Eating Disorders

Question 1

SCOFF screening tool.

a) Used to diagnose…?
b) Score of __ or above is positive for diagnosis
c) What are the 5 criteria?

Answer 1

a) Anorexia and bulimia
b) 2
c) SCOFF:

S - Do you ever make yourself SICK after eating?
C - Do you feel you have lost control over how much you eat?
O - Have you lost more than ONE stone in the past month?
F - Do you think yourself FAT when others say you’re thin?
F - Does FOOD dominate your life?

Question 2

A 20 year old student has been admitted to Medical Assessment Unit (MAU) after a collapse in her Hall of Residence. Her BMI is 12.

• O/E: emaciated, HR 50 bpm, BP 86/60, RR 8.
• Angular stomatitis and proximal muscular weakness.

a) What questions would you ask to clarify diagnosis?
b) What other findings would you look for on physical examination?
c) What investigations would you order and why?
d) What are the immediate risks for this young woman?
e) Discuss immediate and longer term management

Answer 2

a) -

Question 3

Anorexia nervosa: features

a) 3 core criteria
b) Risk factors
c) Physical symptoms and signs

Answer 3

a) - Low body weight (BMI < 17.5 in adults; < 85% predicted weight in children)
- Due to restriction of food intake or persistent behaviour which interferes with weight gain
- Intense fear of gaining weight/ think they’re fat

b) - Female, western society, young, FHx eating disorder, personal history of abuse, occupational/recreational pressure
- Personality: EUPD, perfectionism, obsessive, anxious

c) Symptoms.
- amenorrhoea, hirsutism
- anaemic/hypokalaemic: pallor, lethargy, weakness, dizziness, intolerance to cold

Signs.

• Low HR, low BP (+ postural drop), low temperature
• Peripheral oedema
• Reduced muscle mass and power
• Squat/sit-up tests failed
• Lanugo hair, scanty pubic hair, and acrocyanosis
• Anaemia: pallor, angular stomatitis, kolionychia

Question 4

Anorexia: assessment and investigations

Answer 4

Full examination.

• Height and weight
• Obs
• CV exam - risks

ECG

• prolonged QT
• bradyarrhythmias

Bloods.

• FBC, ESR (anaemia, other causes of weight loss)
• U+Es, creatinine (hypokalaemia) glucose, LFTs
• TFTs

Imaging.
- DEXA scan

Question 5

Assessing risk in anorexia.
- MARSIPAN

• sign suggesting severe anorexia

Answer 5

• Management of Really Sick Patients with Anorexia Nervosa

Examination.

• BMI < 13, or weight loss > 0.5 kg/week
• CV: HR < 40, SBP < 90, long QT
• Temp < 35
• Failed sqaut test or sit-up test

Metabolic.

• Low potassium, sodium, magnesium or phosphate.
• Raised urea, creatinine or transaminases.
• Low albumin or glucose

Question 6

Eating disorders: management

Answer 6

Psych risk.

• Assess suicide risk
• section if required

Weight management.

• Weight monitoring
• SAFE refeeding
• Beware refeeding syndrome
• If laxative/diuretic abuse - reduce slowly

Manage complications.

• U+E monitoring and supplementation
• Bone protection if required
• Dental review if repeat vomiting

1st line in young people:

• Anorexia-nervosa-focused family therapy (FT-AN)
• Alternative: CBT

1st line in adults:
- Eating-disorder focused CBT

Question 7

Bulimia nervosa.

a) Criteria
b) Possible physical signs
c) Management

Answer 7

a) Repeated episodes of uncontrolled overeating (binges) followed by compensatory weight loss behaviours*
* If no compensatory behaviours = binge-eating disorder

b) - Salivary glands (especially parotid) may be swollen.
- Russell’s sign (calluses on the back of hand, caused by abrasion against teeth during inducement of vomiting)
- Erosion of dental enamel
- Oedema if there has been laxative or diuretic abuse

c) As for anorexia

Question 8

Malnutrition.

a) Define
b) Kwashiorkor vs. marasmus
c) Tool to assess and assessments
d) Nutritional support in who?

Answer 8

a) Nutrient deficiency state of protein, energy or micronutrients (vitamins and minerals)
- technically includes under- and over-nutrition

b) - Kwash - protein deficiency with normal energy intake; associated with oedema and hepatomegaly
- Marasmus - protein AND energy deficiency; associated with wasting

c) MUST:
- Height, weight, BMI
- Unplanned weight loss (%)
- Mid-upper arm diameter
- Acute disease effect

d) - BMI <18.5.
- Unintentional weight loss >10% over the previous 3-6 months.
- Eaten little or nothing for >5 days and who are unlikely not to for the following 5 days or longer.
- Poor absorption, high nutrient losses or increased nutritional needs

Question 9

Refeeding syndrome.

a) What is it?
b) Pathophysiology
c) Biochemical features
d) Prevention

Answer 9

a) Potentially fatal shifts in fluids and electrolytes that can occur in malnourished patients during re-feeding

b) - Prolonged fasting: body’s main energy source becomes fats and proteins (rather than glucose)
- Refeeding: glucose load leads to insulin release, which stimulates cellular uptake of Pi, K+ and Mg2+ for glycogen synthesis
- This leads to severely depleted serum Pi, K+ and Mg2+

c) - Fluid-balance abnormalities
- Hypo…phosphataemia, magnesaemia, kalaemia
- Thiamine deficiency
- Glucose metabolism dysregulated

d) - Refeed at no more than 50% of energy requirements in patients who have eaten little or nothing for > 5 days
- Replace K+, Mg2+ and Pi (as well as any other electrolyte or metabolic deficiencies)
- Monitor U+Es, and cardiac monitoring, etc.
- Gradually build up feeds