Primary Care Management of Eating Disorders Reviewed

January 18, 2008 — Primary care management of patients with eating disorders is reviewed in the January 15 issue of the American Family Physician, along with diagnostic criteria for anorexia nervosa, bulimia nervosa, and binge-eating disorder.

"Because most patients do not typically present with the chief complaint of an eating disorder, a physician must be attentive to the possible diagnosis, especially when caring for young women," write Pamela M. Williams, MAJ, USAF, MC, from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and colleagues. "Screening for eating disorders should be considered in the routine care of at-risk patients. Presenting symptoms may include fatigue, dizziness, low energy, amenorrhea, weight loss or gain, constipation, bloating, abdominal discomfort, heartburn, sore throat, palpitations, polyuria, polydipsia, and insomnia."

For eating disorders, lifetime prevalence estimates are 0.6% for anorexia nervosa, 1.0% for bulimia nervosa, and 2.8% for binge-eating disorder. Risk is up to 3 times higher in women vs men, and median age of onset is 18 to 21 years.

Most patients with eating disorders do not have signs on physical examination. However, in patients with advanced eating disorders, general appearance may be emaciated (although normal weight or even overweight is possible), with sunken cheeks, sallow skin, or flat affect. Abnormalities of vital signs may include bradycardia, hypotension, hypothermia, or orthostatic changes. Examination of the skin may reveal dryness, lanugo, dull or brittle hair, nail changes, hypercarotenemia, or subconjunctival hemorrhage.

Other abnormalities on examination of the head, eyes, ears, nose, and throat may be sunken eyes, dry lips, gingivitis, loss of tooth enamel on lingual and occlusal surfaces, dental caries, and parotitis. Breasts may be atrophied, and cardiovascular evaluation may detect mitral valve prolapse, click or murmur, or arrhythmias.

The abdomen may be scaphoid and tender, with palpable loops of stool. The extremities may be edematous, with calluses on the dorsum of the hand (Russell's sign), acrocyanosis, or Raynaud's phenomenon. Finally, neurologic evaluation may detect Trousseau's sign, or decreased deep tendon reflexes.

Most patients with eating disorders can be effectively managed as outpatients by a multidisciplinary healthcare team including a physician, a registered dietitian, and a therapist. In addition, psychiatric consultation is often helpful. Psychosocial and clinical factors should initially be considered and periodically reevaluated.

The physician should serve as the care coordinator, facilitating the management strategies of other team members, while evaluating medical complications and monitoring weight and nutrition status. The dietitian should educate the patient regarding a healthy diet and meal planning and may collaborate with the team in identifying appropriate weight goals.

Cognitive-behavior, interpersonal, or family therapy should be administered by behavioral healthcare professionals, who may also assist with pharmacotherapy. With a stepped-care approach, the first intervention may be determined by the patient's specific needs and available treatment resources.

Some specific questions or statements useful in the evaluation of eating disorders, setting goals, and changing behaviors are included. They address starting a conversation about eating habits, determining motivation to change eating habits, determining the antecedents and consequences of disordered eating patterns, developing alternatives to bingeing, and changing negative thinking.

Patients who are suicidal or who have life-threatening medical complications may require inpatient care. Complications requiring hospitalization may include marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight less than 85% of healthy body weight.

Good evidence supports the use of interpersonal and cognitive-behavior therapies, as well as antidepressants, for treatment of binge-eating disorder and bulimia nervosa. For these disorders, however, evidence is limited supporting the use of guided self-help programs as a first step in a stepped-care approach.

For treatment of binge-eating disorders, a systematic review of randomized controlled trials shows moderate evidence of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, antiepileptics, and appetite suppressants.

Fluoxetine (60 mg/day) is the only drug approved by the US Food and Drug Administration (FDA) for the treatment of eating disorders, specifically bulimia nervosa. Although various classes of antidepressant drugs have been shown to decrease binge eating and vomiting in patients with bulimia nervosa, SSRIs are recommended as first-line agents because of their efficacy and safety profile.

The efficacy of behavioral or pharmacologic treatments for patients with anorexia nervosa remains unclear.

After receiving treatment in a tertiary care setting, approximately 70% of persons with bulimia nervosa and 27% to 50% of persons with anorexia nervosa will not show evidence of a clinical eating disorder within 10 years of follow-up.

Specific recommendations, and their accompanying levels of supporting evidence, are as follows:

* Patients with bulimia nervosa and binge-eating disorder should be offered interpersonal or cognitive-behavior therapy (level of evidence, A).
* As the initial step in the treatment of bulimia nervosa and binge-eating disorder, a self-help program may be considered (level of evidence, B).
* Most patients with anorexia nervosa should be managed by a multidisciplinary team in an outpatient tertiary care setting (level of evidence, C).
* In patients with bulimia nervosa, a trial of an antidepressant may be offered as a primary therapy or in combination with psychotherapy (level of evidence, B).

"Binge-eating disorder, bulimia nervosa, and anorexia nervosa are potentially life-threatening disorders that involve complex psychosocial issues," the review authors conclude. "A strong therapeutic relationship between the physician and patient is necessary for assessing the psychosocial and medical factors used to determine the appropriate level of care."


Clinical Context

Patients with eating disorders typically do not state this as their chief complaint. Because eating disorders are common and may be life threatening, clinicians must be vigilant to recognize this diagnosis, especially when caring for young women. Lifetime prevalence estimates are 0.6% for anorexia nervosa, 1.0% for bulimia nervosa, and 2.8% for binge-eating disorder. Risk is up to 3 times higher in women vs men, and median age of onset is 18 to 21 years.

After receiving treatment in a tertiary care setting, approximately 70% of persons with bulimia nervosa and 27% to 50% of those with anorexia nervosa will have no apparent evidence of a clinical eating disorder within 10 years of follow-up. This review of primary care management of patients with eating disorders presents management strategies to optimize outcomes, along with diagnostic criteria for anorexia nervosa, bulimia nervosa, and binge-eating disorder.


Study Highlights

* Clinicians should consider screening for eating disorders in the routine care of at-risk patients.
* Presenting symptoms may include fatigue, dizziness, low energy, amenorrhea, weight loss or gain, constipation, bloating, abdominal discomfort, heartburn, sore throat, palpitations, polyuria, polydipsia, and insomnia.
* Most patients with eating disorders do not have signs on physical examination until they are in the advanced stages of these diseases.
* Physical signs of advanced eating disorders may include emaciated appearance, sunken eyes or cheeks, sallow or dry skin, flat affect, bradycardia, hypotension, hypothermia, orthostasis, hair or nail changes, hypercarotenemia, subconjunctival hemorrhage, gingivitis, loss of tooth enamel, dental caries, parotitis, breast atrophy, mitral valve prolapse, arrhythmias, palpable loops of stool, edema, Russell's sign, acrocyanosis, Raynaud's phenomenon, Trousseau's sign, or hyporeflexia.
* Most patients with eating disorders can be effectively managed as outpatients by a multidisciplinary healthcare team including a physician, a registered dietitian, and a therapist, for ongoing review of psychosocial and clinical factors.
* The physician should coordinate care, facilitate management by other team members, evaluate medical complications, and monitor weight and nutrition. Psychiatric consultation may be needed.
* A strong therapeutic relationship between the physician and patient is needed to evaluate psychosocial and medical factors used to determine the appropriate level of care.
* Patients who are suicidal or who have life-threatening medical complications may require inpatient care.
* Complications requiring hospitalization may include marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight less than 85% of healthy body weight.
* Patients with bulimia nervosa and binge-eating disorder should be offered interpersonal or cognitive-behavior therapy.
* Behavioral healthcare professionals should administer cognitive-behavior, interpersonal, or family therapy, and they may also assist with pharmacotherapy.
* A stepped-care approach may determine the first intervention based on the patient's specific needs and available treatment resources.
* A self-help program may be considered as the first step in the treatment of bulimia nervosa and binge-eating disorder.
* Most patients with anorexia nervosa should be managed by a multidisciplinary team in an outpatient tertiary care setting.
* In patients with bulimia nervosa, a trial of an antidepressant may be offered as a primary therapy or in combination with psychotherapy.
* A systematic review of randomized controlled trials shows moderate evidence of efficacy of SSRIs, tricyclic antidepressants, antiepileptics, and appetite suppressants for binge-eating disorders.
* Fluoxetine (60 mg/day) is the only FDA-approved drug for treatment of eating disorders, specifically bulimia nervosa. SSRIs are recommended as first-line agents for bulimia nervosa because of their efficacy and safety profile.
* The efficacy of behavioral or pharmacologic treatments for patients with anorexia nervosa remains unclear.
* In patients with suspected eating disorders, clinicians should start a conversation about eating habits, determine motivation to change eating habits, determine the antecedents and consequences of disordered eating patterns, and help patients develop alternatives to bingeing and change negative thinking.

Pearls for Practice

* In patients with eating disorders, hospitalization may be needed for those who are suicidal or who have life-threatening medical complications such as marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight less than 85% of healthy body weight.
* Patients with bulimia nervosa and binge-eating disorder should be offered interpersonal or cognitive-behavior therapy, and a self-help program may be considered as the first step in treating these patients. Most patients with anorexia nervosa should be managed by a multidisciplinary team in an outpatient tertiary care setting. In patients with bulimia nervosa, a trial of an antidepressant may be offered as a primary therapy or in combination with psychotherapy.

News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD

SOURCE: www.medscape.com