Medical Implications &
Management of Eating
Disorders
The physical and medical implications of eating disorders are complex and carry a high mortality rate regardless of weight. As the length of the disorder increases, as in Severe and Enduring, the more complex they can become at end of life, especially in conjunction with
What are we Managing
High Mortality from medical compromise and high comorbidity
Complex medical concerns affecting all organs of the body
Bio-adaptation to starvation and malnutrition whereby medical stability is maintained by the body adjusting to starvation
In Severe and Enduring Eating Disorders, with increased and prolonged malnutrition, more complex medical conditions caused by general loss of muscle and fat pads supporting organs may occur.
Again in Severe and Enduring ED the increased vulnerability of age and
decreasing resilience (of the body) over many years, years of bio adaption, will lead to a poor prognosis
Body will react with energy saving mechanisms and/or structural failure of body organs
Due to the high mortality rate of patients suffering from eating disorders there is high medical risk not
dependent on weight.
Causes of death are most commonly due to:
Starvation
Cardiac failure
Working alongside the Co-morbidities
Approximately 60% of patients with an eating disorder have a comorbid diagnosis, the eating disorder may be providing a sense control.
When the enduring primary psychiatric diagnosis is seen to be responding to treatment, the risk of the disordered eating may increase
Be mindful of the medical risks of the primary diagnosis (may not be the eating disorder)
Drugs
Alcohol
Managing the Medical Risk
In non specialist settings
Services working together to provide care, with focus on the primary diagnosis and consult into the eating disorder
May require an Acute Management Plan in collaboration with Physicians via ‘Healthpathways’ and/or Advance Care Planning if the patient has a medical instability which is life threatening
Monitoring for deterioration by the GP if increased weight loss or increase in physical symptoms – working with GP and Practice Nurses
Include level of medical monitoring required on the Treatment Plan, to manage risk. Adhering to these boundaries, ending treatment if non compliant – non negotiable
Being mindful of destabilisation of emotions – exacerbating self harm/suicidal ideation and intent, with loss of control of the eating disorder and how to manage this risk
Medical Monitoring
Medical monitoring of a patient with an eating disorder includes Weekly weight – be mindful of water loading, weights etc
Heart rate and Blood pressure lying and standing (at 2 minute intervals) Normal heart rate for an adult is between 60 and 100 bpm
Normal blood pressure for an adult is around 120/80
Patients with stable medical parameters may be monitored on a less frequent basis due to the bio-adaption of the body to the starved state and they may remain medically stable for long periods.
Initial Physical Assessment by Service or
GP
Weight (without shoes or heavy outer clothing)
Height (without shoes)
BMI (calculate by BMI = Weight (kg) / Height (m)²)
ECG
Pulse (lying and standing after 2 mins) and any pulse differential
Hydration
Blood Pressure (lying and standing after 2 mins)
Temperature
Respirations
Squat test
Menstruation – bone density scan –female triad
When to
Medically Monitor
At the assessment to establish base lines
Again during treatment if
▪ There is further weight loss ▪ Become symptomatic
▪ If medical instability is identified at assessment and needs to be
monitored more regularly by the GP
Barriers to medical monitoring
Finances – benefits available (ie Disability Allowance – WINZ) Non Attendance
Weight gain fear – Declining to be weighed
Presenting Signs and Symptoms
General
▪
Marked weight loss, gain or fluctuations
▪
Cold intolerance
▪
Generalised weakness
▪
Fatigue or lethargy/tired all the time
▪
Fainting/Dizziness
▪
Hair loss
▪
Hot flashes, sweating episodes
▪
Lanugo
Osteoporosis
Severe and Enduring
Eating Disorders
Duration of eating disorder studies show anything between 5.5
and 10 years, with at least two evidence based treatments
Identity intertwined with AN
Low BMI with associated medical risks increasing with longevity
Entrenched patterns of behaviour
Co-morbidities
Biological adaptation to starvation
Poor quality of life
Severity: significant impairment to
Quality of Life
Impact on Nutritional Health
Medical and psychological impacts
Employment
Family relationships
Housing
Social connections
Hobbies
Financial implications
Co-morbidities
(Robinson 2009)Optimal Pie Chart
Friends Church God Family Work Hobbies Health School Home Stuff Finances MeEating Disorder Pie Chart
Client's Current Self-Evaluation Pie Chart
What treatment
might look like
Holding Hope
Crisis/medical management
Personal goals – focus on ‘their’ goals and pie chart and how ‘they’ might want it to look
Primary focus of treatment is not always weight gain to a normal BMI but to increase the person’s sense of autonomy for living their best life and developing self-responsibility for managing their health and wellness challenges
Supportive psychotherapy (studies show both CBT
and SSCM to be effective) – usually 4 sessions in an outpatient setting
Inpatient short stay to address ‘their goals’
What Might Work
Impact of the disorder on QOL – primary target of interventions
Client may be more motivated in these areas
Secondary outcomes include weight gain and increased BMI
Weight gain encouraged but not mandated or primary focus
Focus on regular eating, psycho-education and motivation
Improvements can be monitored in QOL questionnaire
Working on the purpose of the eating disorder and formulation
What might Not Work
Clinician’s ‘own’ goals or expectation of weight gain or ‘recovery’
Existing treatment focus on medical symptoms and weight gain
Ill matched to offer treatment where Client is focussed on unrealistic recovery ie ‘the magic pill’
Leads to low retention and engagement and non achievement resulting in further shame
Keep Calm and Carry
on
Seek supervision for yourself
Take to MDT
Beware change may not happen Be aware that ACP and Advance
Directives may be required
Does not mean end of treatment but putting things in place