Eating Disorder Screening for Health Care Providers: What you see is not always what you get… (January 2017)
I hear this scenario all the time from clients: “my doctor has no idea that I have an eating disorder, since I don’t look like I have one,” or, “I have fallen back into my eating disorder and my doctor is not aware how to handle it.” For those familiar with the eating disorder and nutrition realm, the last statement can be surprising. When a client is referred to the registered dietitian nutritionist for constipation and bloat by the gastroenterologist, this would seem like an obvious referral, wouldn’t it? Cases such as these, where eating disorders are going undetected and untreated by general practitioners, make clear the importance of medical professionals having an awareness of eating disorder behaviors and symptomology.
If a doctor is unaware that the patient has developed food rules, and that they have become afraid of food due to the gastrointestinal challenges that they have faced, there can be serious physical consequences. For example, in regard to the above scenario, as I begin to explore the client’s medical history on a deeper level, I often learn that he/she has lost a significant amount of weight (40 lbs.) and his/her body is in a place where it naturally is not meant to be. These physical symptoms are correlated with Refeeding Syndrome, which occurs as a result of reinstitution of nutrition to patients who are severely malnourished or starved. In regard to re-feeding syndrome, metabolic disturbances can occur as a result of the patient’s electrolytes being imbalanced, which increases cardiac workload and heart rate. Patients with refeeding syndrome can experience heart failure if their team is unaware of their eating disorder behaviors and, therefore, not monitoring their fluids, cardiac workload, and heart rate. A doctor that has not developed a knowledge and understanding of eating disorders may overlook these symptoms, to the detriment of a patient.
According to the National Eating Disorders Association (NEDA), an estimated 30 million Americans (20 million women and 10 million men) will experience an eating disorder at some point in their lives. Those who experience eating disorders are known for their silence. Most of these people don’t come forward to express their thoughts or experiences with their eating disorder. It’s only when they are working with a cohesive treatment team that he or she learns how to process their thoughts, create boundaries, and articulate what their needs are. A treatment team consists of a therapist, dietitian, internist or pediatrician, and psychiatrist, all of whom are trained in eating disorder treatment. Assembling such a team is no small feat and can be a challenge in-and-of-itself. The earlier that an individual obtains help by setting up a treatment team, the greater the clients chances are to be recovered on a physical and emotional level.
Early detection and intervention is key, as, too often, clients slip through the cracks due to the inherent secrecy and shame of their disease. This article will provide some screening strategies to help the medical community recognize common eating disorder symptoms and behaviors. I believe that all individuals in the medical community should have specific screening questions during their initial appointment and follow-up’s. Many of the medical practitioners that I work with have disclosed that they are limited on time or don’t feel comfortable bringing up these questions. These questions do not have to be invasive in order to provide key information. Some general questions which may feel less threatening for the clinician and the patient could include reviewing their typical diet and exercise regimen, how the clients feels about their body, if they have recently gained or lost weight in a certain time frame, and what a healthful diet looks like to them.
The reason that many clients are able to “trick” their medical team about their eating disorder is because they don’t “look sick.” Physically, they may be at a normal weight, or even overweight. Emotionally, they often don’t feel comfortable sharing the thoughts that go along with these behaviors with their doctor, especially since a large percentage of them are not trained in eating disorders. There are many societal misconceptions about eating disorders and how those experiencing them look and behave. These misconceptions can make it difficult for those who aren’t informed to identify the problem and know how to approach it when it arises.
For the above reasons, I always like to reiterate that weight changes are not the only screening criteria for an eating disorder. There are many other factors to assess. For example, missed menstrual cycles, low testosterone levels, elevated cortisol levels, thyroid issues and Endocrine abnormalities are all indicators that there is a possible problem. It is also important to be aware of the emotional symptomology involved with eating disorders, such as increased anxiety or feelings of depression. Many healthcare providers don’t realize that males also experience eating disorders, as it’s more common in females. As a result, male eating disorders are particularly undiagnosed. Other areas to be on the lookout for include: compulsive exercise, skipping meals, counting calories, wearing baggy clothes to hide one’s body, and preparing extensive meals and then choosing to skip them. Feeling dizzy and lightheaded are also very common due to being dehydrated and having hypoglycemia, which occurs when a patient has low blood sugar due to starving the brain of glucose.
Binge Eating Disorder is the number one eating disorder diagnosis, affecting 60% of women and 40% of men. This disorder has been acknowledged by the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) as well as by the American Psychiatric Association. However, despite its recognition as a serious disorder, and its prevalence, binge eating disorder is often overlooked due to a lack of awareness of its symptoms. Binge Eating Disorder is defined as binge eating a large amount of food in a short period of time. It is also described as three or more of the following: 1) Consuming a large amount of food, or more than what is normal for the individual, rapidly in a concentrated period of time, 2) Eating large amounts of food when not feeling physically hungry, 3) Eating until the individual reaches an uncomfortable level of fullness 4) Feeling shame, guilt, depression, and disgust with oneself. Additionally, the individual may eat alone, as they feel embarrassed about the quantity and/or kinds of food they are consuming.
A helpful screening tool that all healthcare clinicians can use in their screening process is the SCOFF questionnaire.
These questions can be used with all patients:
S – Do you make yourself Sick because you eat until you feel uncomfortably full?
C – Do you worry you have lost Control over how much you eat?
O – Have you recently lost more than One stone (14 lbs. or 6.35 kilograms) 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 would indicate a need for further questioning and a more comprehensive assessment. Internal medicine doctors often see clients who are at risk for eating disorders, since they see a large volume of patients with varying issues. Additionally, physicians who are specialists, such as gastroenterologists, gynecologists, cardiologists, endocrinologists and psychiatrists, may encounter these clients, since the individual is coming in for a specific issue that has developed secondarily due to the eating disorder. Should a patient answer “yes” to two (or more) of the SCOFF questions, practitioners should consider referring them to a mental health clinician and a registered dietitian who are trained in eating disorders so that the patient can access appropriate support.
Another screening test that healthcare clinicians may incorporate into their practice is the Eating Attitudes Test (EAT26). This is a self-report to determine if a client should be referred to an eating disorder specialist. The test is free, and online, with 26 statements, that the individual answers on a six point scale of “always”, “usually”, “often”, “sometimes”, “rarely”, or “never” in terms of thoughts or behaviors. An example of one of these statements would be: “I feel extremely guilty after eating.” There are then six behavioral questions to be answered in regard to the past six months and this extensive questionnaire allows loved ones to see how an individual’s relationship with food may have changed in a negative manner. The test shows that, if the individual scores 20 or higher, expert help with an eating disorder professional is necessary. This can help to make a clinician’s referral more official. It also helps to provide support for such a referral, as, often times, the client may be in denial about their disorder or it’s severity and believe they can make changes on their own.
When it comes to eating disorders, and their subsequent medical consequences, it is important to remain positive in remembering that they are treatable and that recovery is possible with the proper medical, nutritional, and psychological support. I encounter many clients that express dismay that their primary care physician wasn’t informed in eating disorder signs and symptoms, as they feel this would have made a big difference in their diagnosis and path to recovery. As such, it is important for healthcare clinicians, to develop knowledge, resources, and a skillset in this area so that those experiencing and eating disorder can receive the necessary referrals and appropriate treatment. I hope this article can allow all of us to become better educated friends and loved ones to those that are trying to have their message heard.
- Philip S. Mehler, M.D. and Arnold E. Anderson, M.D., Eating Disorder: A Guide to Medical Care and Complications, Second Edition (Baltimore, Maryland: The Johns Hopkins University Press, 2010), 64-65.
- Luck, A.J. et al. “The SCOFF Questionnaire and Clinical Interview for Eating Disorders in General Practice: Comparative Study,” British Medical Journal, (2002): 755-756.