Far too many staff in primary care feel out of their depth when faced with a young person or adult presenting with an eating disorder – indeed, many may not even be aware of some of the critical signs and symptoms.
The recent NICE guideline on eating disorders is therefore particularly welcome. It comprehensively covers the identification and management of anorexia nervosa, bulimia and atypical eating disorders in adults and young people over the age of 8 years.
The guideline identifies common strands of care for all the conditions. GPs need to take responsibility for the coordination of care as well as initial assessment, which should involve looking at the patient’s physical, psychological and social needs and also estimating risk. Some patients may need emergency referral to psychiatric or acute medical services.
The care of most patients with eating disorders will be shared between primary and specialist care (see Figure 1, below). NICE emphasises that there must be clear (and preferably written) agreement between care providers about which aspects of care each manages. I suspect that for most patients referred to specialist services, GPs will take care of their general health and monitor progress while leaving key decisions to the psychiatric team.
|Figure 1: Extract from 'Eating disorders: summary of identification and management'|
|Reproduced from Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders by kind permission of the National Institute for Clinical Excellence|
Some primary care support will involve putting patients and carers in touch with information services and self-help groups. The GP should also, at an early stage, identify and help reduce risk factors. Individuals at particular risk include patients with diabetes, those with bone disease, patients who are vomiting, those who are suspected of laxative abuse, and pregnant or postpartum women.
Four additional issues are identified for consideration in children and adolescents. These are:
- Their right to confidentiality must be respected
- Clinicians need to be aware of the possibility of abuse (and here the GP is in a pre-eminent position to provide input)
- Growth and development need special consideration
- The whole family needs to be involved in treatment.
The guideline recognises that GPs are in a special position to screen certain groups of patients. Alarm bells ring in my mind when I see young women with very low BMI, others with normal BMI seeking treatment with anti-obesity drugs and anyone showing signs of starvation, all of whom the guideline identifies as at high risk.
Others at risk include individuals with gastrointestinal disturbances, menstrual irregularities or amenorrhoea and any child with growth problems. Most of these patients will have other reasons for their symptoms, but the guideline should make us consider excluding an eating disorder.
To help GPs in this screening process it is suggested that we ask a direct question, for example, "Do you think you have an eating problem?” or "Do you worry excessively about your weight?”
The guideline offers advice specific to each condition. Teenage girls between the ages of 13 and 19 years comprise 50% of anorexia nervosa sufferers. Primary care is particularly well placed to look at weight changes and growth rates in individuals in whom the diagnosis is being considered. Other patients with an established diagnosis will need ongoing review.
GPs are not in a good position, however, to implement the NICE recommendations for psychological treatments directly. It is envisaged that most patients under specialist care will be managed as outpatients and offered therapies such as cognitive behavioural therapy, cognitive analytic therapy and interpersonal psychotherapy as well as dietetic support.
|Key issues in primary care|
|Additional issues to consider in children and young people|
|Issues to consider in anorexia patients|
Like many GPs, in the past I have been tempted to start anorexia patients on an antidepressant, perhaps because access to other measures is difficult and often delayed. However, the guideline cautions against using medication as a sole or primary measure as these patients may be particularly at risk from adverse effects of drug treatment.
For patients medically at risk, the GP will need to ensure that a physician or paediatrician with expertise in treating these patients is involved, and for pregnant women that enhanced antenatal care is provided.
Treatment will almost always be with the patient’s or parent’s consent, but GPs are reminded that the Mental Health Act or Children Act may be invoked if required.
The guideline indicates that bulimia nervosa lends itself more to management in primary care, with good evidence to support self-help programmes, direct encouragement and support for patients.
Fluoxetine can be helpful at an early stage. The guideline recommends a higher dose than for depression, of 60 mg per day. As with anorexia, psychological therapies, in this case cognitive behaviour therapy and interpersonal psychotherapy, can be important.
GPs are in a good position to recognise individuals in whom there is excessive vomiting or laxative use. If suspected, blood chemistry should be monitored because of the risk of electrolyte disturbance.
Atypical eating disorders
The final section of the guideline covers atypical eating disorders including binge eating disorder. Binge eating disorders are straightforward, and the guideline goes into modest detail. Again, the GP’s role is important in directing patients to consider self-help programmes and encouraging and supporting individuals. As many patients will suffer associated obesity, GPs will need to consider offering measures to help promote weight loss. Psychological therapies also play a role.
Treatment for patients with other atypical eating disorders should be along the lines of the treatment for the condition that most closely resembles the patient’s eating disorder.
This guideline will give added confidence to GPs and their primary care colleagues in identifying patients with eating disorders.
Treatment paths are identified and many of the interventions and responsibilities lie within primary care. Practice nurses will often be involved and the guideline is also relevant to other community-based staff, for example school nurses, midwives and health visitors.
One challenging aspect will be for health commissioners to ensure that services are adequate to back up the primary care team. In many areas the child and adolescent mental health service has difficulty meeting demand, inpatient facilities are scarce and psychological therapy services rudimentary.
GPs with roles in PCOs will be able to use this guideline to solicit support for service development. Indeed, the guideline could form the basis for a shared care protocol to provide an enhanced service locally under the new GMS contract.
Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Clinical Guideline 9, can be downloaded from the NICE website: www.nice.org.uk.