APPENDIX 33
PHYSICAL ASSESSMENT OF EATING DISORDERS
Physical assessment is always useful and sometimes essential prior to being
seen at the Eating Disorder Service. As well as simple inspection, full
physical examination allows the opportunity to do blood pressure, pulse, take
a temperature and take basic bloods (please refer to Section on Physical
Complications of Eating Disorders).
Blood tests should include baseline full blood count. Us & Es and creatinin,
LFTs, glucose, calcium and magnesium. Bicarbonate can also be usefully
requested. An ECG is mandatory if the patient is severely underweight or has
a low pulse rate.
Weighing of patients is obviously useful but may cause problems, especially
in the early stages of building up rapport with the patient. However, any
referral to the Eating Disorder Service should include a weight. It is also
important to ask about laxative and/or diuretic use. Factors that should make
referral to the Eating Disorder Service a matter of urgency and also a physical
examination extremely important include; laxative use to an extreme extent,
vomiting several times a day, rapid weight loss, fluid restriction, depression
and/or suicidal ideation.
INFORMATION ABOUT EATING DISORDERS
What is an Eating Disorder?
Eating disorders are behavioural syndromes associated with the physical
factors and physiological disturbances. They feature the preoccupation with
eating and/or food alongside an altered body image so that there is a selfperception of being too fat in most cases. Anorexia Nervosa is characterised
by deliberate weight loss. Patients impose a low eight threshold on
themselves.
Bulimia Nervosa is characterised by repeated bouts of
overeating followed by excessive attempts to control their body weight, thus
self-induced vomiting or use of purgatives for example. Other eating
disorders include Atypical Anorexia Nervosa and Atypical Bulimia Nervosa
which are disorders which do not have all the characteristic features of the
indexed disorder. Also there are conditions of overeating associated with
other psychological disturbances, for example bereavement and likewise
vomiting associated with other psychological disturbances. Binge eating
disorder is recognised by some and can be seen as a variant of Bulimia
Nervosa.
Diagnostic Criteria ICD 10 Anorexia Nervosa
a) There is weight loss, or in children lack of weight gain, leading to a body
weight of at least 15% below the expected, or BMI17.5 or less.
b) Weight loss self induced by avoidance of fattening foods.
c) Self perception of being too fat, a dread of fatness, a self-imposed low
weight.
d) An endocrine disorder manifesting in women as amenorrhoea and in men
as a loss of sexual interest.
Diagnostic Criteria ICD 10 Bulimia Nervosa
a) Recurrent episodes of overeating at least twice a week for a period of 3
months.
b) Patients attempts to counteract the fattening effects of food by one or
more of the following:
i)
ii)
iii)
iv)
Self-induced vomiting
Self-induced purging
Alternating periods of starvation
Use of drugs such as appetite suppressants, thyroid
preparations or diuretics. Neglecting insulin treatment in a
diabetic.
c) Self perception of being too fat with a dread of fatness.
EFFECTS OF STARVATION
Anorexia Nervosa is a condition of self-induced starvation. Starvation affects
many systems. Most changes are completely reversible as weight is regained
and these include psychological symptoms.
1.
Metabolic and Endocrine Effects:
these are changes that are
adaptive and are about trying to conserve body mass. Growth rate is
slowed and puberty will be delayed. Physical activity is often initially
reduced but there can be symptoms of hyperactivity in some. Cortisol
and insulin secretion are both altered. Muscle starts being broken
down to use as an energy source. As starvation proceeds losses of
electrolytes such as calcium, potassium, sodium and magnesium
occur. There will be marked loss of calcium from bones. Patients with
Anorexia Nervosa are as much at risk of Osteoporosis as women in
their 70’s and 80’s. Overall muscle, liver and gut all shrink very rapidly.
Shrinkage in the gastrointestinal tract means feelings of fullness even
after only little amounts of food are eaten. Later on kidneys and heart
may also lose mass.
Women, if post puberty, will become
amenorrhoeaic and Anorexia Nervosa and Bulimia Nervosa are
diagnosis that should be considered in cases of infertility.
2
Cardiovascular Changes:
with weight loss a patient can
become bradycardic and arrhythmias are sometimes seen particularly
where there is low potassium. Cardiac arrest occasionally occurs.
Blood pressure is low in Anorexia Nervosa and there may be postural
hypotension.
3
Biochemistry: dehydration can occur with vomiting, laxative misuse or
fluid restriction.
4
Low Sodium, Low Potassium and sometimes low levels of other
elements such as calcium, magnesium are sometimes seen.
Phosphate supplements may be needed, especially when patients are
being re-fed. Repeated vomiting can cause an alkalosis.
5
Vomiting and Laxative Abuse: can disturb fluid balance which can
lead to an accumulation of fluid, especially in the ankles.
Hypoglycaemia and abnormal glucose tolerance are sometimes seen
and there can be a variety of protein and vitamin deficiencies. All these
disturbances can cause weakness and lack of energy.
6
Skeletal Changes: in Anorexia nervosa, osteoporosis is frequently
seen. Due to lack of calcium and vitamin D particularly. Low
oestrogen levels also play part. There can be growth retardation
before full stature is reached. A Milder form of bone thinning is
osteopaenia. Fractures can occur as a result.
7
Body Temperature:
cold intolerance is seen with Anorexia
Nervosa and very low body temperature or hypothermia can occur.
Raynaud’s Phenomenon is also often seen.
8
Gastrointestinal Tract: damage to the teeth can result from repeated
vomiting as well as inflammation of the throat and swelling of the
parotid glands. Oesophageal tears are sometimes seen and atomic
bowel can occur from excessive laxative abuse. Dependence on
laxatives is then seen.
9
Haematological:
anaemia can occur adding to weakness and
tiredness. White cell counts are also impaired and immune deficiency
state can result. Occasionally low platelet concentrations can lead to
clotting problems.
10
Dermatological: skin may become dry or discoloured. Excess hair
growth on the face, arms and down the neck is often seen in Anorexia
Nervosa. Lanugo hair.
11
Renal, Liver and Pancreatic Function:
in advanced Anorexia
Nervosa these three systems can all be impaired.
12
Neuro-Psychiatric: cognition is slowed, concentration is impaired and
thinking becomes very restricted and focused in established Anorexia
Nervosa. States of depression and anxiety can result in both Bulimia
and Anorexia Nervosa.
13
Muscle Changes: in advanced stages of Anorexia Nervosa there can
be severe muscle weakness.