Healthcare professionals in many settings encounter patients who show signs of an eating disorder, but, unfortunately, those symptoms often are overlooked or little is done to get proper care for the illness. The medical community as a whole is united in watching for symptoms of many illnesses that might be beyond their expertise, and willing to refer that patient to the right provider. Yet eating disorders can go undiagnosed without a conscious effort to spot them.
Once a physician or nurse recognizes the signs of an eating disorder, it is important to understand how severe these illnesses can be and how to best refer the patient for treatment. For health professionals to recognize patients who may have or be at risk for an eating disorder, they must first understand the disease and dispel some common myths. The most important misconception is that eating disorders are voluntary, a willful act by the patient in response to vanity, bullying, or a desire for attention or to be defiant. While some of those factors may come into play with eating disorders, the disease itself is not voluntary. It is neither effective nor compassionate to simply insist that the patient stop the behavior. The same way you can’t tell someone with depression to just be happy, you can’t tell someone with an eating disorder to just eat normally. These are serious illnesses. In fact, eating disorders have the highest death rate of all mental illnesses and, unfortunately, many of those deaths are suicides.
Also, some people think that if a patient successfully completes a course of inpatient or outpatient treatment, the eating disorder is cured and need not be monitored on an ongoing basis. Actually, eating disorders are chronic diseases and even patients who have achieved excellent recovery and maintained their healthy eating can relapse. A variety of health professionals have the opportunity to detect an eating disorder or a patient at risk. By the time a patient reaches a clinic dedicated to treating eating disorders, it is common for that person to have had recent visits with primary care physicians, gynecologists, therapists, pediatricians, cardiologists, endocrinologists and other providers who were focused on either a specific effect of the eating disorder or an entirely unrelated health need.
In either case, those health professionals often do not recognize the symptoms of eating disorders and miss the opportunity to intervene or refer the patient to specialized care. Patients often are in denial about their eating disorders, or actively hiding them, so they usually do not admit their conditions during a healthcare visit. When people with eating disorders see a physician for other issues, or related issues, the signs and symptoms of this disease are overlooked at least half the time. The medical community is missing the opportunity to intervene in a significant number of patients who have eating disorders.
The greatest opportunity for spotting someone with an eating disorder is when that person visits a doctor for a related issue. The patient may not know the health complaint is related to the eating disorder or may suspect the connection but be reluctant to inform the doctor. Healthcare professionals should remember that people suffering from eating disorders typically are embarrassed, deeply ashamed, and fearful of anyone finding out. Many of them also fear they are doing damage to their bodies but are unwilling to say so.
Patients seeking care for gastrointestinal issues such as gastroparesis, constipation, bloating, or laxative abuse may have eating disorders that are at the root of those conditions. Particularly if the patient has other risk factors for eating disorders, physicians and other health providers treating those conditions should consider exploring that possibility further and perhaps referring the patient for treatment. Endocrine abnormalities, thyroid issues, elevated cortisol levels, missed menstrual cycles, and low testosterone levels in males are other red flags for possible eating disorders. It is important to remember that although eating disorders are more common in females, males also can develop the disease. Because the stereotype of an eating disorder patient is a teenage girl, boys and men with the disease are more likely to be overlooked. Likewise, eating disorders cross all socioeconomic boundaries. Other flags for an eating disorder include dramatic weight loss, low body weight, or low body weight in the context of developmental trajectory, excessive exercise, excessive dieting and preoccupation with counting calories, preoccupation with weight or body image, and refusal to eat certain kinds of food. Family members may also notice red flags such as missing mealtimes, wearing baggy or loose clothing, preparing elaborate meals and then refusing to eat them. Many people with eating disorders also damage their enamel and are at increased risk for cavities due to self-induced vomiting, which can be a red flag as well as they are at increased risk for osteopenia and bone fracture. Patients may also present to gynecology clinics due to infertility problems, which can be related or due to an eating disorder. Patients with eating disorders can also present to the emergency department for a variety of conditions such as dizziness, lightheadedness, loss of consciousness, seizures (which can be related to electrolyte disturbance as a result of their eating disorder), and heart palpitations or other cardiac issues. Suicide and cardiac events are the most common causes of death in patients with anorexia nervosa.
Another eating disorder that is often overlooked is binge eating disorder. This eating disorder has recently been recognized in the Diagnostic and Statistical Manual of Mental Disorders fifth edition by the American Psychiatric Association. It consists of binge eating episodes in which an individual eats a large amount of food in a short time but is not followed by any compensatory behaviors. The disorder is also associated with three or more of the following: 1) eating much more rapidly than normal, 2) eating until feeling uncomfortably full, 3) eating large amounts of food when not feeling physically hungry, 4) eating alone because of feeling embarrassed by how much one is eating 5) feeling disgusted with oneself, depressed, or very guilty afterward. This is currently the most common eating disorder, yet is often missed because it is new and many people are unaware or unfamiliar with binge eating disorder. All healthcare providers can look for opportunities to screen for eating disorders. A good technique is the SCOFF questions, developed by researchers in London. These are questions that can be used with any patient:
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry that you have lost control over how much you eat?
- Have you recently lost more than One stone (14 lb.) in a three-month period?
- Do you believe yourself to be fat when others say you are too thin?
- Would you say that food dominates your life?
Any positive answers can be followed up with additional questions like whether the patient uses laxatives or purges and what a typical day’s diet is like. Screening and intervention by any healthcare provider can be useful for people with eating disorders, who often are ambivalent about treatment. They may acknowledge that they have some degree of an eating disorder but not so much that they need help, and then the primary care doctor or another provider can urge them to seek specialized care. It also is important to emphasize that eating disorders are treatable and patients can make significant progress in fighting them. People with eating disorders commonly think that their situation is hopeless, that no amount of intervention is going to make them better and help them eat normally. Some also do not want to change their eating disorders because of some deep rooted psychological issues, but health providers who recognize the symptoms can alert family members and other treatment professionals.
Primary care physicians are most likely to spot patients with, or who are at risk, for eating disorders, simply because they see a high volume and wide variety of patients. Some specialists also are more likely to see these patients because they treat the conditions that are associated with eating disorders. They include gastroenterologists, endocrinologists, cardiologists, and gynecologists. Psychiatrists, psychologists, and therapists also commonly encounter patients with eating disorders as individuals with eating disorders have increased co-morbidities with depression, anxiety, and substance use disorders. When it is suspected that someone may have an eating disorder, the health provider should talk to the patient about it, keeping in mind that he or she is likely to be embarrassed or ashamed and deny the possibility at first. Gentle probing and reassurance might help the patient open up and speak more freely about fears and eating habits. With younger patients, the health provider should also discuss the concern with parents. With adult patients, permission will be necessary before discussing the issue with parents or other family members due to HIPPA laws. It is worth the effort to obtain that permission because family support can be important in helping someone overcome an eating disorder.
Once the subject has been broached, the health provider should assure the patient and family members that eating disorders can be successfully treated and that help is available from a range of health professionals who specialize in this disease. The patient should be reminded at this point that eating disorders are not a matter of willpower and that there is no shame in accepting help. The entire process of treating eating disorders is founded on compassion and understanding that patients can’t fight the disease on their own, so that message should be conveyed at the earliest opportunity.
The health provider who recognizes the symptoms of eating disorders and can help the patient on to the path of recovery is helping address a problem that can ruin lives. Professionals in any health field should be on the lookout for these patients who need help overcoming eating disorders.
