la Vie saine Manitoba

Information for Health Professionals

As a health care professional you may see individuals with eating disorders during the course of your day-to-day practice.  While prevention of an eating disorder is optimal, early identification and effective treatment are linked with positive outcomes.

Often, it is family members / caregivers who are the first to realize that there may be 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. In fact, 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.

• Screening Identification
• What Should I Look For In Children And Adolescents?
• Key Screening Questions For An Eating Disorder
• Eating Disorder Screening Questions For Adolescent And Pre-Adolescents
• Obtaining An Eating History
• Evidence-Based Approach For Treating Eating Disorders
• Evidence-Based Practice For Treatment Of Anorexia Nervosa
• Evidence-Based Practices For Treatment Of Bulimia Nervosa
• Evidence-Based Practices For Treating Binge Eating Disorder
• Evidence-Based Practice For Treatment Of Other Eating Disorders Not Otherwise Specified
• Should I Prescribe A Specific Diet If An Individual Is Overweight?
• Resources And Referrals

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Screening / Identification

How A Person With An Eating Disorder May 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 energy
• 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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What Should I Look For In Children And Adolescents?

Adolescents need to be considered separately and differentiated from adults with eating disorders (Society for Adolescent Medicine, 1995). Diagnostic criteria, such as the DSM-IV may not be reliable indicators for the following reasons:

• there is a wide variability in height and weight gain during normal puberty;
• for girls, there may be an absence or unpredictability of menstrual periods in early puberty;
• lack of psychological awareness regarding abstract concepts (such as self-concept, motivation to lose weight or affective states); and


• clinical features such as pubertal delay, growth retardation or impairment of bone mineral acquisition may occur at sub-clinical levels of eating disorders.

Reliance on strict criteria may delay or preclude the early identification of eating disorders. Sub-clinical levels of disordered eating and significantly abnormal eating attitudes may result in significant long-term impairments to health. Therefore, for children and adolescents, assessment for the possibility of an eating disorder should occur if there is:

• any evidence of excessive dieting (i.e., omitting food groups, skipping meals, fasting, rigid rules around foods, rituals);
• excessive concern with weight / body image;
• weight fluctuations; and
• failure to achieve appropriate increases in weight or height.

If the assessment provides reason for concern, close monitoring and referral for further assessment is appropriate (Pediatrics, Committee on Adolescence, 2003). For more information please go to www.adolescenthealth.org/PositionPaperSummary.htm#Eating

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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.

 

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Eating Disorder Screening Questions For Adolescent And Pre-Adolescents

The U.S. Department of Health and Human Services provides the following questions for practitioners wishing to screen children and adolescents for eating disorders (See www.4woman.gov/BodyImage/bodywise/hp/HCP-eattips.pdf.)

Attitudes about weight and shape

• How do you feel about the shape and size of your body?
• Have you ever used any type of supplements to change the shape of your body? (e.g., steroids, creatine, supplements for weight gain)

Dieting/ Eating History

• Have you ever tried to lose weight? If yes, how? (dieting, vomiting, taking diet pills or laxatives)
• Have you ever felt out of control with your eating? (e.g., eating a large amount of food in a short period of time)?

Menstrual History

• When did you start to menstruate?
• Have you noticed any changes to your menstrual cycle? If yes, what has changed
• How often do you menstruate?
• When was your last menstrual period?

Eating Disorder Screening Questions For Parents

• Is there a family history of eating disorders or addictions?
• Does your child make negative remarks about his or her body?
• Have you noticed any changes in food related habits? If so, what?
• Are you concerned about your child’s weight, eating or exercise habits?
• Does your child eat regular meals with the family?
• Does your child have an increased interest in food-related activities, but with decreased intake of food?
• Does your child seem depressed or withdrawn?
• Is your child experiencing severe mood swings or obsessive/compulsive behaviours?
• Have you noticed any changes in your child’s sleep patterns?
• Has your child’s school performance changed?
• Do you have any other concerns about your child?

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Obtaining An Eating History

1. Screen for important physical symptoms

• When was your last period?
• Have you noticed any weakness in your muscles? What about climbing stairs or brushing your hair?
• Are you more sensitive to the cold than other people?
• What is your sleep like?
• Have you fainted or had dizzy spells?
• Do you have any problems with your teeth (hot/cold sensitivity, etc.)?
• Have you had any problems with your digestive system?

2. Eliciting psychopathology

• What do you think of your current weight?
• Do you think you would feel different if your weight was lower?
• How do you think your life would be different if you lost weight?
• Do you ever get depressed or feel guilty?
• Do you ever feel suicidal?
• Do you have any special rules about exercise or food (e.g., eating only low calorie or fat-free foods, skipping meals or making yourself exercise before eating)?
• Do you have compulsions to do things (e.g., binge or over-exercise)?

3. Establishing eating behaviours

• Do you avoid eating with others?
• Which foods feel ‘safe’ and which do you avoid?
• Do you ever vomit, exercise, use laxatives and/or diuretics? If so, how often and when?

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Evidence-Based Approach For Treating Eating Disorders

Unless otherwise noted, the following guidelines have been drawn from the National Institute of Clinical Excellence (NICE), Eating Disorders Treatment Guidelines that was published in January 2004. (www.nice.org.uk/cat.asp?c=101239). The site also contains a Quick Reference Guide (www.nice.org.uk/page.aspx?o=cg009quickrefguide) that clinicians may find useful.

There are a number of broad areas of agreement regarding what makes treatment most effective for eating disorders. These are:

• intervention at the earliest possible opportunity
• family involvement / therapy is key to the success of treatment, particularly with children and adolescents and often beneficial when working with adults.
• treatment should begin with the least intrusive and then move to more intensive interventions only as warranted by the clinical situation.
• in more complex cases, the involvement of clinicians from various disciplines including psychologists, social workers, general practitioners, occupational therapists, dietitians and nurses is warranted.
• follow-up care should be at least 12 months.

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Evidence-Based Practice For Treatment Of Anorexia Nervosa

Treatment goals should include:

a) reducing risk;
b) encouraging weight gain and healthy eating;
c) reducing other symptoms related to an eating disorder; and
d) facilitating psychological and physical recovery.

No single professional or professional discipline is able to provide the necessary broad medical, nutritional, and psychiatric care necessary for recovery. A team of professionals who communicate regularly must provide this care. This teamwork is necessary whether the individual is undergoing inpatient or outpatient treatment.

1. Medical monitoring

• General physical status
• treatment of any physical / medical conditions associated with the eating disorder

2. Psychological Treatment

• cognitive behavioural therapy (CBT)
• interpersonal psychotherapy (IPT)
• focal dynamic therapy
• family interventions focused explicitly on eating disorders
• motivational interviewing (MI) techniques
• follow-up treatment should be at least 12 months.
• rigid inpatient behaviour modification programs should not be used in the management of Anorexia.

3. Nutritional Support/Dietary Counselling

• Individualized guidance and a meal plan that provides a framework for meals and snacks and food choices (but not a rigid diet)
• Trials of ‘safe’ and ‘unsafe’ foods
• Provision of nutrition sessions where food and weight concerns can be discussed
• Dietary counseling should not be provided as the sole treatment for Anorexia. Weight restoration alone does not indicate recovery, and forcing weight gain without psychological support and counselling is contraindicated (American Dietetic Association, 2001).

4. Family Involvement

• Therapeutic involvement of siblings and other family members
• Provision of information to family members about eating disorders and treatment goals
• Connecting family members to self-help and other supports, as appropriate

5. Pharmacological Options

• Medication may be an adjunct to nutritional rehabilitation but should not be used as the sole or primary treatment for Anorexia
• Cardiac side effects of any medications used should be considered due to compromised cardiovascular function

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Evidence-Based Practices For Treatment Of Bulimia Nervosa

Treatment will have the following goals: a) reducing harm; b) establishing regular eating; c) reducing other symptoms related to eating disorder; and d) to facilitate psychological and physical recovery. The following are recommended treatment options.

1. Psychological Treatment

• individuals with bulimia nervosa should be encouraged to follow an evidence-based self-help program, along with the provision of active support and encouragement by practitioner. This may be sufficient for a subset of individuals with Bulimia.
• Cognitive Behaviour Therapy for bulimia nervosa (CBT-BN), a specifically adapted form of CBT for 16 to 20 sessions over 4 to 5 months for adults.
• In situations where individuals do not respond to CBT-BN, or do not want CBT-BN, interpersonal psychotherapy (IPT) should be considered. However, people should be informed that it takes 8-12 months to achieve the same results as 4-5 months with CBT-BN.
• Adolescents with bulimia nervosa may be treated with CBT-BN, adapted to be age appropriate, and including family, as appropriate.

2. Pharmacological Options

• As an alternative or additional first step to using an evidence-based self-help program, adults with bulimia may be provided with a trial of an anti-depressant drug. Selective serotonin reuptake inhibitors (SSRIs) especially fluoxetine, are the drugs of first choice in terms of acceptability, tolerability and reduction of symptoms. For individuals with bulimia nervosa, the effective dose is higher than for depression (60 mg daily).

3. Nutritional Counselling

• A focus on working toward establishing regular meals has been proven to reduce the urge to binge (King’s College, 2005).

4. Family Involvement

• It is helpful to include the family in any plan of treatment, especially with children and adolescents.
• However, the involvement of family and/or friends can be beneficial to both the individual and family for older individuals also (King’s College, 2005).
• Individuals with bulimia nervosa who have poor impulse control, particularly with substance use, may be less likely to respond to a standard program of treatment. In order to be effective, treatment should be adapted to the problems presented.

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Evidence-Based Practices For Treating Binge Eating Disorder

Treatment will have the following goals:

a) reducing harm;
b) establishing regular eating;
c) reducing other symptoms related to eating disorder; and
d) to facilitate psychological and physical recovery. The following are recommended treatment options.

1. Psychological Treatment

• individuals with binge eating disorder should be encouraged to follow an evidence-based self-help program, along with the provision of active support and encouragement by practitioner. This may be sufficient treatment for a subset of individuals with binge eating disorder (BED).
• Cognitive behaviour therapy for binge eating disorder (CBT-BED), a specifically adapted form of CBT, should be offered to adults with binge eating disorder.
• In situations where individuals do not respond to CBT-BED or do not want CBT-BED, interpersonal psychotherapy (IPT) should be considered.
• Adolescents with binge eating disorder may be treated with CBT-BED adapted to be age appropriate, and including family, as appropriate.

2. Pharmacological Options

• As an alternative or additional first step to using an evidence-based self-help program, adults with bulimia may be provided with a trial of an anti-depressant drug. Selective serotonin reuptake inhibitors (SSRIs) especially fluoxetine, are the drugs of first choice in terms of acceptability, tolerability and reduction of symptoms. For individuals with bulimia nervosa, the effective dose is higher than for depression (60 mg daily).

3. Nutritional Counselling

• Nutritional counseling sessions with a focus on the promotion of regular meals each day, which reduces the urge to binge (King’s College, 2005).

4. Family Involvement

• It is helpful to include the family in any plan of treatment, especially for children and adolescents. However, the involvement of family and/or friends can be beneficial to both the individual and family for older individuals also (King’s College, 2005).

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Evidence-Based Practice For Treatment Of Other Eating Disorders Not Otherwise Specified (Ednos)

In the absence of evidence to guide the management of atypical eating disorders (eating disorders not otherwise specified) other than binge eating disorder, it is recommended that health professionals consider following the guidance on the treatment of the eating problem that most closely resembles the individual’s eating disorder.

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Should I Prescribe A Specific Diet If An Individual Is Overweight?

• 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. Rather, 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 www.cps.ca/english/statements/AM/AH04-01.htm.

 

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Resources And Referrals

1. Eating Disorders Treatment Programs & Services

The following are hospital-based treatment programs for eating disorders:

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

More descriptive information on the nature of the programming is available in the Provincial Inventory of Eating Disorder Services at: www.gov.mb.ca/health/mh/ed-inventory.html

2. For information and links on available supports in Manitoba 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

3. For treatment options in the community ranging from weight preoccupation to eating disorders, contact:

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

4. General resource information on eating disorders

Boundary Trails Public Health Department – Lending library (Winkler/Morden)
Phone 1-204-331-8832

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

5. Best practice treatment information

The following are links to clinical guidelines, position papers, frequently asked questions for practitioners, and research on various aspects of eating disorders.

Academy for Eating Disorders
Website: www.aedweb.org/eating_disorders

The Academy for Eating Disorders is an international transdisciplinary professional organization that promotes excellence in research, treatment and prevention of eating disorders.

American Dietetic Association
Website: www.eatright.org/images/journal/0701/adap.pdf

In 2001, the American Dietetic Association published their position paper on nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS).

Canadian Paediatric Society
Website: www.cps.ca/english/statements/AM/am96-04.htm

In 2004, the Canadian Paediatric Society re-affirmed its position statement on identifying and treating eating disorders in adolescents.

Geneva Foundation for Medical Education and Research
Website: www.gfmer.ch/Guidelines/Obesity_eating_disorders/Eating_disorders.htm

The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organisation established in 2002 and supported by the Department of Health of the Canton of Geneva, the Faculty of Medicine, Geneva University, and the Geneva Medical Association. The GFMER works in close collaboration with the World Health Organization (WHO). The Foundation’s website includes links to a range of guidelines and journal articles on eating disorder prevention, identification and treatment.

King’s College London Institue of Psychiatry at Maudsley
Website: www.iop.kcl.ac.uk/IoP/Departments/PsychMed/EDU/GPguide.shtml

A General Practitioners Guide to Eating Disorders is comprised of ‘Frequently Asked Questions for GPs’ and contains many links including one to a comprehensive guide to the management and treatment of eating disorders in Primary Care produced by the Royal College of Psychiatrists.

National Institute for Clinical Excellence
Website: www.nice.org.uk/cat.asp?c=101239

In January 2004, the National Institute for Clinical Excellence (NICE) in the UK published their Eating Disorders Treatment Guideline. The site contains a Quick Reference Guide that clinicians may find useful.

The American Psychiatric Association
Website: www.aafp.org/afp/20000701/tips/15.html

In 2000, the American Psychiatric Association (APA) published treatment guidelines for eating disorders.