Eating Problems

General assessment and admission-threshold guide covering Anorexia Nervosa, Bulimia Nervosa, and other eating disorders.

“Eating disorder not otherwise specified” (EDNOS) covers any eating disorder that doesn’t meet full criteria for anorexia or bulimia — including binge eating disorder: recurrent, distressing binge episodes without the regular compensatory/weight-control behaviours seen in bulimia. Around 2–3% of young women have binge eating disorder, and up to 5% have EDNOS more broadly. An intense preoccupation with weight/shape as a marker of self-worth is common across all these conditions. ~90% of anorexia/bulimia patients are women, but binge eating disorder has much less gender imbalance.

Assessment

SCOFF screening — score 1 point per “yes”; ≥1 positive answer warrants a fuller eating-disorder assessment:

• Do you make yourself Sick because you feel uncomfortably full?
• Do you worry you’ve lost Control over how much you eat?
• Have you recently lost more than One stone (6.4 kg) in 3 months?
• Do you believe yourself to be Fat when others say you’re too thin?
• Would you say Food dominates your life?

Also use a HEADSS assessment in adolescents (including suicide risk).

Look for: cognitive changes (impaired concentration/alertness, easy distractibility, lethargy, intrusive thoughts about food); compensatory behaviours (self-induced vomiting, laxative/diuretic/diet-pill misuse, insulin misuse, increased gum-chewing/smoking, excessive exercise); menstrual irregularity/amenorrhoea.

Physical examination: temperature; BP and postural drop; pulse and postural change; height, weight, BMI (in under-18s, use a paediatric BMI calculator — healthy range is the 25th–85th centile, with <5th centile an indicator for hospital treatment); hydration status; oral exam for signs of vomiting-related acid damage (enamel erosion, throat inflammation).

Investigations: baseline bloods (U&E, calcium, magnesium, phosphate, LFTs, random BGL, FBC, iron studies, B12, folate, TSH; consider oestradiol, FSH, LH, vitamin D); ECG; bone mineral densitometry if restrictive eating with amenorrhoea >6 months.

Management

All treatment in patients <14 requires parental consent; follow mandatory-reporting processes if a parent refuses treatment that places a child <16 at risk. Engage the patient and family in psychoeducation, and refer to a dietitian, psychologist, psychiatrist, and/or paediatrician, plus eating-disorder support programs.

Indicators for medical inpatient admission

• Heart rate <50 bpm, or postural tachycardia (>20 bpm rise on standing)
• BP <80/50 mmHg, or postural drop >20 mmHg
• ECG: arrhythmia, or QTc >450 msec
• Temperature <35.5°C
• Serum potassium ≤3 mmol/L, or other significant electrolyte disturbance
• BGL <3 mmol/L
• BMI <5th centile
• Weight loss >1 kg/week for ≥6 weeks
• Acute dehydration, or the patient has stopped fluid intake
• Failed intensive community-based treatment, or another special consideration (diabetes, pregnancy)

Mental health admission may also be indicated independently of the physical criteria above.

Refeeding syndrome

Highest risk in patients needing intensive refeeding, with no oral nutrition for 7–10 days, severely underweight (BMI <14, or <5th centile in children/adolescents), pre-existing electrolyte abnormalities, a prolonged QTc, or prolonged malnutrition/ rapid weight loss (at any starting weight). Occurs within the first 2 weeks of refeeding as severe fluid/electrolyte shifts develop — can cause cardiac arrest and sudden death.

Management: start refeeding incrementally, restricting and spreading caloric intake through the day; correct electrolyte abnormalities before starting and monitor throughout, watching particularly for hypophosphataemia and cardiovascular risk.