Identifying Eating Disorders in Primary Care

Eating disorders are often misunderstood, sometimes overlooked, and tragically underestimated in their severity, especially in the healthcare setting. Contrary to common misconceptions, they are not phases or lifestyle choices but rather serious, biologically influenced illnesses. With an estimated 28 million Americans grappling with eating disorders, it's crucial to recognize that these conditions are far more prevalent than once believed.

The Hidden Struggle

One of the challenging aspects of eating disorders is their ability to hide in plain sight. Many individuals struggling with these disorders may not exhibit obvious signs or symptoms, making early detection and intervention all the more challenging. Additionally, there's significant crossover between different eating disorders; someone may start with one and then develop another over time. Let’s dive into the different types of eating disorders and how we can screen for them in clinical practice. 

The Spectrum of Eating Disorders

The spectrum of eating disorders is wide, encompassing various conditions beyond the well-known ones like anorexia nervosa and bulimia nervosa. Other Specified Feeding and Eating Disorder (OSFED) serves as a catch-all category for individuals who don't meet all the criteria for classic eating disorders. OSFED can occur in anyone, regardless of age, sex assigned at birth, gender identity, or socioeconomic status. 

Within this spectrum, there's a subtype known as atypical anorexia nervosa, where individuals exhibit all the behaviors associated with anorexia nervosa without being necessarily underweight.

Anorexia Nervosa

Anorexia nervosa itself is characterized by a predominant fear of weight gain, leading individuals to restrict their daily calorie intake drastically. This restriction often leads to severe malnutrition, with some individuals consuming dangerously low amounts of calories, sometimes even less than 500 per day. Tragically, anorexia nervosa carries a high mortality rate, with many deaths occurring due to medical complications associated with malnutrition and, distressingly, suicide.

There are 2 subtypes of anorexia:

• Restricting subtype, where people limit caloric intake
• Binge-purge subtype, where people restrict intake and have binge-purge behaviors

Bulimia Nervosa

Bulimia nervosa presents another facet of disordered eating, marked by recurrent binge eating episodes followed by compensatory behaviors such as self-induced vomiting or misuse of laxatives or diuretics. Individuals with bulimia nervosa may maintain a normal body mass index (BMI) or even be overweight or obese.

Avoidant Restrictive Food Intake Disorder (ARFID)

Avoidant Restrictive Food Intake Disorder (ARFID) is another lesser-known but equally significant eating disorder. It's characterized by persistent failure to meet nutritional needs, often resulting in malnourishment. ARFID can manifest in various subtypes, including avoidance of certain foods due to sensory characteristics or past negative experiences.

Binge-Eating Disorder

Binge-eating disorder is actually the most common eating disorder, affecting 3% of U.S. adults in their lifetime. The diagnostic criteria require recurrent episodes of binging, at least once a week for 3 months, in conjunction with at least 3 of the following:

• Eating faster than normal
• Eating until feeling uncomfortable
• Eating large quantities of food when not hungry
• Feeling bad/embarrassment about eating behaviors

Spotting the Signs

Recognizing the signs of eating disorders is crucial for early intervention. Dramatic fluctuations in weight, regardless of an individual's current weight, should raise concerns. Screening tools like the SCOFF Questionnaire and the Eating Disorder Screen for Primary Care can aid in identifying individuals at risk. Remember that it's essential to approach conversations about eating disorders with empathy and curiosity rather than judgment or shame.

There are some questions that can help you acknowledge a person’s thoughts or beliefs about their behaviors around exercise/eating while exploring their thoughts behind those actions:

• What does it look like if you need to rest a day from your exercise?
• Does not exercising affect your eating at all?
• What’s the goal of dieting for you?
• What are you concerned about?
• Are there other ways to address the concerns that you have?

The SCOFF Questionnaire for Eating Disorders

For the SCOFF Questionnaire, a positive screen is a “yes” response to 2 or more of the following questions:

• Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?
• Do you worry you have lost Control over how much you eat?
• Have you recently lost more than One stone [approximately 15 pounds] in a 3 month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?

Eating Disorder Screen for Primary Care

In the Eating Disorder Screen for Primary Care, a positive screen is a “yes” response to two or more of the following questions:

• Are you satisfied with your eating patterns?
• Do you ever eat in secret?
• Does your weight affect the way you feel about yourself?
• Have any members of your family suffered with an eating disorder?
• Do you currently suffer with, or have ever suffered in the past with, an eating disorder?

SBIRT: Screening, Brief Intervention, Referral to Treatment

SBIRT is a framework that allows primary care providers to screen for patients at risk, briefly intervene, then get patients into specialty care if indicated. Check out https://eatingdisorderscreener.org/ for the SBIRT package that is developed specifically by the National Center of Excellence for Eating Disorders (NCEED). 

Navigating Treatment

A treatment plan for eating disorders typically involves a multidisciplinary approach, including therapists, primary care physicians, psychiatrists, and dieticians. Medications, such as fluoxetine for bulimia nervosa or lisdexamfetamine for binge eating disorder, may be prescribed in conjunction with therapy.

Eating disorders are complex, serious illnesses that require understanding, empathy, and comprehensive treatment approaches. By raising awareness, promoting early detection, and providing effective interventions, we, as health professionals, can support individuals in their journey towards recovery from eating disorders.

Want to learn more? Listen to "Eating Disorders in Primary Care" in February's episode of Primary Care RAP  or check out Mental Health Bootcamp!