Information for Physicians

Eating disorders are a range of illnesses characterized by psychological and behavioural disturbances associated with food and weight. Types of eating disorders include anorexia nervosa, bulimia nervosa, and binge eating disorder. For definitions of these disorders, please go to: www.anred.com/defswk.html.

People may present with symptoms of more than one disorder and it is common to see overlap between disorders. For these reasons, the most frequent diagnosis by physicians is for eating disorders not otherwise specified or eating disorders that are not categorized. For information on less common eating disorders, please go to www.anred.com/defslesser.html.

• Prevention And Early Intervention
• Relationship Between Dieting And Eating Disorders
• How May A Person With An Eating Disorder Present
• Key Screening Questions For An Eating Disorder
• Checklist – Signs And Symptoms Of Extreme Weight Loss
• Checklist– Signs Of Binging And Compensatory Behaviours
• Checklist - Investigations/Tests That May Be Considered
• Evidence-Based Multi-Disciplinary Treatment
• When To Refer For Further Psychiatric Assessment
• When To Consider Hospitalization
• Additional Resources

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Prevention And Early Intervention

While prevention of an eating disorder is optimal, early identification and effective treatment is linked with positive outcomes.

Often, it is family members / caregivers who are the first to realize that there is a problem. It is important to listen to parents / guardians / partners who express concerns about their family member’s issues around food, body image and weight. It may be a family member who comes to see you first – often the individual with an eating disorder will not feel that there is a problem, or may feel embarrassed about seeking help.

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Relationship Between Dieting And Eating Disorders

• Body image dissatisfaction and subsequent dieting behaviour are the primary antecedents to disordered eating and eating disorders.
• As a practitioner, the most important action you can take is to never promote dieting behaviour – regardless of weight status. The emphasis should be on messages about healthy lifestyles and healthy choices.
• For the Canadian Paediatric Society’s position statement, Dieting in Adolescence please go to see www.cps.ca/english/statements/AM/AH04-01.htm.

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How May A Person With An Eating Disorder Present

Individuals often present with apparently unrelated symptoms which are a result of disordered eating patterns or an undiagnosed eating disorder, including:

1. Physical

• low iron
• menstrual disturbances or amenorrhea
• gastrointestinal symptoms
• Type 1 diabetes and poor treatment adherence
• low body mass index (BMI) compared with age norms OR fluctuating weight.

2. Psychological

• depression, mood swings, anxiety
• substance abuse
• sleep disturbance
• lack of concentration
• obsessive symptoms, particularly related to food and weight
• self-harming behaviours

3. Social Difficulties

• change in social pattern
• school or work problems
• problems in the family and/or other relationships
• involvement with the justice system

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Key Screening Questions For An Eating Disorder

When an eating disorder is suspected, the issue can be explored through questions such as:

• Many people have concerns about food. Please tell me about your eating habits. Do you worry about your eating or do you think that others do?
• Some people have concerns about their weight. Please tell me how you feel about your body and weight?
• Some people have trouble with eating to the point of discomfort or until they are uncomfortable. Please tell me when this has been a problem for you?

If the person indicates having concerns, then ask more detailed questions in an empathetic and non-judgmental manner.

The SCOFF questionnaire has been determined to be a reliable five-question screening tool for women who may have anorexia nervosa or bulimia nervosa. (It will not identify binge eaters who are not thin). The SCOFF questions*: S – Do you make yourself Sick because you feel uncomfortably full? C – Do you worry you have lost Control over how much you eat? O – Have you recently lost more than (One stone) or 14 pounds in a three month period? F – Do you believe yourself to be Fat when others say you are too thin? F – Would you say Food dominates your life? *One point for every ‘yes’; a score of greater than 2 indicates further question is warranted. (http://ebm.bmjjournals.com/cgi/content/full/8/3/90)

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Checklist – Signs And Symptoms Of Extreme Weight Loss

Reproductive function:

• loss of menstruation
• fertility and pregnancy difficulties

Musculoskeletal:

• myopathy particularly of the limb girdle muscles
• pathological fractures
• periodontal disease
• osteopenia

Cardiovascular:

• palpitations
• syncope
• postural & resting hypotension
• bradycardia

Renal:

• Nocturia (night time urination)
• renal stones
• acute failure

Skin and hair:

• loss of head hair
• increase in body hair (lanugo hair)
• Raynaud’s (discoloration of fingers and/or toes)
• self-mutilation
• abrasions on knuckles

Metabolic:

• hypoglycemia
• liver dysfunction
• hypercholesterolemia
• hypothermia

Gastrointestinal:

• delayed gastric emptying
• constipation
• Barrett’s esophagus
• tears on the esophagus

Central nervous system:

• poor concentration
• difficulty in undertaking complex thought

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Checklist– Signs Of Binging And Compensatory Behaviours (e.g., Vomiting, Laxative Abuse, Over-Exercise)

Gastrointestinal tract:

• teeth, loss of enamel, abrasions
• salivary gland hypertrophy
• upper and lower intestinal tract bleeding
• abdominal distension
• constipation

Renal:

• edema
• dehydration
• kidney stones
• kidney failure

Cardiovascular:

• dysrhythmias (abnormal rhythms)
• postural hypotension
• electrolyte imbalance

Central nervous system:

• hyperreflexia
• carpopedal spasm
• cramps
• laryngospasm

For Diabetics:

• insulin manipulation for weight loss

Physical Injury:

• stress fractures

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Checklist - Investigations/Tests That May Be Considered

Physical Exam

• a review of skin for lanugo hair, Raynaud's, abrasions on knuckles, self mutilation.
• an examination of teeth for loss of enamel, abrasions.
• check lying and standing blood pressure for dehydration and reduced autonomic nervous system function.
• check ability to rise from a squat for proximal myopathy.

Standard

• Complete Blood Count (CBC) with differential
• Urinalysis
• Complete Metabolic Profile: Sodium, Chloride, Potassium, Glucose, Blood Urea Nitrogen, Creatinine, Total Protein, Albumin, Globulin, Calcium, Carbon Dioxide, AST, Alkaline Phosphates, Total Bilirubin
• Serum magnesium
• Thyroid Screen (T3, T4, TSH)
• Electrocardiogram ( ECG)

Special Circumstances

• 15% or more below healthy body weight (HBW)
• Chest X-Ray
• Complement 3 (C3)
• 24 Creatinine Clearance
• Uric Acid

20% or more below HBW or any neurological sign:

• Brain Scan

20% or more below HBW or sign of mitral valve prolapse:

• Echocardiogram

30% or more below HBW

• Skin Testing for Immune Functioning

Weight loss 15% or more below HBW lasting 6 months or longer at any time during course of eating disorder:

• Dual Energy X-Ray Absorptiometry (DEXA) to assess bone mineral density
• Estadiol Level (or testosterone in males)

Compiled for the National Eating Disorders Association by Margo Maine, PhD (www.healthyplace.com/communities/eating_Disorders/treatment_1.asp)

• Medical tests often fall short of revealing problems until the more advanced stages of the illness. Patients engaging in dangerous behaviors may have normal test results.
• As a physician it is important to not only check for any medical complications that need attention, but also to establish a baseline for future comparisons.
• In cases where laboratory tests come back normal, it could be explained to the patient that this may not be an indicator of healthy functioning – but rather that the body finds ways to compensate for starvation; for example, decreasing the metabolic rate to conserve energy.
• Birth control pills are not recommended for abnormal menses as they can mask one of the primary symptoms of an eating disorder.

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Evidence-Based Multi-Disciplinary Treatment

Type	Treatment Goals	Treatment Components	Cautions
Anorexia Nervosa (AN)	reducing risk encouraging weight gain and healthy eating reducing other symptoms related to an eating disorder facilitating psychological and physical recovery.	Multi-disciplinary treatment with any combination of: medical monitoring psychological treatment (individual and group) nutritional rehabilitation dietary counselling family counselling	Rigid inpatient behaviour modification programs are not effective for AN. Dietary counselling should not be used as the sole treatment for AN. Pharmacological options should be de-emphasized prior to weight stabilization.
Bulimia Nervosa (BN)	Reducing harm Establishing regular eating Reducing other symptoms related to BN Facilitating psychological and physical recovery	In less complex cases: evidence-based self-help program for BN (CBT-BN) along with medical monitoring and encouragement provided by general practitioner More complex cases: individualized combination of medical monitoring and psychological treatment – For example, Cognitive Behaviour Therapy (CBT)-BN nutritional counselling,  family counselling and pharmacology.	Pharmacological options should not be the sole treatment response.
Binge Eating Disorder (BED)	Reducing harm Establishing regular eating Reducing other symptoms related to BED Facilitating psychological and physical recovery	In less complex cases: evidence-based self-help program for BED (e.g., CBT-BED) along with medical monitoring and encouragement provided by general practitioner More complex cases: individualized combination of medical monitoring and psychological treatment – For example, CBT-BED	Pharmacological options should not be the sole treatment response.
Eating Disorders-Not Otherwise Specified (ED-NOS)	Reducing harm Establishing regular eating Reducing other symptoms related to BED Facilitating psychological and physical recovery	Follow the guidance on treatment of the eating disorder that most closely resembles the individuals’ eating disorder.	Pharmacological options should not be the sole treatment response.
For all Diagnoses:  Attendance at support groups may benefit both individuals and family members.

For more detailed information on treatment, see Information for Health Care Professionals.

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When To Refer For Further Psychiatric Assessment

Indications for referral for assessment include:

• Psychological complications
  • Co-morbid disorders (moderate to severe depression, OCD, suicidal ideation, substance abuse including laxatives, steroids and nutritional supplements
• Difficulties with treatment compliance and failure to progress
• Diagnostic uncertainty

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When To Consider Hospitalization

Nearly all individuals with eating disorders can be treated on an outpatient basis. Hospitalization is a last resort and should only be considered when an individual is severely medically compromised or at risk of serious self-harm.

Adults

• Heart rate < 40 bpm
• Blood pressure <90/60mm Hg
• Symptomatic hypoglycemia
• Potassium <3 mmol per liter
• Temperature < 36.1 c (97.0 F)
• Dehydration
• Cardiovascular abnormalities other than bradycardia
• Weight <75 per cent of the expected weight
• Any rapid weight loss of several kilograms within a short period of time
• Lack of improvement or rapid worsening while in outpatient treatment

Children and Adolescents

• Heart rate <50 bpm
• Orthostatic blood pressure resulting in increase in heart rate of >20 bpm or resulting in drop in blood pressure of >10 to 20 mm Hg
• Blood pressure <80/50 mm Hg
• Hypokalemia or hypophosphatemia
• Rapid weight loss within a short period of time
• Symptomatic hypoglycemia or fasting glucose <3.0 mmol per litre
• Lack of improvement or worsening despite outpatient treatment

Psychological Indications

• Poor motivation or insight (inability to recognize the seriousness of severe weight loss), lack of cooperation with outpatient treatment.
• Inability to eat independently or need for nasogastric feeding
• Suicidal plan, marked suicidal ideation
• Severe coexisting psychiatric disease
• Anti-therapeutic family environment, especially if abuse present

Source: Yager, J., & Anderson, A.E. (2005) Clinical Practice: Anorexia Nervosa. The New England Journal of Medicine, 353:14, pp.1481-1486 (www.nejm.org)

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Additional Publicly Funded Services

For information on treatment in hospital and community, contact:

Adult Eating Disorder Program (Inpatient and Outpatient)
PsychHealth Centre
771 Bannatyne Avenue
Winnipeg MB R3E 3N4
Phone: 1-204-787-3482
Fax: 1-204-787-7480

Child and Adolescent Eating Disorders Service (Outpatient and Day Treatment)
771 Bannatyne Avenue
Winnipeg MB R3E 3N4
Phone: 1-204-787-7218
Fax: 1-204-787-7219

Women’s Health Clinic (individual and group counseling)
3rd Floor, 419 Graham Avenue
Winnipeg MB R3C 0M3
Phone: 1-204-947-1517
Website: www.womenshealthclinic.org

For resource information and supports for individuals and family members, contact:

Canadian Mental Health Association – Eating Disorders Self-Help Program (Winnipeg)
4 Fort Suite, Suite 100
Winnipeg, Manitoba R3C 1C4
Phone : 1-204-953-2358
Fax: 1-204-775-3497
Email: eatingdisorders@cmhamanitoba.ca
Website: www.eatingdisordersselfhelp.ca.

Disordered Eating Program Specialist
(for information on resources available in the Winnipeg Region)
Telephone: 1-204-940-2653
Email: ewatson1@wrha.mb.ca

Mental Health Education Resource Centre (MHERC)
4 Fort Street - Suite 100
Winnipeg MB R3C 1C4
Phone: 1-204-953-2355
Toll Free: 1-866-997-9918
E-mail:  info@mherc.mb.ca
Website: www.mherc.mb.ca

More descriptive information on the nature of the programming is available in the Provincial Inventory of Eating Disorder Services.