As summer approaches, we all want to have a great beach body, but for some, it can be a life-threatening obsession. Today’s TED explored Eating Disorders and we were lucky enough to have Dr Warren Ward, Director of RBWH Eating Disorder Service as a guest presenter and the venerable Dr Charles Denaro, Director of Internal Medicine, RBWH to offer his perspective of the management of these patients on the ward.
To put things in perspective, Dr Maya Aoude, Emergency Registrar, gave us “the skinny” on current state of affairs of presentations in the local RBWH context.
- 32 patients over the last six months were seen at RBWH, ninety percent were female. 1 in 20 Australian suffer from an eating disorder. There was some surprise from the local audience that the largest age demograph was in the 25-35 year age group. Dr Denaro and Dr Ward pointed out, the disease is chronic and that although the age of onset is around 14-20, it takes time to develop the physiological abnormalities that manifest in a need to present. Most are referred by their GP or community mental health.
- About 50 % of all eating disorder admissions start out requiring medical admissions. Our network partners eluded that presentations to their EDs of patient with eating disorders requiring admissions are rare. The majority were voluntary patients
Anorexia Nervosa and Eating Disorders
Dr Ward took some time to offer some educational pearls and wisdom on the treatment of this group. Here are some of the key points as I saw them:
Three types of eating disorders
-> Anorexia Nervosa
-> Eating disorders associated with increased weight (binge eating disorder)
15 % of females in Australia will have an eating disorder in their lifetime
10-20% of anorexia nervosa patients will die – it has the highest mortality rate of all psychiatric illnesses. However it also has a 70% cure rate within 5 years, with a multidisciplinary team approach.
The biggest risk for patients with an eating disorder is unintentional death due to starvation. Someone can feel well and have normal bloods, but can suddenly drop dead from an arrhythmia.
Indications of cardiac risk:
BMI < 14
No oral intake for 1 week
Purging several times per day
SBP < 90
HR <50 or >110
My pants don’t fit me, how did it let myself go … without eating??
Culture, genetics, female gender and abuse or disturbed attachments in the first five years of life all play a role in the development of anorexia. And we can all can probably appreciate the effect of peer pressure and media on developing a negative self-image. The biggest cause however is dieting!!
Dr Ward showed two interesting studies:
1.) Eating attitudes and behaviours prior and post introduction of TV to a culture (Fiji) previously without this media
-> 60 % increase in abnormal eating behaviour in adolescents who were exposed to TV compared to those that were not
2.) More interestingly, the Minnesota Starvation Experiment, Ancel Keys, just post war
-> Participants dropped 25 % of body weight
-> increases in depression and hypochondriasis and preoccupation with food
-> so dieting a major risk factor for developing anorexia nervosa
-> participants became obsessional and detailed in their thinking, lost libido
This means that behaviours of anorexia nervosa initially more likely to be related to biochemical effects of starvation syndrome, rather than underlying primary psychiatric problems.
SO WHAT CAN I DO??
Assessment of Eating Disorder Patients in ED
- Should only really take 5-10 minutes despite being emotionally charged
- History is the key -> the process of how they got to ED. They are here for a reason
- If they are in ED, they are more than likely further down the slippery slope than we realise
-> episodes of fainting key indicator need admission
-> often will tell you “everything is ok” if asked generalised questions on welfare, but be honest when asked specific questions about eating
-> Get collateral from family members and GP
-> Fainting, light-headedness, chest pain, palpitations, ankle swelling, weakness, fatigue, regular periods -> I send young, articulate, well-looking patients with non-specific symptoms like this home all the time!! Protection for you and your patient is to correlate with quick eating history
(No it’s not Mel Gibson and Danny Glover)
Patient and doctor denial of seriousness of condition
Easy -> postural HR, BP, weight and height.
-> Can add in a request to do a squat – de-conditioned patients find this hard to do
-> In patients with eating disorders, HR increases with standing/walking, as opposed to athletes who can maintain bradycardia with mild exertion
Once again, pretty straight forward
-> ELFT (including phosphate), FBC, ECG
Fix what is not normal -> Na, K, Glucose, Phos preferentially IV -> they are more depleted and these parameters, particularly K likely to get worse with refeeding.
Myocardium de-conditions as well as skeletal muscle, just watch how much fluids you give them, especially if already puffy
DON’T FORGET THIAMINE, again IV
Start continuous NG feeds, 50mL/hr NGT of nutrison protein plus or liquid supplements in ED. Need 6300kJ/1500kCal per day.
Use the RBWH guidelines for assistance
Eating disorder admission guide
“WE DON’T NEGOTIATE WITH TERRORISTS”
Eating disorder patients are often high achievers as they are obsessional and detailed. They will provide a good arguments not to be admitted. Use the mental health act to keep them against their will and Guardianship act to treat their starvation syndrome. If you think they will leave, do a Request and Recommendation, even if they will agree to stay, even if PEC says not to. Use their guardians (parents are guardians in the event of them being assessed as incompetent to make decisions) and often do not need to use more aggressive measures to keep these patients.
Anorexia is a chronic disease, needing long-term help.