Letters

RAPID RESPONSES FROM BMJ.COM Two e-letters posted on bmj.com in response to the paper by Waller are reproduced (after minor editing) below.Editor

Understanding the patient

Binge eating: Physical assessment is important

Understanding the patient

This article originally appeared in BMJ USA

EDITORI always appreciate organized and clear clinical guidance about complex conditions. Dr Waller covered several angles to watch out for (depression, drug abuse, etc). The family doctor is often the first professional to have a chance to identify an eating disorder. Having criteria for the diagnosis is the basic step.

However, patients often are delayed in getting, or are unable to get, psychological help beyond symptom resolution, if the symptoms and relating problems are not identified early. If the patient developed the bingeing behavior six months ago, asking "why then" could lead to helping her, as a whole person, rather than just treating a symptom or a disease.

I have treated many people who were reluctant to get psychological help for years, and their anxieties about their emotional competence could have been identified at a very early stage, when bingeing and/or their concern about their weight began. Separation anxiety, history of being abused, and chronic low self-esteem are among the problems I have found in patients with binge eating.

Kati Morrison, community psychiatrist. 
Ottawa, Canada katimorrison{at}hotmail.com

Binge eating: Physical assessment is important

EDITORIn her paper on binge eating, Dr Waller has provided useful advice for general practitioners (GPs) but does not mention the importance of physical assessment for these patients. Patients with persistent vomiting and laxative abuse may develop serious electrolyte disturbances, and those with substantial weight loss may develop any of the complications associated with anorexia nervosa.¹

In a questionnaire study of GPs in Scotland, 88% said that they would weigh a patient and 72% would order blood tests,² but a recent audit of patients currently open to our eating disorder service suggests that basic physical assessment may be overlooked in primary care. We reviewed the referral letters for 84 patients currently open to our service to identify which physical assessments had been undertaken and documented in the referral letter: 36% of the letters mentioned weight, and 20% had enough information to calculate body mass index (BMI). None of the letters mentioned the patients' heart rate and/or rhythm, blood pressure, or temperature. Six percent made reference to blood urea and electrolyte values; 7% reported a full blood count.

It is possible that more detailed physical assessments had been done but not mentioned in the referral letter; only a more detailed study of primary care records would establish this. However, our findings suggest that only a limited physical assessment is undertaken. We believe that a minimum assessment for a patient with an eating disorder would include weight, height (in order to calculate BMI), pulse, blood pressure, temperature, blood urea and electrolyte measurements, and a full blood count.

H R Millar, consultant psychiatrist. 
David Lim, medical student. 
Eating Disorder Service, Fulton Clinic, Aberdeen, UK harry.millar{at}gpct.grampian.scot.nhs.uk