director of service, university of bristol students health
TRANSCRIPT
Dr Dominique Thompson
Director of Service, University of Bristol Students’ Health Service
&
NICE Eating Disorders Guideline Committee
The Day Job!
Age when Mental Health affects us
But I never see eating disorders… Average practice with 10 000 patients would see 2 new
cases of Bulimia a year (total incidence 4 new EDs per year)
And 1 % of females aged 15-30 have anorexia
6.4% of the population of England over 16 thought to have problem with food
11% of ED sufferers are male (180k estimate in UK)
10% of ED are anorexia, 40% are bulimia,50% are OSFED
If you’re not seeing them, its probably because you’re not asking!
Meet Alice… Alice is a 19 year old geography undergraduate. She is an
articulate, diligent, creative and high-achieving student. She is funny, kind, and popular. She is active at the Student’s Union and is committed to social causes and volunteering projects…
But Alice also has a secret…she struggles with food, often feels low, and she hates her body
She has an appointment to discuss her pill/ ‘weight gain’ She looks quite thin to you. How confident do you feel to manage her likely eating and
weight issues? Scale 1-5
Alice’s Mind Map
How do I raise the issue? Do you worry a lot about your weight? Maybe too
much?
Do you think you have an eating problem?
You look quite slim. Does that worry you at all?
Do you spend a lot of time thinking about your weight and what you eat?
Screening Tools Do you worry that you have lost control over how much you
eat? Do you make yourself sick when you feel uncomfortably
full? Do you currently suffer with or have you ever suffered in
the past with an eating disorder? Do you ever eat in secret? The best individual questions for ruling out an eating
disorder were: Does your weight affect the way you feel about yourself? Are you satisfied with your eating patterns?
New Classification DSM V(5)
6 classes of ED
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Other Specified Feeding or Eating Disorders (prev EDNOS) ‘OSFED’
Avoidant restrictive food intake disorder
Pica and rumination disorder
People have to want to change behaviour
Build the relationship/trust
Top Symptoms Weight changes Eating pattern/ avoidance Body image Vomiting pattern Exercise regime Bingeing Laxative/ diuretic use/ other drugs Fluid intake/ restriction Menstrual pattern Other health; diabetes/ pregnancy/ coeliac Mental health; mood/ anxiety/ self esteem/ self harm Physical sx; headaches/ bowel upset/ dizzy/ palps/ reflux
Top Signs BMI
BP (& postural drop)
Pulse
Temp
Squat and sit up tests (low BMI)
Skin quality/ purpura/ lanugo hair/ oedema
Oral health (teeth eroded/ salivary glands enlarged)
PHQ9/ GAD7 scores
Alice’s History Alice discloses that she restricts her calories to 900 a
day, and has done for 2 years. She doesn’t purge
Amenorrhoea for >12m
Her BMI is 16.2
You plan a f/up appointment
What tests would you arrange in the meantime? How confident are you re guidance? Scale 1-5
Bloods?
ECG?
Dexa scan for Bone mineral density?
Top Investigations FBC/ UE&Cr/ CK/ Gluc/ LFT/ Mg/ PO4/ Ca / bicarb
(+TFT/ ESR first time)
ECG if BMI<15 or meds affect QT interval
DEXA scan if anorexia >2y or amenorrhoea>12m
What am I looking for? Low K from vomiting or laxative abuse
High bicarb from vomiting
Low bicarb from laxative abuse
Low Mg from diarrhoea
Low PO4 from malnourishment
Low Hb 90-120
Low WCC 2-4
Alice comes for follow up Which medications might you consider or discuss?
Do you feel confident re current guidance? Scale 1-5
Do you know when to refer urgently? Scale 1-5
Red flags (admit same day) BMI <12 Wt loss >1kg/ week Purpuric rash BP<80/60 (postural drop >20) Pulse <40 Temp<34.5c Hb <90, WCC <2.0, Neuts <1.0, Plts<110 K <3.0 Na<130 Gluc <2.5 LFTs >2x upper limit normal
Referral (weekly rv, urgent appt) BMI <14
Wt loss >0.5kg/ week
BP<90/70 (postural drop >10)
Pulse <50
Hb <110, WCC <4.0, Neuts <1.5, Plts <130
K<3.5
Na<135
LFTS abnormal
Gluc <3.5
Vocational students
Resources/ 3rd sector etc Anorexia Bulimia Care website
B-eat website
Student Minds
Men Get Eating Disorders Too
The Succeed Foundation (Carers)
Book; Bite Sized by Fiona Hamilton
For professionals; Kings College, London; eating disorders research group website
Amazing books for all! Lighter than my Shadow Seconds to Snap
Blogs/ twitter/ facebook @BristolSHS
Service provision: ‘First Step’ First primary care eating disorder service Simple referral criteria; ‘Over 18 & have ED’ Refer to primary care based therapists for triage Single point of entry Stepped model of care; community through to
inpatient unit Therapy delivered in GP settings Rapid access Great communication 1/3 of cost
Next steps; Consider joining Network-ED http://www.network-
ed.org.uk/ for central professional resource/ support
RCGP member eLearning module (CPD)
Update your patient resources
Consider a practice template for ED
Check out MARSIPAN checklist (RCPsych)
Await new NICE ED Guidance 2017
Consider (with CCG) setting up primary care assessment/ triage/ treatment service? (eg First Step, Bristol)
Contact me for queries;
www.drdominiquethompson.com