Eating Disorders Medical Guide - AED Report 2016 (PDF)

EATING DISORDERS A GUIDE TO MEDICAL CARE AED REPORT 2016 | 3RD EDITION Critical Points for Early Recognition & Medical Risk Management in the Care of Individuals with Eating Disorders  DISCLAIMER: This document, created by the Academy for Eating Disorders’ Medical Care Standards Committee, is intended as a resource to promote recognition and prevention of medical morbidity and mortality associated with eating disorders. It is not a comprehen- sive clinical guide. Every attempt was made to provide information based on the best available research and current best practices. For further resources, practice guidelines and bibliography visit: www.aedweb.org and www.aedweb.org/Medical_Care_Standards MEMBERS OF THE AED MEDICAL CARE STANDARDS COMMITTEE: Ovidio Bermudez, MD, FAED Michael Devlin, MD, FAED Suzanne Dooley-Hash, MD Angela Guarda, MD Debra K. Katzman, MD, FAED Sloane Madden, MD, PhD, FAED Beth Hartman McGilley, PhD, CEDS, FAED Deborah Michel, PhD, CEDS Ellen S. Rome, MD, MPH Michael A. Spaulding-Barclay, MD, MS Edward P. Tyson, MD Mark Warren, MD, MPH, FAED Therese Waterhous, PhD, RDN, CEDRD Cover Image Copyright: http://www.123rf.com/profile_harishmarnad  TABLE OF CONTENTS Key Guidelines 4 Eating Disorders 4 Important Facts about Eating Disorders 5 Presenting Signs and Symptoms 6 Early Recognition 7 A Comprehensive Assessment 9 Criteria for Hospitalization for Acute Stabilization 11 Refeeding Syndrome 12 Information for Medical Specialty Providers 15 Timely Interventions 18 Goals of Treatment 19 Ongoing Management 20 Appendix 1 20 References 23 About the Academy for Eating Disorders 23 AED REPORT 2016 | 3RD EDITION EATING DISORDERS: A GUIDE TO MEDICAL CARE  4 AED REPORT 2016 | 3RD EDITION KEY GUIDELINES All eating disorders (EDs) are serious mental illnesses with significant, life-threatening medical and psychiatric morbidity and mortality, regardless of an individual’s weight. Patients with EDs have the highest mortality rates of any psychiatric disorder. The risk of premature death is 6-12 times higher in women with Anorexia Nervosa (AN) as compared to the general population, adjusting for age. Early recognition and timely intervention, based on a developmentally appropriate, evidence-based, multidisciplinary team approach (medical, psychological & nutritional) is the ideal standard of care, whenever possi- ble. Members of the multidisciplinary team may vary and will depend upon the needs of the patient and the availability of these team members in the patient’s community. In communities where resources are lacking, clinicians, therapists, and dietitians are encouraged to consult with the Academy for Eating Disorders (AED) and/or ED experts in their respective fields of practice. EATING DISORDERS For the purpose of this document, we will focus on the most common EDs including: 1. Anorexia Nervosa (AN): Restriction of energy intake relative to an individual’s requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and health status. Disturbance of body image, an intense fear of gaining weight, lack of recognition of the seriousness of the illness and/or behaviors that interfere with weight gain are also present. 2. Bulimia Nervosa (BN): Binge eating (eating a large amount of food in a relatively short period of time with a concomitant sense of loss of control) with purging/compensatory behavior (e.g. self-induced vomiting, laxative or diuretic abuse, insulin misuse, excessive exercise, diet pills) once a week or more for at least 3 months. Disturbance of body image, an intense fear of gaining weight and lack of recognition of the seriousness of the illness may also be present.  5 EATING DISORDERS: A GUIDE TO MEDICAL CARE 3. Binge Eating Disorder (BED): Binge eating, in the absence of compensa- tory behavior, once a week for at least 3 months. Binge eating episodes are associated with eating rapidly, when not hungry, until extreme fullness, and/or associated with depression, shame or guilt. 4. Other Specified Feeding and Eating Disorder (OSFED): An ED that does not meet full criteria for one of the above categories, but has specific disordered eating behaviors such as restricting intake, purging and/or binge eating as key features. 5. Unspecified Feeding or Eating Disorder (UFED): ED behaviors are present, but they are not specified by the care provider. 6. Avoidant/Restrictive Food Intake Disorder (ARFID): Significant weight loss, nutritional deficiency, dependence on nutritional supplement or marked interference with psychosocial functioning due to caloric and/or nutrient restriction, but without weight or shape concerns. Consult www.aed.org, DSM-5 or ICD-10 for full diagnostic descriptions. IMPORTANT FACTS ABOUT EATING DISORDERS — All EDs are serious disorders with life-threatening physical and psychological complications. — EDs do not discriminate. They can affect individuals of all ages, genders, ethnicities, socioeconomic backgrounds, and with a variety of body shapes, weights and sizes. — Weight is not the only clinical marker of an ED. People who are at low, normal or high weights can have an ED and individuals at any weight may be malnourished and/or engaging in unhealthy weight control practices. — Individuals with an ED may not recognize the seriousness of their illness and/or may be ambivalent about changing their eating or other behaviors. — All instances of precipitous weight loss or gain in otherwise healthy individuals should be investigated for the possibility of an ED as rapid weight fluctuations can be a potential marker of an ED. — In children and adolescents, failure to gain expected weight or height, and/or delayed or interrupted pubertal development, should be investigated for the possibility of an ED.  6 AED REPORT 2016 | 3RD EDITION — All EDs can be associated with serious medical complications affecting every organ system of the body. — The medical consequences of EDs can go unrecognized, even by an experienced clinician. PRESENTING SIGNS AND SYMPTOMS Individuals with EDs may present in a variety of ways. In addition to the cognitive and behavioral signs that characterize EDs, the following physical signs and symptoms can occur in patients with an ED as a consequence of restricting food or fluid intake, nutritional deficiencies, binge-eating, and inappropriate compensatory behaviors, such as purging. However, it is important to remember that a life-threatening ED may occur without obvious physical signs or symptoms. GENERAL: — Marked weight loss, gain, fluctuations or unexplained change in growth curve or body mass index (BMI) percentiles in a child or adolescent who is still growing and developing — Cold intolerance — Weakness — Fatigue or lethargy — Presyncope (dizziness) — Syncope (fainting) — Hot flashes, sweating episodes ORAL AND DENTAL: — Oral trauma/lacerations — Perimyolysis (dental erosion on posterior tooth surfaces) and dental caries (cavities) — Parotid (salivary) gland enlargement CARDIORESPIRATORY: — Chest pain — Heart palpitations — Orthostatic tachycardia/ hypotension (low blood pressure) — Dyspnea (shortness of breath) — Edema (swelling) GASTROINTESTINAL: — Epigastric discomfort — Abdominal bloating — Early satiety (fullness) — Gastroesophageal reflux (heartburn) — Hematemesis (blood in vomit) — Hemorrhoids and rectal prolapse — Constipation  7 EATING DISORDERS: A GUIDE TO MEDICAL CARE ENDOCRINE — Amenorrhea or oligomenorrhea (absent or irregular menses) — Low sex drive — Stress fractures — Low bone mineral density — Infertility NEUROPSYCHIATRIC — Depressive/Anxious/ Obsessive/Compulsive symptoms and behaviors — Memory loss — Poor concentration — Insomnia — Self-harm — Suicidal thoughts, plans or attempts — Seizures DERMATOLOGIC — Lanugo hair (fine hair growth on the body and face) — Hair loss — Carotenoderma (yellowish discoloration of skin) — Russell’s sign (calluses or scars on the back of the hand from self-induced vomiting) — Poor wound healing — Dry brittle hair and nails EARLY RECOGNITION Consider evaluating an individual for an ED who presents with any of the following: — Precipitous weight changes (significant weight lost or gained) or fluctuations — Sudden changes in eating behaviors (new vegetarianism/veganism, gluten-free, lactose-free, elimination of certain foods or food groups, eating only “healthy” foods, uncontrolled binge eating) — Sudden changes in exercise patterns, excessive or compulsive exercise or involvement in extreme physical training — Body image disturbance, the desire to lose weight despite low or normative weight, or extreme dieting behavior regardless of weight — Abdominal complaints in the context of weight loss behaviors — Electrolyte abnormalities without an identified medical cause (especially hypokalemia, hypochloremia, or elevated bicarbonate) — Hypoglycemia  8 AED REPORT 2016 | 3RD EDITION — Bradycardia — Amenorrhea or menstrual irregularities — Unexplained infertility — Type 1 diabetes mellitus with poor glucose control or recurrent diabetic ketoacidosis (DKA) with or without weight loss — Use of compensatory behaviors (i.e., self-induced vomiting, laxative abuse, dieting, fasting or excessive exercise) to influence weight after eating or binge eating — Inappropriate use of appetite suppressants, caffeine, diuretics, laxatives, enemas, ipecac, artificial sweeteners, sugar-free gum, prescription medi- cations that affect weight (insulin, thyroid medications, psychostimulants, or street drugs) or nutritional supplements marketed for weight loss Malnutrition is a serious medical condition that requires urgent attention. It can occur in patients engaging in disordered eating behaviors, regardless of weight status. Individuals with continued restrictive eating behaviors, binge eating or purging, despite efforts to redirect their behavior, require immediate intervention.  9 EATING DISORDERS: A GUIDE TO MEDICAL CARE COMPREHENSIVE ASSESSMENT COMPLETE HISTORY TO INCLUDE: — Rate and amount of weight loss/change in past six months — Nutritional history to include dietary intake (quantity and variety of foods consumed), restriction of specific foods or food groups (such as fats or carbohydrates) — Compensatory behaviors and their frequency (fasting or dieting, self- induced vomiting, exercise, laxative, diuretic or ipecac abuse, insulin misuse, use of diet pills and/or other over-the-counter supplements) — Exercise (frequency, duration and intensity). Is the exercise excessive, compulsive or rigid or is it used to manage weight? — Menstrual history (menarche, last menstrual period, regularity, oral contraceptive use) — Current medications including any supplements & alternative medications — Family history including symptoms or diagnosis of EDs, obesity, mood & anxiety disorders, substance use disorders — Psychiatric history including symptoms of mood, anxiety and substance use disorders — History of trauma (physical, sexual or emotional) — Growth history (obtain past growth charts whenever possible) PHYSICAL EXAMINATION TO INCLUDE: — Measurement of height, weight, and determination of body mass index (BMI = weight (kg)/height (m2)); record weight, height and BMI on growth charts for children and adolescents — Lying and standing heart rate and blood pressure — Oral temperature INITIAL DIAGNOSTIC EVALUATION: — Laboratory and other diagnostic studies recommended for consideration in evaluating a patient with an ED, along with potential corresponding abnormalities seen in patients with EDs, are outlined in the following chart. — It is important to note that laboratory studies may be normal even with significant malnutrition.  10 AED REPORT 2016 | 3RD EDITION DIAGNOSTIC TESTS INDICATED FOR ALL PATIENTS WITH A SUSPECTED ED BASIC TESTS POTENTIAL ABNORMAL FINDINGS AND CAUSES Complete blood count Leukopenia, anemia, or thrombocytopenia Comprehensive panel to include electrolytes, renal function tests and liver enzymes Glucose: i poor nutrition Sodium: i water loading or laxatives Potassium: i vomiting, laxatives, diuretics Chloride: i vomiting, laxatives Blood bicarbonate: h vomiting i laxatives Blood urea nitrogen: h dehydration Creatinine: h dehydration, renal dysfunction, muscle wasting Calcium: slightly i poor nutrition at the expense of bone Phosphate: i poor nutrition Magnesium: i poor nutrition, laxative use Total protein/albumin: h in early malnutrition at the expense of muscle mass, i in later malnutrition Prealbumin: i in protein-calorie malnutrition Aspartate aminotransaminase (AST), Alanine aminotransaminase (ALT): h starvation Electrocardiogram (ECG) Bradycardia (low heart rate), prolonged QTc (>450msec), other arrhythmias ADDITIONAL DIAGNOSTIC TESTS TO CONSIDER ADDITIONAL TESTS POTENTIAL ABNORMAL FINDINGS Leptin level Leptin: i in malutrition Thyroid stimulating hormone (TSH), thyroxine (T4) TSH: i or normal T4: i or normal euthyroid sick syndrome Pancreatic enzymes (amylase and lipase) Amylase: h vomiting, pancreatitis Lipase: h pancreatitis Gonadotropins (LH and FSH) and sex steroids (estradiol and testosterone) LH, FSH, estradiol (women) and testosterone (men) levels: i or normal  11 EATING DISORDERS: A GUIDE TO MEDICAL CARE CRITERIA FOR HOSPITALIZATION FOR ACUTE MEDICAL STABILIZATION PRESENCE OF ONE OR MORE OF THE FOLLOWING: 1. ≤ 75% median BMI for age, sex, and height 2. Hypoglycemia 3. Electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia and/or metabolic acidosis or alkalosis) 4. ECG abnormalities (e.g., prolonged QTc > 450, bradycardia, other arrhythmias) 5. Hemodynamic instability — Bradycardia — Hypotension — Hypothermia 6. Orthostasis 7. Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.) 8. Comorbid psychiatric or medical condition that prohibits or limits appropriate outpatient treatment (e.g., severe depression, suicidal ideation, obsessive compulsive disorder, type 1 diabetes mellitus) 9. Uncertainty of the diagnosis of an ED Erythrocyte sedimentation rate (ESR) ESR: i starvation or h inflammation Dual Energy X-ray Absorptiometry (DEXA) Patients with EDs are at risk of low bone mineral density (BMD). There is no evidence that hormone replacement therapy (estrogen/progesterone in females or testosterone in males) improves BMD. Nutritional rehabilitation, weight recovery, and normalization of endogenous sex steroid production are the treatments of choice.  12 AED REPORT 2016 | 3RD EDITION PRESENCE OF ONE OR MORE OF THE FOLLOWING: 1. Acute food refusal 2. Suicidal thoughts or behaviors 3. Other significant psychiatric comorbidity that interferes with ED treatment (anxiety, depression, obsessive compulsive disorder) OTHER CONSIDERATIONS REGARDING HOSPITALIZATION: 1. Failure of outpatient treatment 2. Uncontrollable binge eating and/or purging by any means 3. Inadequate social support and/or follow up medical or psychiatric care REFEEDING SYNDROME Refeeding syndrome describes the clinical and metabolic derangements that can occur during refeeding (orally, enterally, or parenterally) of a malnour- ished patient. The clinical features of refeeding syndrome include edema, cardiac and/or respiratory failure, gastrointestinal problems, profound muscle weakness, delirium and, in extreme cases, death. Laboratory abnormalities may include hypophosphatemia (most significant), hypoglycemia, hypokale- mia, hypomagnesemia and hyponatremia. Refeeding syndrome can occur in patients of any age and weight, and is a potentially fatal condition requiring specialized care on an inpatient unit. RISK FACTORS FOR REFEEDING SYNDROME INCLUDE: — The degree of malnutrition at presentation (< 70% median BMI in adolescents, BMI <15 most at risk in adults) — Patients who are chronically undernourished and those who have had little or no energy intake for more than 10 days — History of refeeding syndrome — Patients with rapid or profound weight loss, including those who present at any weight after rapid weight loss (> 10-15% of total body mass in 3-6 months) CRITERIA FOR HOSPITALIZATION FOR ACUTE PSYCHIATRIC STABILIZATION  13 EATING DISORDERS: A GUIDE TO MEDICAL CARE IMPORTANT – Consider initiating refeeding in an inpatient set- ting if one or more risk factors for refeeding are present. Ideally patients should be admitted to a hospital that has access to, or onsite ED specialist support. — Patients with significant alcohol intake (these patients are also at risk for the development of Wernicke’s encephalopathy with refeeding. Prior to refeeding they should receive thiamine and folate supplementation) — Post-bariatric surgery patients with significant weight loss (increased risk with electrolyte losses from malabsorption) — Patients with a history of diuretic, laxative or insulin misuse — Patients with abnormal electrolytes prior to refeeding HOW TO PREVENT AND MANAGE REFEEDING SYNDROME: — Know the signs, symptoms and risk factors for refeeding syndrome. — Whenever possible, refer patients at risk for refeeding syndrome to physi- cians with expertise in medical and behavioral management of EDs and/ or admit to an inpatient medical or med-psych unit with this expertise. — Serum electrolytes (sodium, potassium, phosphorous and magnesium) and glucose should be checked prior to initiating refeeding. Be aware that these may be normal prior to refeeding. Phosphorus will reach its lowest point 3-7 days after initiation of nutritional rehabilitation. — While treating a patient on an inpatient unit, monitor serum electrolytes and glucose frequently (at least daily if significantly abnormal) during early refeeding until stabilized (at least 72 hours). — Aggressively replete all electrolyte deficiencies. Oral repletion is prefera- ble but IV supplementation may be necessary. It is not necessary to cor- rect fluid and electrolyte imbalance before initiating feeding. With careful monitoring, this can be safely achieved simultaneously. — Start a multivitamin daily prior to initiating and throughout refeeding. Add thiamine supplementation in severely malnourished patients due to the risk of Wernicke’s encephalopathy. — In consultation with a nutrition specialist with expertise in refeeding patients with ED, adjust rate of refeeding according to the age, develop- mental stage, and degree of malnourishment.  14 AED REPORT 2016 | 3RD EDITION — Monitor fluid replacement to avoid overload. The preferred rehydration route is oral. In cases where IV fluid is deemed necessary, it is best to avoid large fluid boluses. Replace losses slowly instead with continuous IVF at low rates (e.g., 50-75 cc/hour for adult patients or ½ normal maintenance in children). — Closely monitor vital signs and cardiac and mental status of all patients during refeeding. — Monitor blood glucose frequently. Postprandial glucose is often low in severely starved patients with AN. UNDERFEEDING Underfeeding due to overly cautious rates of refeeding can lead to further weight loss, and may be associated with a worse prognosis, slower response to treatment, and even death in seriously malnourished patients. METHODS OF REFEEDING: — “Start low and go slow” methods of refeeding have recently been chal- lenged and more rapid refeeding with close medical monitoring is now preferred during inpatient treatment. For instance, an adult with an ED who is significantly malnourished, and has had very low intake prior to hospitalization, might be safely started at approximately 1600 kcal/day and increased by 300 kcal/day every 2-3 days until consistent weight gain of at least 2-4 lb (1-2 kg)/week is achieved. — Most patients will require high calorie intake (3500-4000 kcal/day) to achieve consistent weight gain once medically stabilized beyond the initial stages of refeeding. This may be initiated as an inpatient and con- tinued as an outpatient (once the patient is medically stabilized) until complete weight restoration is achieved. At this time, a reassessment of nutritional needs should be performed for weight maintenance and/or growth. — Children/adolescents and their families may need to be reminded that they are in a state of growth and development. Treatment goal weights and nutritional needs will change with time as children and adolescents continue to grow and develop. — Oral refeeding is always preferred. Supplemental enteral feeds may be indicated when rates of weight gain are low (<2 lb/week) or access to an expert behavioral refeeding program is limited. Parenteral feeding is not recommended and should only be used in patients without a functional gut.  15 EATING DISORDERS: A GUIDE TO MEDICAL CARE INFORMATION FOR MEDICAL SPECIALTY PROVIDERS Individuals with EDs are frequently referred to specialty providers for evalu- ation of medical complaints. It is important that every provider, regardless of specialty, recognize the signs and symptoms consistent with an ED, manage complications appropriately, and know when to refer a patient for specialized ED evaluation and treatment and/or when to refer for hospital admission due to significant medical compromise. Collaborative care with an ED specialist is in the best interest of all patients. FOR ALL PROVIDERS: Please maintain a high index of suspicion for EDs, especially in high-risk patients. Keep in mind that EDs may be present in patients of any age, race, gender or size. Screen and refer to specialty care as indicated. A validated screening tool such as the SCOFF (see Appendix 1) may be used in identifying adult patients who would benefit from further evaluation for an ED. CARDIOLOGY — Bradycardia is a physiologic, adaptive response to starvation and is the most common arrhythmia in patients with EDs. Bradycardia should not be automatically attributed to athleticism or training in patients who are underweight, who have experienced rapid weight loss, or who have inadequate nutritional intake for their level of activity. — Cardiologists should consult with ED specialists if they are considering an ED, or evaluating a known patient with an ED. Collaborative care helps put the patient’s diagnosis and clinical presentation into an appropriate context. — Arrhythmias due to electrolyte abnormalities are a common cause of death in patients with EDs. EMERGENCY MEDICINE — Patients with EDs present to emergency departments at rates higher than individuals without EDs for a variety of complaints. — An emergency department visit may be the first interaction with health- care providers for a patient with an ED. The severity and treatment resistance of EDs increase with length of illness. The sooner a patient receives appropriate treatment, the more likely they are to fully recover from their illness. A positive clinician-patient interaction in the emer- gency department, and referral to appropriate ED specialty care may help to significantly reduce the length and severity of illness.