Eating disorders Flashcards
(15 cards)
How would you explain the cause of re-feeding syndrome?
Re-feeding syndrome happens when a patient starts to eat at faster than advised rate following a period of starvation.
When in starvation the body survives by breaking down fat and this can deplete stores of salts and minerals
However when the patient begins to eat the body needs to switch from breaking down fats and instrad over to carbohydrates
In order to break down carbohydrates and store these sugars it can lead to further decline of salts and minerals in the blood and result in fluid gathering in parts of the body
What are the risks of re-feeding syndrome?
Re-feeding syndrome is not only troubling for the patient due to distressing syndromes but it is a medical emergency and if confirmed requires management in a medical hospital
That is because if the level of these salts and minerals fall too low it can leads to funny rhythms in the heart, as well as seizures
Additionally if fluid accumulates too rapidly it can cause heart failure and if severe there can be a risk of death
How can we prevent re-feeding syndrome?
Re-feeding syndrome can be prevented in a number of ways:
Manage in a MDT manner including input from dieticians, psychology and medical doctors if required.
Firslty we will slowly start the amount of calories you eat and slowly increase - 1000–350 kcal/day. If oral foods are difficult we can do liquid foods/supplements. In terms of weight gain we will aim to increase your weight 0.5-1kg a week if inpatient and out patient 0.5kg a week. We will aim not to increase your weight more than 2kg a week. Note the weight aim is the premorbid weight or the weight that periods stopped + 5kg.
Secondl we will start you/the patient on a thiamine, B12 and a multivitamin prior to starting feeding and continue this for the first 10 days
We will also perform daily bloods to monitor for the risk and conduct an ECG at the start and if there any abnormalities on the bloods/symptomatic.
If the salt or mineral levels are low we can correct these. If we are worried that you may have re-feeding syndrome we will send you to a medical hospital/A&E to be investigated and treated if needed.
What pneumonic may be helpful for eating disorder history?
SPILL
Speedy weight loss
- What was your lowest / highest ever weight
- Do you ever check your weight / check your body shape
Pattern of behaviour
- Restriction of intake? (CALORIE COUNTING / FOOD RULES / DIETARY RESTRICTION)
- Behaviours aimed at preventing weight gain/weight loss (VOMITING / LAXATIVES / INSULIN MISUSE / EXERCISE)
Inaccurate perception of body shape
- Do you think you’re overweight when others think you’re not
Low body weight crucial to self-identity
- In Anorexia - need to see if thin body shape/image/low weight is important to perception of self
- In Bulimia - need to see if body shape/weight in general is important to sense of self
Low BMI
What are the diagnostic criteria for bulimia nervosa?
Recurrent binges - increase in what food is consumed in 2 hr window - inappropriate and excessive - LOSS OF CONTROL
Recurrent compensatory behaviours - self-induced vomiting, misuse of laxatives, diuretics, other medications, strenuous exercise)
THESE BEHAVIOURS OCCUR AT LEAST ONCE A WEEK FOR 3 MONTHS
Self-evaluation is unjustifiably linked to body weight/shape
Marked distress about behaviours and loss of functioning
What are the diagnostic criteria for anorexia?
Weight?
Psychological response to gaining weight? - are you frightened?
Behaviour that prevents weight gain?
Low body weight/body shape important to self image?
Anorexia
- Low BMI - < 18.5 (can be rapid weight loss or for CAMHs a failure to meet expected weight/height for age)
-Persistent behaviour that interferes with weight gain (restriction, purging, exercise)
- Typically fear of gaining weight
- Disturbance in way body/shape/image is experienced - it is crucial to self identity
How would you structure and eating disorder hx?
FOOD HX:
Dietary intake:
- Regular day
- FOOD RULES / RESTRICTIONS
- Calorie count (1800 for women / 2500 for men)
Binges:
- Are there times you’ve ate more than wanted in one go? –> can you describe the last time
Fluid intake:
- Caffeine, sugar-intake
WEIGHT HX:
- Current/historic - when was your last weight
- Rate of weight loss - > 1kg a week –> likely physical health hospital for re-feeding
- Recorded by whom
- Highest/lowest weight
- If can’t do weight - mid-arm circumference or hand strength
BEHAVIOUR
- Exercise –> formal / informal (step count / calorie burn)
- “Any medications or behaviours to influence your shape or weight?”
- “Anything you do to influence your shape/weight” - skinny teas
SELF-EVALUATION
- How important is your body weight + shape?
- How would you feel is you gain weight? What would you think about yourself? What would others think about you?
SECONDARY FEATURES
- Menorrhoea
- Pain - abdo/oesophageal
- Memory/concentration
- Fatigue
- Dizziness/faintness
- Weakness
- Dentition
OTHER PARTS OF HX:
- Co-morbidity - OCD, self-harm/EUPD, depression
- Medical hx - T1DM, gastro diagnosis, pregnancy
- FHx
- Substances
- SHx
How could patients with T1DM lose weight with insulin?
- Omit insulin - high BMs, but low intracellular - fat burning “ketosis” - lose weight/calories as glucose is peed out (calorie wasting)
- Typically occurs in bulimia
- Patients may be ambivalent about the long terms risks retinopathy, PVD, nephropathy etc
Outline good/bad prognostic factors for Anorexia + Bulimia
Anorexia good:
- Early onset < 25yrs
Anorexia bad:
- Long DUP
- Late onset
- Male sex
- Extreme weight loss BMI 13 or under
- Binge/Purge subtype
- Poor parental relationships
- Poor childhood adjustment/trauma
- Co-morbidity - personality disorder/affective disorder/suicidality/hospital admission
Bulimia good:
- Young onset
Bulimia bad:
* Old age
* Premorbid control
* Poor social adjustment
* Substance
* Affective
* Low self-esteem
* Impulse control disorders - ADHD
* childhood obesity
What are the risk factors for anorexia / bulimia?
Anorexia:
- Female sex
- Westernised
- Perfectionism
- Low self-esteem
- High expressed emotion around food
- FHx of ED and depression
- Occupational pressure
- Childhood sexual abuse
Bulimia nervosa:
- Childhood obesity
- Early menarche
What do eating disorder services do?
Medical input:
- Managing and assessing physical risk - vital signs/bloods/weight monitoring
- DEXA scans
- Medication (Fluoxetine for bulimia and Olanzapine for AN)
Dietician inputs:
- Meal plans
- Safe weight restoration
Psychology:
- Group psychoed
- Self-help bibliotherapy
- CBT-E or MANTRA (individual)
- Psychodynamic 2nd line
Family therapy:
- For CAMHS - 1st line
- < 25 - 1st line for anorexia nervosa
Occupational therapy/peer support service
Increased risk
- Day hospital
- EDU
How to advise anorexia in general hospital?
!MEED guidelines!
Dietician:
- Normal food early on if can
- NG if required
- Support with re-feeding
Physical health
- Twice weekly weights
- QDS obs
- Daily bloods or twice daily in re-feeding
- ECG
- Regular BMs
Nursing obs:
- 1:1 particularly at meal times
- Avoid side room
- Toilet supervision
- Encourage bedrest/minimal exercise
Legal considerations:
- Can only NG if under MHA
- If leaves 5(2)
Outline some red flags in the MEED criteria
- HR < 40
- BMI < 13
- Recent weight loss > 1kg for more than 2 weeks
- Recurrent syncope with standing BP.< 90 and postural drop > 20mmHg
- Temp < 35.5
- Prolonged QTc
- Low WCC or Hb < 10
- Low K/Ph/Ca/Glucose/Na/Albumin
- Daily purging –> malorie weiss
- Self-harm
- Suicidal ideation
- Acute food refusal
- Physical fights with care givers over food
- > 2 hr a day of exercise
When are we worried about risk of re-feeding???
- Low intake < 500kcl for 3 days
- Underweight
- Previous re-feeding
STATE worried about re-feeding therefore
Need multivitamins, B12 and thiamine prior to feeding (then for 7-10 days)
Slow feeding schedule
Daily / twice daily bloods - 7-10 days
ECG prior and during feeding
Admission to general medical hospital ideally
