A professional resource for general practitioners (PDF)

Evidence Experience Expertise Eating Disorders: A professional resource for general practitioners  The National Eating Disorders Collaboration (NEDC) is funded by the Australian Government Department of Health. This booklet is for general information only and should not be a substitute for medical or health advice. While every effort is made to ensure the information is accurate NEDC makes no warranties that the information is current, complete or suitable for any purpose. Reviewed and updated in November 2021. To find help or learn more, visit nedc.com.au Evidence Experience Expertise  Contents Introduction 3 Key Features for Early Identification 5 Initial Response 12 Shared Care 19 Treatment 25 Recovery Support 29 References 32  Introduction  To find help or learn more, visit nedc.com.au Eating Disorders: A Professional Resource for General Practitioners will provide GPs with key information about identifying, responding to, and managing eating disorders. For more in-depth information about the topics covered in this booklet, as well as an interactive learning experience that includes videos, resources and activities, access NEDC’s free online training Eating Disorder Core Skills: eLearning for GPs. Online Learning for General Practitioners The National Eating Disorders Collaboration has developed Eating Disorder Core Skills: eLearning for GPs – comprehensive foundational eating disorder training developed specifically for GPs. The training provides GPs with the key information needed to provide best practice care for patients with eating disorders. This freely accessible four-hour, self-paced and interactive online training includes practical real-life scenarios and activities, videos from leaders in the field and people with a lived experience of an eating disorder, up-to-date resources, and a formal assessment. The training will equip GPs with the knowledge and skills needed to understand, identify and assess eating disorders, provide medical treatment, lead the multidisciplinary team, manage MBS items and provide ongoing recovery support. Eating Disorder Core Skills: eLearning for GPs is accredited by: • Royal Australian College of General Practitioners (RACGP) as a CPD Accredited Activity (40 points) • General Practice Mental Health Standards Collaboration (GPMHSC) as Mental Health CPD • Australian College of Rural and Remote Medicine (ACRRM) under the Professional Development Program For more information and to access the training, click here. The role of the GP in the treatment of eating disorders GPs have a crucial role in the prevention, identification, diagnosis and medical management of eating disorders. As a GP, you can: • identify eating disorders by recognising and following up on warning signs, and proactively screening at-risk groups • assess, diagnose and medically manage eating disorder presentations • refer to eating disorder-specific mental health treatment • refer to dietitian and other health professionals and medical specialists, as required • manage the care team across the course of treatment • prevent eating disorders through early intervention and patient education in cases of disordered eating/body image concerns, and through the promotion of body diversity and resilience. 4  Key Features for Early Identification  To find help or learn more, visit nedc.com.au What are eating disorders? Eating disorders are serious, complex mental illnesses accompanied by physical and psychiatric complications which may be severe and life threatening. They are characterised by disturbances in behaviours, thoughts and feelings towards body weight and shape, and/or food and eating. Types of eating disorders Eating disorders are classified into different types, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition (1). Classifications are made based on the symptoms and how often these occur. Avoidant/restrictive food intake disorder (ARFID) ARFID is characterised by a lack of interest, avoidance and aversion to food and eating. The restriction is not due to a body image disturbance, but a result of anxiety or phobia of food and/or eating, a heightened sensitivity to sensory aspects of food such as texture, taste or smell, or a lack of interest in food/eating secondary to low appetite. ARFID is associated with one or more of the following: significant weight loss, significant nutritional deficiency, dependence on enteral feeding or supplementation, and a marked interference with psychosocial functioning. Anorexia nervosa Anorexia nervosa is characterised by restriction of energy intake leading to significantly low body weight accompanied by an intense fear of weight gain and body image disturbance. Changes that happen in the brain because of starvation and malnutrition can make it hard for a person with anorexia nervosa to recognise that they are unwell, or to understand the potential impacts of the illness. Atypical anorexia nervosa is a subtype of OSFED (see Page 7). A person with atypical anorexia nervosa will meet all of the criteria for anorexia nervosa, however, despite significant weight loss, the person’s weight is within or above the normal BMI range. Atypical anorexia nervosa is serious and potentially life threatening, and will have similar impacts and complications to anorexia nervosa. Bulimia nervosa Bulimia nervosa is characterised by recurrent episodes of binge eating, followed by compensatory behaviours, such as vomiting or excessive exercise to prevent weight gain. A person with bulimia nervosa can become stuck in a cycle of eating in an out-of-control manner, followed by attempts to compensate for this, which can lead to feelings of shame, guilt and disgust. These behaviours can become more compulsive and uncontrollable over time, and lead to an obsession with food, thoughts about eating (or not eating), weight loss, dieting and body image. Binge eating disorder (BED) BED is characterised by recurrent episodes of binge eating, which involves eating a large amount of food in a short period of time. During a binge episode, the person feels unable to stop themselves eating, and it is often linked with high levels of distress. A person with BED will not use compensatory behaviours, such as self-induced vomiting or overexercising after binge eating. 6  To find help or learn more, visit nedc.com.au Other specified feeding or eating disorders (OSFED) A person with OSFED may present with many of the symptoms of other eating disorders such as anorexia nervosa, bulimia nervosa or BED but will not meet the full criteria for diagnosis of these disorders. This does not mean that the eating disorder is any less serious or dangerous. The medical complications and eating disorder thoughts and behaviours related to OSFED are as severe as other eating disorders. Unspecified feeding or eating disorder (UFED) UFED is a feeding and eating disorder that causes significant distress and impairment in social, occupational, or other important areas of functioning, however, does not meet the full criteria for any of the other feeding and eating disorders. This category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific feeding and eating disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., emergency room setting). Pica Pica is characterised by persistent eating of nonnutritive, nonfood substances, which is inappropriate to the development level of the individual. Rumination disorder Rumination disorder is characterised by the repeated regurgitation of food. The repeated regurgitation cannot be associated with another medical condition or occur exclusively in the course of another eating disorder diagnosis. People with higher weight and eating disorders Higher weight (termed ‘obesity’ in a biomedical context) is not an eating disorder or mental disorder. While there is not one universally agreed-upon term for people with higher weight, the term ‘people at higher weight‘ is recommended in place of ’overweight’ or ‘obesity’ as people with a lived experience have indicated this as their preference (2). People with higher weight are at increased risk of disordered eating compared with the general population, while people who use unhealthy weight-control practices (e.g. fasting, purging, and diet pills) are more likely to be at a higher weight. People with eating disorders are more than twice as likely to contact health professionals for weight-reduction assistance than they are to seek treatment specifically for their eating disorder. GPs caring for people with higher weight should screen patients for eating disorders as well as being aware of the possible unintended negative consequences of dieting and weight-reduction strategies. 7  To find help or learn more, visit nedc.com.au Figure 1: Prevalence of eating disorders by diagnosis *Other Eating Disorders includes all other eating disorder diagnosis excluding anorexia nervosa, bulimia nervosa and BED. Prevalence Approximately one million Australians are living with an eating disorder in any given year; that is, 4% of the population (3). Prevalence of eating disorders by diagnosis Of people with an eating disorder, 3% have anorexia nervosa, 12% bulimia nervosa, 47% binge eating disorder (BED) and 38% other eating disorders* (3). Prevalence of eating disorders by gender While females comprise approximately 80% of people with anorexia nervosa and 70% of people with bulimia nervosa, recent data suggests that the prevalence of BED may be nearly as high in males as in females (4). Emerging research suggests transgender and non-binary people are at two to four times greater risk of eating disorder symptoms or disordered eating behaviours than their cisgender counterparts (5). 8  To find help or learn more, visit nedc.com.au Risk factors Based on the known risk factors for eating disorders, high-risk groups and presentations have been identified. A patient presenting in these groups, or with these presentations, should lead the GP to screen for an eating disorder and, if required, conduct a comprehensive assessment. High risk groups People at a high risk of developing an eating disorder include: • Females, especially during biological and social transition periods (e.g., onset of puberty, change in relationship status, pregnancy and postpartum, menopause, change in social role) • Children and adolescents; although eating disorders can develop at any age, risk is highest for young men and women between 13 and 17 years of age (6) • People engaging in competitive occupations, sports, performing arts and activities that emphasise thin body shape/weight requirements (e.g., modelling, gymnastics, horse riding, dancing, athletics, wrestling, boxing) • Minority groups (e.g., LGBTQI+) High risk presentations People at a high risk of developing an eating disorder include presentations of individuals who: • are seeking to lose weight • are experiencing weight loss, intentional or unintentional • are following a diet that limits energy intake, requires calorie counting or eliminates a food or food group • are on restrictive diets due to food intolerances or allergies (e.g., coeliac disease, irritable bowel syndrome) • are experiencing comorbid conditions that cause weight loss or gain/focus on body, weight, shape and eating (e.g., type 1 and type 2 diabetes, polycystic ovary syndrome, coeliac disease) • are experiencing mental health conditions including anxiety and depression • are experiencing low self-esteem • are experiencing substance misuse • have a history of trauma • have current or historical experience of food insecurity • have perfectionist or compulsive personality traits 9  To find help or learn more, visit nedc.com.au Warning signs There are several psychological, behavioural and physical signs or changes that may identify a patient is experiencing an eating disorder. A patient may present with no obvious signs and may appear well, although may have underlying eating disorder behaviours and be at medical or psychiatric risk. Psychological Psychological warning signs may include: • Preoccupation with eating, food (including activities related to food), body shape and weight • Intense fear of weight gain • Heightened anxiety or irritability around mealtimes • Feeling of being ‘out of control’ around food • Disturbed body image • Extreme body dissatisfaction/negative body image • Rigid ‘black and white’ thinking (e.g., thoughts about food being ‘good’ or ‘bad’) • Heightened sensitivity to comments or criticism (real or perceived) about body shape or weight, eating or exercise habits • Depression, anxiety, non-suicidal self-injury, or suicidality • Low self-esteem or shame (e.g., feelings of shame, guilt and self-loathing) • Using food as self-punishment (e.g., refusing to eat due to depression, stress or other emotional reasons) Physical Physical warning signs may include: • Sudden weight loss, gain or fluctuation • In children and adolescents, an unexplained decrease in growth curve or body mass index (BMI) percentiles • Sensitivity to the cold (e.g., feeling cold most of the time, even in warm environments) • Delayed onset, loss or disturbance of menstrual periods • Reduced morning tumescence • Signs of frequent vomiting (e.g., swollen cheeks or jawline, calluses on knuckles, bad breath, damage to teeth) • Lanugo – fine hairs covering the body or face • Fatigue or lethargy • Fainting or dizziness • Hot flashes or sweating episodes • Gastrointestinal disturbances with no clear cause (e.g., gastroesophageal reflux, bloating, constipation, nausea, early satiety) • Cardiorespiratory complications (e.g., chest pain, heart palpitations, orthostatic tachycardia/hypotension, dyspnea, oedema) • Osteoporosis or osteopenia 10  To find help or learn more, visit nedc.com.au Behavioural Behavioural warning signs may include: • Constant or repetitive dieting behaviour (e.g., fasting, counting calories/kilojoules, skipping meals, avoidance of certain food groups, underdosing insulin if type 1 diabetes present) • Evidence of binge eating (e.g., disappearance of large amounts of food, hoarding of food in preparation for binge) • Evidence of vomiting or laxative use for weight-control purposes (e.g., frequent trips to the bathroom during or after meals, regular purchasing of laxatives) • Compulsive or excessive exercise patterns (e.g., exercising in bad weather, continuing to exercise when sick or injured, failure to take regular rest/recovery days, and experiencing distress if exercise is not possible) • Patterns or obsessive rituals around food, food preparation and eating (e.g., eating very slowly, cutting food into very small pieces, insisting that meals are served at a certain time, rigid repetitive meal content, inflexible use of crockery and cutlery) • Changes in food preferences (e.g., claiming to dislike foods previously enjoyed, sudden preoccupation with ‘healthy eating’, or replacing meals with fluids) • Avoidance of, or change in behaviour in social situations involving food (e.g., no longer eating family meals at home, bringing own food to social events, refusal of food in social settings) • Avoidance of eating by giving excuses (e.g., claiming to have already eaten, claiming to have an allergy/ intolerance to particular foods) • Social withdrawal or isolation from friends and family (e.g., avoidance of previously enjoyed activities) • Changes in behaviour around food preparation and planning (e.g., shopping for food, preparing meals for others but not consuming meals themselves, taking control of family meals) • Strong focus on weight and body shape (e.g., interest in weight loss or muscle building, dieting or bulking books and magazines) • Repetitive or obsessive body checking behaviours (e.g., pinching waist or wrists, repeated self-weighing, excessive time spent looking in the mirror) • Changes in clothing style (e.g., wearing baggy clothes, wearing more layers than necessary for the weather) • Covert or secretive behaviour around food (e.g., secretly throwing out food, hiding uneaten food, eating in secret) • Inappropriate hydration behaviours (e.g., consuming little to no fluids, or consuming excessive fluids above requirements) • Continual denial of hunger • Making rigid food rules (e.g., lists of ‘good’ and ‘bad’ foods) ‘Watchful waiting’ should never be used in the management of eating disorders. Early identification and access to effective treatment prevents the eating disorder from becoming established and improves the course and prognosis. 11  Initial Response  To find help or learn more, visit nedc.com.au Screening Screening for eating disorders can and should be a part of any GP assessment as any patient, at any stage of their life, can be experiencing an eating disorder. Screening may involve a formal screening tool and/or a series of non-judgmental, unstructured questions. Screening tools There are several screening tools that can be used in the primary care setting to assist in the detection of eating disorders. Screening tools are not diagnostic eating disorder tools, but rather, are used to detect the possibility of an eating disorder and identify when a comprehensive assessment is warranted. The Eating Disorder Screen for Primary Care (ESP) below can be used as a screening tool in primary care settings. Eating Disorder Screen for Primary Care (ESP) (7) 1. Are you satisfied with your eating patterns? 2. Do you ever eat in secret? 3. Does your weight affect the way you feel about yourself? 4. Have any members of your family suffered with an eating disorder? 5. Do you currently suffer with, or have you ever suffered in the past, with an eating disorder? • A ‘no’ to question 1. is classified as an abnormal response. • A ‘yes’ to questions 2-5 is classified as an abnormal response. • Any abnormal response indicates that the patient needs further assessment. An assessment for an eating disorder involves two stages: 1. Assessment of medical and psychiatric risk 2. Comprehensive assessment a. Medical assessment b. Assessment of eating disorder symptoms and severity c. Mental health assessment Assessment 13  To find help or learn more, visit nedc.com.au 1. Assessment of medical and psychiatric risk The first priority in assessing a patient for a possible eating disorder is securing medical and psychiatric safety. This step must be completed immediately following screening, at the initial session with the GP. Admission to hospital is indicated if a patient is at imminent risk of serious medical or psychiatric complications. Indicators for hospital admission for adults, adolescents and children are outlined in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the treatment of eating disorders. The initial assessment of medical and psychiatric risk should include physical assessment and diagnostic tests, as well as a mental health risk assessment. To assess medical and psychiatric risk, refer to the RANZCP clinical practice guidelines and/or the guidelines for admission and management available in your region. 2. Comprehensive assessment a. Medical assessment Physical assessment • Measurement of height, weight, and determination of body mass index; record weight, height and BMI on growth charts for children and adolescents • Sitting and orthostatic heart rate and blood pressure • Body temperature • Hydration status (e.g., poor skin turgor, slow capillary return) • Assessment of skin, hair and nails (e.g., brittle nails, carotenaemia (orange discolouration), dry skin, lanugo hair, callused knuckles) • Oral examination (e.g., dental erosions, gingivitis, pharyngeal redness and parotid enlargement) • Assessment of breathing and breath (e.g., ketosis) • Examination of periphery for circulation and oedema • Gastrointestinal function (e.g., bloating, pain, constipation, diarrhoea) • Menstrual history (e.g., menarche, last menstrual period, regularity, oral contraceptive use, oral contraceptive use that may be masking the impact of eating disorder on menstrual status) 14