Home, Education/ Employment, Eating, Activities, Drugs & Alcohol, Sexuality, Suicide/ Depression,Safety - click here for some great online resources for training in this. 
   • SCOFF
     • 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 > 1 stone (6.3kg) in a three-month period?
     • Do you believe yourself to be Fat when others say you are too thin?
     • Would you say that Food dominates your life?  

     (One point should be given for every “yes” answer; a score of ≥2 indicates a likelihood of anorexia nervosa or bulimia nervosa) 

3. Definition

   • The diagnosis of an eating disorder will generally be made within the MDT team at a secondary level. The diagnostic criteria are stated here for reference only and should not be used over and above any clinical suspicion or concern regarding an individual’s presentation.
   • Anorexia Nervosa (DSM V)
     1. Restriction of energy intake resulting in a significantly low body weight, or a less than minimally expected weight (based on age, sex or developmental trajectory)
     2. Intense fear of gaining weight; or persistent behaviour that interferes with weight gain, despite low weight
     3. Disturbance in body image; or persistent lack of recognition of the seriousness of the current low body weight
        Sub-types: Restricting type, binge-eating/purging type 
   • Bulimia Nervosa (DSM V)
     1. Recurrent episodes of binge eating (this involves eating an excessive amount of food in a discrete period of time AND a sense of lack of control)
     2. Recurrent inappropriate compensatory behaviours to prevent weight gain, such as vomiting, laxatives, diuretics, fasting or excessive exercise
     3. Frequency of at least once per week for three months
     4. Self-evaluation unduly influenced by body shape and weight
     5. Absence of anorexia nervosa
        Subtypes: Purging type, non-purging type
   • Avoidant/Restrictive Food Intake Disorder (ARFID)
     1. Eating or feeding disturbance with persistent failure to meet nutritional needs associated with either significant weight loss (or growth failure), significant nutritional deficiency, dependence on enteral/supplemental feeding or marked interference with psychosocial functioning
     2. Not explained by lack of available food or culturally sanctioned practice
     3. Absence of anorexia nervosa, bulimia nervosa or body image disturbance
     4. No intercurrent medical illness

     • • Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnostic category in the DSM-5. It is defined as a persistent feeding or eating disturbance leading to avoidance of food, which results in significant weight loss or nutritional deficiency and/or impairment in psychosocial functioning. Unlike anorexia nervosa and bulimia nervosa, ARFID is not characterised by preoccupation with body shape and weight or by intentional weight loss behaviours. Instead, patients suffering from ARFID may be disinterested in food and eating with lack of appetite leading to slower rate of eating, eating smaller portions, and greater struggles around food.
       • It is quite important to distinguish ARFID from picky eating, which is relatively common among children (20-30%) but only for a small subgroup of picky eaters their behaviour becomes more persistent, leading to either malnutrition and weight loss with medical complications similar to anorexia nervosa and/or impairment of psychosocial functioning. The avoidance of eating may also be caused by traumatic experiences related to consuming food, such as a personal or witnessed episode of choking, gagging or vomiting. 
       • Common Signs of ARFID
         • Long history of ‘picky eating’ since childhood
         • Lack of interest in food and eating
         • Lack of appetite
         • Slow rate of eating
         • Eating smaller portions
         • Greater struggles around food
         • Avoidance of foods because of dislike of colour, texture, smell or taste
         • Fear of choking, gagging or vomiting
         • Gastrointestinal complaints like bloating, heartburn, nausea, constipation
         • Weight loss and signs of malnutrition
         • Avoidance of situations of social eating
   • Binge Eating Disorder
     1. Recurrent episodes of binge eating
     2. Associated with symptoms such as eating more rapidly, feeling uncomfortably full, not feeling hungry, eating alone due to embarrassment and/or feelings of self-disgust
     3. Marked distress regarding binge eating
     4. Frequency of at least once per week for three months
     5. Absence of compensatory behaviours, anorexia nervosa and bulimia nervosa
   • Other specified FED (OSFED)
     • Eating disorders causing significant distress but not meeting criteria for other diagnostic categories.  Examples
       • Atypical anorexia nervosa – ‘normal weight anorexia nervosa’
       • Bulimia nervosa (of low frequency and/or limited duration)
       • Subthreshold binge – eating disorder
       • Purging disorder
       • Night eating syndrome 

4. History

   • Naturally, history will be targeted to the concerns raised. Useful areas to explore:
     • Changes in behaviour around food
     • General functioning at home and school
     • Changes in family and other relationships
     • Weight loss or gain, patterns/trends in BMI
     • Menstruation patterns
     • Specific symptoms – cold sensitivity, sleep disturbances, fainting or dizzy spells, dental problems, digestive problems, vomiting blood
     • Consider medical causes of weight loss, i.e. coeliac disease (see differential diagnosis)

5. Physical Examination

   • Height, accurate weight, BMI and BMI centile and previous measurements – This link has some good graphs.
   • Lying and Standing Heart Rate and Blood Pressure
   • Body Temperature
   • Peripheral Circulation – capillary refill, peripheral cyanosis, peripheral and sacral oedema
   • Pubertal status
   • Signs of binging/purging – including roughness on knuckle of index finger (Russell’s sign), enlargement of the parotid glands and dental erosion
   • Evidence of deliberate self-harm – cuts or scars on the arms, thighs or abdomen

6. Investigations – to consider

   • These may be done at the initial assessment but are not always helpful to do on an ongoing routine basis unless there is a valid reason to do so.
     • Full blood count and ESR
     • Urea and electrolytes, creatinine, calcium, magnesium, phosphate, random blood glucose
     • Luteinising hormone, follicle-stimulating hormone, oestradiol (or testosterone, if male)
   • For young people with more advanced eating disorders or severe weight loss, add:
     • Serum bicarbonate and pH on venous gas analysis (metabolic alkalosis may indicate vomiting)
     • Liver function tests
     • Thyroid function tests
     • ECG – essential if any symptoms or signs of cardiac compromise, e.g. bradycardia, electrolyte abnormality, if patient has a BMI below 15kg/m3

7. Risk Assessment

   • Patients with an eating disorder have a high risk in terms of their own safety and health. They have the highest mortality of any psychiatric disorder.
   • The factors involved in the assessment of risk in people with eating disorders include:
     • Medical risk
     • Psychological risk
     • Insight/capacity and motivation
   • If there is immediate concern for safety it may be appropriate to  Contact the crisis team

     Contact:

     • EBOP: 0800 774545 or during business hours on 07 306 0154
     • WBOP: 0800 800508 or during business hours 07 579 8329
   • If the patient requires compulsory assessment then they will need the Mental Health Act 1992. If this is needed then contact the Duty Authorised Officer using he 0800 numbers above and they will provide the necessary forms.

8. Differential-Diagnosis

   • Keep in mind that eating disorders may co-exist with other disorders.
   • Consider other causes of weight loss if appropriate
     • Malabsorption, e.g. coeliac disease, inflammatory bowel disease
     • Diabetes Mellitus
     • Glandular Fever
     • Cancer
     • Substance or Stimulant Misuse
     • Infection, e.g. Tuberculosis
     • Autoimmune Disease
     • Endocrine Disorder – e.g. hypothyroidism, Addison’s Disease
   • Other causes of amenorrhea include
     • Pregnancy
     • Primary Ovarian Failure
     • Polycystic Ovarian Syndrome
     • Pituitary Prolactinoma
     • Hypothalamic Cause
   • Psychiatric Differential Diagnoses include
     • Depressive disorder or episode
     • Obsessive Compulsive Disorder
     • Psychotic disorder
   • Pre-pubertal children may show symptoms of eating disorder secondary to
     • Emotional and behavioural disorders
     • Phobias
     • Refusal Disorder

Management

1. Red flags and criteria for possible admission

   • Please see admission criteria below for some guidance around who might need to be admitted.
   • This table is for those patients who are acutely unwell when you are assessing them. Please see the  Referral for specialist assessment
     • Refer into Paediatrics or MICAMHS for any concerns around weight loss with no obvious cause as well as any concerns regarding an eating disorder
     • Early intervention is associated with improved prognosis
     • The individual will have a joint MICAMHS/Paediatric assessment which will usually take place within a few weeks of receiving the referral. 
     • Please include all previous height/weight parameters and pulsein referral as well as the relevant history, other examination findings and investigation to date.
     box for guidance on referring patients in for outpatient assessment.
   • If you have any concerns about an individual with possible eating disorders then in the first instance please contact the paediatrician on-call at either Tauranga or Whakatane.
   • It is important to note that those individuals who are admitted often have poorer outcomes and so careful assessment of the need for admission is vital.
   • Admission Criteria

     Life-threatening weight loss <75% expected IBW BMI<14 Acute weight loss of 15-20% in 3 months	Acute medical complications of malnutrition Syncope Seizure Pancreatitis Cardiac failure Gastric Dilatation
     Acute Food Refusal	Significant Dehydration
     Hypoglycaemia	Electrolyte imbalance Hypokalaemia (<3.0 mmol/ L) Hypophosphatemia (0.8 mmol/L)
     Physiological Instability Bradycardia – Heart rate <50/min Hypotension – systolic BP <80mmHG Hypotension – Diastolic BP <40mmHG Significant postural drop in BP (>20mmHG) or rise in HR (increase by >30 bpm)	Arrhythmia
     Significant co-morbid psychiatric states Depression Anxiety Psychosis Obsessive Compulsive Disorder	Failure to Gain Weight Despite Maximum Outpatient Treatment

2. Food Challenge

   • If there is some uncertainly as to whether the individual has an eating disorder:
     • Express concern around stated symptoms or behaviour
     • Highlight possible physical/psychological consequences of continued concerning food related behaviours
     • Encourage healthy behaviour around food and weight, use online resources
     • Establish a weight goal – around 200-500mg/week
     • Set up follow up in 2-3 weeks 

3. Review: 2-3 weeks

   • At this visit – weigh and assess symptoms/behaviours
   • If there has been weight gain, change in behaviour and insight is good then agree to further monitoring with monthly review and weight for next 3 months.
   • If no ongoing concerns, nothing further.

4. If continued concerns

   • Referral for specialist assessment
     • Refer into Paediatrics or MICAMHS for any concerns around weight loss with no obvious cause as well as any concerns regarding an eating disorder
     • Early intervention is associated with improved prognosis
     • The individual will have a joint MICAMHS/Paediatric assessment which will usually take place within a few weeks of receiving the referral. 
     • Please include all previous height/weight parameters and pulsein referral as well as the relevant history, other examination findings and investigation to date.

Information

• For Patient & Carers
  • http://www.ed.org.nz/This is a New Zealand based website with a huge wealth of resources to help support and provide information for people with eating disorders and their families.
  • http://maudsleyparents.org/Maudsley Parents was created in 2006 by parents who helped their children recover with family-based treatment, to offer hope and help to other families confronting eating disorders. They offer information on eating disorders and family-based treatment, family stories of recovery, supportive parent-to-parent advice, and treatment information for families who opt for family-based Maudsley treatment.
  • http://www.feast-ed.org/Families Empowered and Supporting Treatment of Eating Disorders – An American based website 
  • https://icamh.org/informations/?_sft_topic=eating-disorders- Infant, Child and Adolescent Mental Health – information and support for families and friends. 
• For Providers
  • Early identification and treatment of patients with an eating disorder is hugely valuable and makes a real difference in outcome. Patients in this group have the highest mortality of any psychiatric disorder
  • If you have any concerns about a patient with a possible eating disorder then please discuss these with a specialist. 
  • http://www.ed.org.nz/This is a New Zealand based website with a huge wealth of resources to help support and provide information for people with eating disorders and their families.
  • https://icamh.org/informations/?_sft_topic=eating-disorders- Infant, Child and Adolescent Mental Health – information for young people, families and professionals.
  • https://www.nice.org.uk/guidance/ng69- Eating Disorders Recognition and Treatment.
• Acknowledgments

  This pathway was developed in collaboration with the following people:

  Name	Position
  Dr Kendell Crossen	SMO Paediatrician/Adolescent Specialist
  Dr Alison James	GP Liaison
  Amber Fletcher	Clinical Psychologist/Eating Disorder Liaison

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.