Eating Disorders - BB Flashcards
What is refeeding syndrome?
- Potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artifical re-feeding - paraenteral or enteral
- Hallmark = hypophosphataemia
- Can change Na, gloucose, protein, thiamine, hypokalaemia and hypomangesaemia
Guidelines for managing refeeding syndrome
- Identify patients at risk
- Check K+, Ca2+, phosphate and magnesium
- Before feeding give thiamine orally and multivitamins
- Start feeding slowly, increase over 4-7 days
- Observe K+, Ca2+, Mg2+ carefully and ammend treatment appropriately
Why does refeeding syndrome occur?
- When early starvation sets in body switches from using carbohydrates to using fat and protein as main source of energy
- Basal metabolic rate decreases by as much as 20-25%
- Prolonged fasting - body aims to prevent protein and muscle breakdown = decreasee ketone use
- = increased blood levels of ketone bodies
- = brain switch to use use ketones instead of glucose
- Intracellular minerals depleted (serum often normal)
- Refeeding = increased insulin and decreased glucagon
- Insulin = glycogen, fat and protein synthesis
- Requires phosphate and magnesium and stimulates K+ to enter cells
- = low phosphate low Mg2+ and low K+
Patients at risk of refeeding syndrome - criteria from NICE
One of:
* BMI less than 16
* Unintentional weight loss more than 15% in past 3-6months
* Little or no nutritional intake for more than 10 days
* Low levels of K+, Mg2+ or phosphate before feeding
Two of:
* BMI under 18.5
* Unintentional weight loss of more than 10% in 3-6 months
* Little or no nutritional intake for 5 days
* History of alcohol misuse or drugs including insulin, chemotherapy, antacids or diuretics
Starting refeeding - how much?
- No more than 50% energy requirements in patients who have eaten little or nothing for more than 5 days
- rate can then be increased if no refeeding problems
Replacing electrolytes if they do become low for refeeding syndrome
- K+, magnesium and phosphate can be replaced via IV
- Slow feed down too
- Caution if renal impairement, hypocalcaemia (can worsen) or hypercalcaemia (calcification)
What patient groups in general are at high risk of refeeding syndrome?
- Anorexia nervosa
- Chronic alcoholism
- Oncology patients
- Post-op patients
- Elderly
- Uncontrolled diabetes
- Chronic malnutrition - malabsorption, low energy diet
- Long term use antacids
- Long term use diuretics
Support for people with eating disorders
- Beat eating disorders website - information, helpline, web chat, also have info about further support
Differentials for weight loss in an 18 year old patient
- Intentional weight loss - deliberate
- Depression
- Hyperthyroidism
- Inflammatory bowel disease
- Eating disorder
- Cancer eg lymphoma
- Tuberculosis
Features to enquire about in eating disorder history
- Body image disturbance - think they are overweight?
- How much weight lost and over how long?
- Restricting calories - how much /day
- Behaviours that induce weight loss - eg purging or exercising
- Medications to aid weight loss eg diuretics/laxatives/amphetamines
- Are they still having periods
BMI calculation
Weight / height squared
Physical examination findings of anorexia nervosa
- Appears underweight
- Anaemia - pallor, tachycardia, glossitis, koilonychia
- Low B12/folate - glossitis, angular stomatitis
- Bradycardia
- Postural hypotension
- Lanugo hair
- Weak proximal muscles - squat to stand test
- If inducing vomitting - Russells sign (calloused knucles), swelling of parotid gland, erosion of inner surface of front teeth
Initial investigations prior to referral to eating disorders team
Bedside:
* ECG - check for conduction defects, prolonged QTc, consequences of electrolyte abnormalities
Bloods:
* Hormones - low LH, FSH and oestradiol, low T3, normal T4 and normal TSH, mild cortisol increase
* FBC - nomocytic normochromic anaemia, maybe low WCC and plt
* U&E - hypokalaemia (if vomitting), hyponatramia and low K+ (if using laxatives), low phosphate, low magnesium
* Lipid - hypercholesterolaemia
Advanced:
* DEXA scan - usually done by eating disorders team
Risk factors contributing to eating disorder
- Genetic - MZ twins
- Personality - perfectionism, cluster C traits
- Societal - social media, advertising, pursuit of size 0
- Family - family pressure to succeed, conflict in home, overprotectiveness
- Social class - middle to high income families
Recommended treatments for eating disorder from NICE - adults
- Monitor weight and dietary counselling
- Vitamin and mineral supplementation
Psychological:
* Individual eating disorder focused cognitive behvioural therapy (CBT-ED)
* Maudsley anorexia nervosa treatment for adults (MANTRA)
* Specialist supportive clinical management (SSCM)
What is CBT-ED?
- 40 sessions over 40 weeks
- Twice weekly sessions first 2-3 weeks
- Reduce physical health and any other symptoms of ED
- Covers nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self esteem and relapse prevention
- Self monitored dietary intake and thoughts/feelings re this
- Risks of malnutrition etc
What is MANTRA?
- 20 sessions
- Weekly in first 10 weeks then flexible after this
- Up to 10 extra sessions if complex
- MANTRA workbook
- Cover nutrition, symptom management and behaviour change
- Encourage non-anorexic indentity
What is SSCM?
- 20 or more weekly sessions
- Positive relationship between person and practitioner
- Recognise link between symptoms and abnormal eating
- Restore weight
- Psychoeducation, nutritional education and advice
Recommended psychological treatment for anorexia nervosa in children
Anorexia nervosa focused family therapy:
* Combination of single family sessions, multi family sessions and seperate sessions alone
* 18-20 sessions over 1 year
* Emphasise role of family to help recovery
* Not to blame family/carers
* Education - risks, condition and nutrition
* Early in treatment - family take central role
Management of binge eating disorder in adults and children
- Binge eating disorder focused guided self help
- Group eating disorder focused CBT (if self help not worked/unsuitable)
Clarify that weight loss is not goal/part of treatment
Management of bulimia nervosa in adults
- Bulimia nervosa focused guided self help
- CBT-ED (eating disorder focused CBT)
Bulimia nervosa managment children
- Bulimia nervosa focused family therapy
- If not, CBT-ED
Management of ED if physical health severely compromised
Admission to hospital
Guidelines for hospitalised patients with anorexia nervosa
- MARSIPAN - management of really risk patients with anorexia nervosa
