Eating Disorders on the CCFP exam

Approach

• Ask every child, teen and young adult, whatever their sex or gender. The visit in front of you may be the only chance.
• Ask about worry over weight or shape, recent weight change, and changes in eating or exercise.
• Use a structured teen history such as HEEADSSS: home, school, eating, activities, drugs, sex, suicide and mood, safety.
• See the teen alone for part of the visit. Say what stays private and when you must share.
• Plot height and weight on a growth chart. A child who drops off their curve needs questions, even at a normal weight.

Approach

• With ongoing low mood, worry or stress, ask how the patient feels about their body and weight.
• Ask directly about vomiting, laxatives, skipped meals, bingeing and hard exercise. Ask without judging.
• Ask about cutting, other self-harm and thoughts of suicide.
• Think of purging when bloating, sore throat, heartburn or constipation has no clear cause.
• Once vomiting is disclosed, stay with it. Her safety and her methods come before the bloating.

Approach

• Ask what a usual day of eating looks like: skipped meals, food rules, binges and feared foods.
• Ask how and how often she purges: vomiting, laxatives, water pills, diet pills or exercise.
• Ask how she feels about her body, and how much the eating worries or controls her.
• Screen for depression, anxiety, self-harm and suicide. Ask about past trauma or abuse.
• Ask about alcohol, cannabis and other drugs, smoking or vaping, and coffee or energy drinks.
• List everything she takes: prescribed and over-the-counter medicines, laxatives, water pills, diet pills and supplements. In type 1 diabetes, ask about skipped insulin.

Approach

• Check pulse, blood pressure lying and standing, temperature, weight and height.
• Look for harm to the heart rhythm and the blood salts. Starving, vomiting and laxatives all upset them.
• These point to admission: a daytime pulse under 50/min, or under 45 at night. Systolic (top) blood pressure under 90 mm Hg. A temperature under 35.6 °C.
• So does a pulse rise of 30/min or more on standing, or a corrected QT interval (QTc) over 450 ms on an electrocardiogram (ECG).
• Low potassium, sodium or phosphate weighs toward admission too. Decide on the whole picture, including family support and local services, not one lab result.
• Feeding a starved patient can cause refeeding syndrome. Start feeding where blood work and the heart can be watched.
• No sport or hard exercise while unstable. Scan bone density after 6 months without periods, or with a very low body mass index (BMI).

Approach

• Explain the risks now, even if she does not accept the diagnosis. Low potassium can upset the heart rhythm.
• Keep a capable teen's confidence. Work with her toward bringing in her parents, not by threat.
• In a child or young teen who restricts food, use family-based treatment: parents take charge of meals until weight is back.
• Start in the office with steps from cognitive behavioural therapy (CBT): regular meals and snacks, a food and mood record, fewer purges. Not everyone needs a specialist program.
• Build the plan together: add a dietitian, a therapist, or a specialist team if the illness is severe or not getting better.
• No domperidone for the bloating. It has no approval under 18, is not for use with significant electrolyte problems, and can cause dangerous heart rhythms.
• At each visit, recheck weight, vital signs, eating and purging, and how mood, worry, thinking, school and friendships are going.

Approach

• Think of an eating disorder with a slow pulse or rhythm problem in a normal heart.
• Think of it with low potassium when no prescribed drug or kidney problem explains it. Hidden vomiting, laxatives or water pills fit.
• Think of it with missed periods and a negative pregnancy test.
• A slow pulse with fainting, dizziness on standing and weight loss is not an athlete's heart.
• Constipation, feeling cold and bloating often follow eating too little. Treating them alone misses the cause.
• Ask the eating questions, then compare weight with past growth.