Early intervention is key to improved health and quality of life when it comes to providing primary care for people affected by eating disorders.
While early intervention depends on early detection of symptoms, research shows there is currently on average a delay of approximately four years between the start of disordered eating symptoms and first treatment, reaching at times 10 or more years.
But armed with the right information and screening and referral tools, health professionals can play an important role in reducing this delay.
Health Professionals at the forefront
Most people with eating disorders have contact with health professionals, but they will often present with apparently unrelated complaints. While people may not volunteer information about their eating problem, asking questions and allowing the person to see that their eating habits are important may offer a non-judgemental environment for them to start seeking help.
Indeed, for many people with eating disorders, their first attempt at seeking treatment is a test of attitudes and responses. If the first help seeking is a positive experience then the person is more likely to engage successfully with future treatment.
For more information, see the NEDC booklet: Eating Disorders: A Professional Resource for General Practitioners
Common health presentations include:
• emotional problems
• weight loss
• gastro-intestinal problems
• infertility issues
• injuries caused by overexercising
• fainting or dizziness
• feeling fatigued or not sleeping well
• feeling cold most of the time regardless of the weather
• swelling around the cheeks or jaw, calluses on knuckles, damage to teeth and bad breath (signs of vomiting).
Screening questions help to initiate a disclosure which may then lead to earlier access to treatment. Screening for eating disorders involves asking a small number of evidence based questions posed on an opportunistic basis when the patient presents for other reasons (e.g. weight related concerns, depression or anxiety). The questionnaires do not diagnose eating disorders but detect the possible presence of an eating disorder and identify when a more detailed assessment is warranted.
Eating Disorder Screen for Primary Care (ESP)
• Are you satisfied with your eating patterns? (A “no” to this question is classified as an abnormal response).
• Do you ever eat in secret? (A “yes” to this and all other questions is classified as an abnormal response).
• 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 you ever suffered in the past with an eating disorder?
Cotton, Ball & Robinson, 2003 found that the best individual screening questions are:
• Does your weight affect the way you feel about yourself?
• Are you satisfied with your eating patterns?
S – Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry you have lost Control over how much you eat?
O – Have you recently lost more than 6.35 kg in a three-month period?
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life?
An answer of ‘yes’ to two or more questions indicates the need for a more comprehensive assessment.
A further two questions have been shown to indicate a high sensitivity and specificity for bulimia nervosa.
1. Are you satisfied with your eating patterns?
2. Do you ever eat in secret?
Screening for high risk groups
Eating disorders occur in both males and females; in children, adolescents, adults and older adults; across all socio-economic groups and cultural backgrounds. Within this broad demographic however there are some groups with a particularly high level of risk.
Based on the known risk factors for eating disorders, high risk groups who may benefit from screening for eating disorders include:
- Women, particularly during key transition periods
- Women with Polycystic Ovary Syndrome or Diabetes
- People with a family history of eating disorders
- People seeking help for weight loss
For more information, see the NEDC booklet: Eating Disorders: A Professional Resource for General Practitioners.
Eating disorders in males
Population studies have suggested that males make up approximately 25% of people with anorexia or bulimia and 40% of people with binge eating disorder. In a recent study lifetime prevalence for anorexia nervosa in adolescents aged 13 – 18 years found no difference between males and females.
One unique difference between males and females with eating disorders is that men more typically engage in compulsive exercise as a compensatory behaviour, often with the aim of achieving a more muscular, and not just slender, body type. Compulsive exercise describes a rigid, driven urge to exercise, which is a serious health concern.
For more information on compulsive exercise please read the following articles from the NEDC Clearinghouse:
- Exercise in the Eating Disorders: Terms and Conditions
- Compulsive exercise: The role of personality, psychological morbidity, and disordered eating
- Sports-related correlates of disordered eating in aesthetic sports
Patients must be screened for physical health risks and risk of suicide. Medical stabilization, where required, must be provided before or simultaneously with other interventions. Eating disorders can impair a person’s insight and ability to make informed decisions.
Decisions regarding treatment must always take into consideration the person’s capacity to make decisions for their own safety.
General State Assessment
When taking the patient's general history and conducting physical examinations assess their:
General state (eg. well/unwell)
Height and weight history
Disproportion in weight for height (>1standard deviation apart)
Menstruation pattern/menstrual history
Hydration (tongue, lips, skin, sunken eyes)
Ketones on breath, deep, irregular, sighing, breathing seen in ketoacidosis
Temperature <36°C, pulse rate <60 beats per min, regular or irregular, BP – lying and standing (postural drop in BP > 20mmHg)
Limbs – peripheral circulation, cold peripheries, ankle oedema, abdomen scaphoid
Symptoms of electrolyte disturbance (thirst, dizziness, fluid retention, swelling of arms and legs, weakness and lethargy, muscle twitches and spasms) and alkaline urinary pH.
More information, see the NEDC booklet: Eating Disorders: A Professional Resource for General Practitioners.
Referral to appropriate services
The eating disorders treatment team requires a multi-disciplinary approach to address the physical components of the illness, the eating behaviours, the psychological thought processes, and the social and work needs of the person.
Members of the multidisciplinary team will vary depending on the needs of the patient but a minimum team for safe interventions will include both physical and psychological disciplines.
GPs should be aware of the risks of rapid deterioration of health in people with Eating Disorders and should consider the impact of very low BMI on cognition and the role of mental health legislation and compulsory treatment for some patients.
More information about treatment and recovery including treatment approaches for specific disorders and complementary treatment approaches can be found on the NEDC’s treatment and recovery page.
Specialist interventions may also be required by some patients to prevent or treat a wide range of physical health conditions including gastrointestinal disorders, malnutrition, osteoporosis, damage to teeth, infection, cardiac complications, kidney failure, menstrual problems and treatment of comorbid conditions such as diabetes.
Some patients may require referral to a Hospital Emergency Department or an Eating Disorders specialist. More information about treatment options including inpatient treatments, outpatient treatments, day programs, community based support and rural options can be found on the NEDC’s Treatment Options page.
Education professionals are ideally positioned to detect early signs and symptoms of eating issues and disorders. Educators, teachers and trainers therefore play an important role in helping to prevent eating issues from developing further, resulting in better long term outcomes for treatment.
Sports & Fitness Professionals
Coaches, trainers and other fitness professionals are at the frontline when it comes to noticing changes in their athletes and clients, including when it comes to detecting early signs and symptoms of eating issues and disorders.
Friends, Families, Carers
Family, friends and carers play a crucial role in the care, support and recovery of people with eating disorders.