Tip Sheet: Eating Disorders (ED) in Primary Care

Richard E. Kreipe, MD
Medical Director, Western New York Comprehensive Care Center for Eating Disorders
www.nyeatingdisorders.org

1. Recognizing Patterns of Presentation: EDs share common core problems (body image disturbance, dysfunctional weight control habits, over-whelming sense of ineffectiveness and lack of control over life issues), but can present in primary care in a variety of ways that should be recognized, even if they are not the main reason for the visit.
1. DSM-Primary Care (for children and younger adolescents, who may present in an "atypical" manner.
1. Dieting/Body Image Variation (V65.49): Realistic reduction of sweets and/or fats, but intake balanced nutritionally and no food group completely eliminated; body image realistic and dieting can be stopped.
2. Dieting/Body Image Problem (V69.1): More intense dieting, resulting in weight loss (<10% of body weight) or failure to gain weight as expected; pursuit of thinness, fear of gaining weight associated with a consistent body image distortion, and denial that weight loss is a problem .
2. DSM-IV (diagnosis of an eating disorder in primary care setting should not be based on rigid criteria)
1. Anorexia nervosa (AN 307.1): Insufficient caloric intake, often combined with compulsive exercise, leads to wasting of the body, and is associated with a delusion of being fat and an obsession to be thinner; weight loss behaviors do not diminish with weight loss and recommendations to change behaviors are strongly resisted; two subtypes—restrictive (severe restriction of calories) and binge/purge in which episodes of binge eating and purging occurs, but caloric restriction predominates.
2. Bulimia nervosa (BN 307.51): Recurrent, secretive binge-eating is associated with a fear of not being able to stop eating, an awareness that the eating pattern is abnormal, depressed moods and self-deprecating thoughts that are temporarily relieved by efforts to minimize the effects of overeating by compensatory weight loss maneuvers such as vomiting, laxative use, fasting or exercise; these behaviors are repeated in an addictive pattern; the actual amount of food considered a binge may not be large by objective standards.
3. Eating Disorder Not Otherwise Specified (ED-NOS 307.5): Patient does not meet criteria for AN or BN, but represents a category larger than AN and BN combined. Includes Binge Eating Disorder (BED).
2. Evaluation (if patterns above are recognized, or if the patient/parent/loved one have any concerns about an eating disorder)
1. Identify symptoms and signs associated with dysfunctional weight control behaviors, because the history and physical examination will provide the objective data used to determine the severity of the condition and make initial treatment recommendations. Motivational, non-judgmental approaches encourage patients to be honest with their answers.
1. Inadequate caloric intake (symptoms: amenorrhea [loss of erections in males], cold hands/feet, constipation, dry skin, hair loss, headaches, fainting/dizziness, lethargy, anorexia, irritability, difficulty concentrating, social withdrawal; signs: hypothermia, acrocyanosis, alopecia [scalp], lanugo hair [face and torso], hypotension, bradycardia, orthostatic pulse differential >25 beats per minute [BPM] , loss of subcutaneous fat and muscle mass).
2. Binge eating (symptoms: bloating, guilt, depression, anxiety; signs: weight gain, salivary gland enlargement).
3. Purging (symptoms: dizziness, guilt, depression, confusion; signs: weight loss, dental enamel erosion, knuckle calluses [PIP joints: abrasion inducing vomiting], dehydration, hypokalemic hypochloremic metabolic alkalosis).
2. Assess weight control motivation, behaviors and goals (may need multiple sources of information, since patient may "tell you what you want to hear"; father/spouse/S.O. often not present in outpatient visits—and may be actively excluded by other family members—but can be an invaluable source of information and a different perspective.
1. Motivation (may range from "just want to get in shape for soccer" to "I hate my body").
2. Patterns of eating and drinking (meals, snacks, binges; "diet"or fat-free intake; counting calories and/or fat grams).
3. Exercise patterns (type, duration, intensity and frequency of activity throughout the week; intention and goals).
4. Purging patterns (vomiting, laxatives, diuretics; exercise may be used as a means of purging calories).
5. Goal weight (record in chart for future reference, if <85%average weight for height, needs further evaluation).
3. Determine family dynamics related to eating disorder
1. Family history of overweight, eating disorder, diabetes, hyperlipidemia, etc., in which nutrition plays a role.
2. Family history of depression, anxiety, obsessive/compulsive, or other mental health problems.
3. Family structure (intact, blended, divorced; living arrangements; extended family involvement).
4. Conflict regarding eating and methods to resolve conflicts.
4. Laboratory studies (generally dictated by symptoms and signs, recognizing that all blood work may be normal)
1. ECG indicated if any symptoms on history or physical examination.
2. CBC and Chemistry Panel represents a reasonable screening assessment.
3. Thyroid Function Tests are usually normal.
4. X-Rays, CT and other imaging not indicated unless signs or symptoms suggest another condition.
3. Physical examination (targeted to eating disorders in primary care)
1. Measurements: Height; weight in examination gown only (to prevent having weights in underwear) and after voiding (to measure urine specific gravity and to minimize likelihood of water loading prior to weigh-in); body temperature.
2. Skin: Cold, blue hands/feet with slow capillary refill indicates hypo-metabolism and poor peripheral perfusion; edema usually due to capillary fragility rather than hypoproteinemia; decreased skinfold thickness. Carotenemia common.
3. Hair: Lanugo hair on face and torso to conserve body heat; parietal alopecia (may occur 1-2 months after weight gain).
4. HEENT: Salivary enlargement and dental enamel erosion (lingual surfaces of maxillary pre-molars and molars) can occur with recurrent bingeing/vomiting; dry mucous membranes can occur with marked vomiting or laxative abuse; facial petechiae and/or subconjunctival hemorrhage with forceful vomiting. Otherwise, minimal findings on HEENT exam.
5. Cardiovascular: Pulse <60 suggests hypometabolism; orthostatic pulse change (supine to standing) >25 BPM suggests indicate autonomic dysregulation and/or volume depletion (positional increase in pulse more sensitive than blood pressure drop). Blood pressure generally low in AN. Heart sounds may be distant with reduced cardiac output (which is usually normal when corrected for body surface area). ECG changes generally non-specific, but QTc>0.45 deserves attention.
6. Abdomen: NO organomegaly, but can be scaphoid with severe caloric restriction or distended with significant binge eating. Stool may be prominent throughout colon, especially in left lower quadrant in AN. Bowel sounds: hyperactive with recent laxative use, underactive with significant weight loss (gastric atony and decreased bowel motility).
7. Genitalia: Females: unremarkable [minimal estrogen effect with prolonged low weight]; Males: unremarkable.
8. Rectal: Usually normal.
9. Orthopaedic: Usually unremarkable; skin over vertebrae, sacrum and/or pelvis may show irritation or breakdown with compulsive exercise (sit-ups, etc.) due to inadequate subcutaneous tissue. Osteo-penia/porosis usually asymptomatic, and is not responsive to sex hormone therapy unless weight is normalized.
10. Neurologic: Comprehensive exam should be normal; with extreme weight loss, deep tendon reflexes can be diminished.
11. Mental Status Examination: Body image distortion, depression, anxiety (especially with issue of weight) and obsessive/compulsive symptoms often co-exist. With significant weight loss, psychomotor retardation can occur. If other MSE findings occur in patients with bulimia nervosa, consider substance abuse, which often co-exists. Suicidal risk greater in BN than AN, but safety should be assessed.
4. Treatment in primary care based on categorizing patient into mild, moderate, or severe eating disorder
1. Mild: (minimally distorted body image + goal of ³ 90% of average weight for height + no symptoms or signs of excessive weight loss + healthy weight loss methods [e.g., >1200 cal/day, moderate exercise, no purging] ).
1. Complete assessment of weight loss (intention, methods, symptoms and signs).
2. Assessment and plan to monitor diet and weight loss, if further weight loss not contraindicated.
3. Nutrition education and meal planning, with referral to a nutritionist, if indicated. "Food = Medicine".
4. Refer for mental health services, if problems identified in evaluation.
5. Establish weight loss limit at patient's own goal weight, if reasonable, and re-evaluate 1 to 2 weeks.
2. Moderate: (moderately distorted body image that has not diminished with weight loss, +/- < 90% of average weight for height associated with a refusal to gain weight, +/- symptoms or signs of excessive weight loss associated with a denial that any problems exits, +/- unhealthy means to lose weight [e.g., <1200 cal/day, excessive exercise or purging], +/- family dysfunction, +/- anticipated lack of engagement in treatment).
1. Medical and nutritional assessment of weight loss, including lab studies.
2. Establishing weight gain goal (target weight ³ 90% average at a rate of gain of ~1 to 2 lbs/week.
3. Providing specific guidelines for structure of daily activities (Meal and snack schedule; limiting or eliminating exercise, sports, recreation or after-school activities unless eats/drinks before participation).
4. Nutritional and mental health counseling an essential element of care—note that SSRI's only approved for use in BN and have minimal effect in low weight AN. "Food = Medicine".
5. Consultation with and referral to specialists involved in the care of patients with eating disorders (age-appropriate).
6. Establish criteria for higher levels of care (intensive outpatient treatment, partial hospitalization, hospitalization, residential treatment), but also determine what is available and covered by insurance.
7. Follow-up visits every 1 to 2 weeks to monitor health and provide primary care, to maintain therapeutic relationship with patient (and parents for youth), and to ensure that nutrition and mental health services have been engaged.
3. Severe: (grossly distorted body image, +/- weight goal < 85% of average weight for height associated with a refusal to stop weight loss, +/- symptoms or signs of extreme malnutrition, often coexisting with denial regarding thinness, +/- using unhealthy means to lose weight [e.g., <1000 cal/day, daily compulsive exercise and purging] ).
1. Medical and nutritional assessment of weight loss, including lab studies and ECG
2. Referral to medical and mental health specialists involved in the care of patients with eating disorders, preparing patient (and family) for treatment that will span more than one year.
3. Continuing primary care provision during and after treatment of eating disorder.

Further reading

Rome ES, et al. Children and adolescents with eating disorders: the state of the art. Pediatrics 2003; 111:e98-108 (http://pediatrics.aappublications.org/cgi/reprint/111/1/e98.pdf).

Mehler PS. Diagnosis and care of patients with anorexia nervosa in primary care settings. Annals Internal Medicine 2001;134:1048-59 (http://www.annals.org/content/vol134/issue11)