A physician is an integral part of the interdisciplinary team to identify and support people with eating disorders. Physicians may be the only healthcare provider that a person sees regularly, so they are often faced with the challenge of identifying these disorders and ensuring patients receive the treatment they need. However, many physicians do not feel equipped to treat eating disorders or to even screen for them. So, we developed eating disorder screening questions for physicians. In this post, we highlight 7 Questions to ask for eating disorder screening in primary care.
Many physicians know the basics, like looking for changes in weight. But it’s extremely important to remember that eating disorders are mental health illnesses and do not always manifest physically. This blog aims to provide physicians with a bit of framework on screening and assessing for eating disorder behaviors. From there, they will have the ability to refer to a treatment team.
Before we discuss the eating disorder screening questions for physicians, it is worth noting that the average time to diagnose an eating disorder is 4 years, but for some, it could take as long as 10. This means eating disorders go unnoticed for quite some time before a person is able to get support. As you could imagine, reducing this delay is vital, since eating disorders can have many long term mental consequences (think: depression, anxiety, suicidality) and physical consequences. Not to mention that eating disorders have the highest mortality rate among all mental health illnesses.
Here are some helpful tips and things to consider regarding your clients.
And please remember: eating disorders do NOT discriminate. It’s extremely important to screen ALL patients for eating disorder symptoms, regardless of size/weight, race, gender, ethnicity, age and socioeconomic status.
Question 1: For adolescent and young adult clients: Are there changes in growth curve (up or down)? Or a stagnant growth curve?
For the most part, children follow a consistent growth curve throughout childhood. Sometimes we see jumps in the curve around 9/10 or around puberty. We know that a growth curve is individualized for each person. This means, not everyone is supposed to be at the 50th percentile. Whatever percentile a child has landed on throughout their life, is likely the percentile that is a “healthy weight” for them.
When eating disorder symptoms occur, we often see shifts in a growth curve. This could be a dramatic spike down or up or even a stagnant curve. A spike up could indicate bingeing. A spike down and a stagnant curve could indicate restriction. Please remember, children who fall off their growth curve may experience delays in physical and cognitive development.
Weight loss in childhood throughout teenage years is never normal. If you don’t know where to refer to or if you’re unsure if weight changes are “normal,” go ahead and refer to a dietitian who specializes in eating disorders, like Courage to Nourish. The RD can do a full screening and recommend necessary follow up steps.
Question 2: Have your patients mentioned dieting behaviors? Like cutting out food groups, suddenly becoming vegan or vegetarian, or self-diagnosed food allergies?
Dieting behaviors are difficult to navigate as a healthcare professional. Dieting in general is so prominent in our society. The internet is filled with incorrect nutrition recommendations. So, it’s very easy for our patients to find these recommendations and start a diet.
Because dieting is so pervasive, following these diet recommendations may be seen as “acceptable.” Your patient may be getting positive feedback from friends or family about following a specific diet, or even trying to seek that positive affirmation from you.
Even if your patient presents these diet behaviors in a positive light or provides a health-based rationale for their diet behaviors, cutting out multiple foods or following fasting diets is cause for concern. And time to refer to a dietitian for a full assessment of these behaviors.
Please note: it’s not “normal” for anyone to cut out food groups, but especially for children/adolescents.
Question 3: Do your patients complain of frequent GI distress or describe very restrictive diets to manage GI symptoms?
GI distress may stem from eating disorder behaviors. And/or GI distress may influence eating disorder behaviors. Eating disorder behaviors, like restricting, bingeing or purging, generally disrupt normal digestion. Patients may disclose they are struggling with bloating, constipation, GERD or general abdominal pain.
On the other hand, GI distress could lead to future eating disorder behaviors, especially if a patient has heard to follow a super restrictive diet.
In these scenarios, it could be helpful to refer to an eating disorder RD.
Question 4: Are there any compensatory behaviors like purging by vomiting or laxative use or exercising to burn off food?
Patients may or may not disclose these behaviors directly. Whether it is because they don’t realize that a certain behavior aligns with an eating disorder or because they feel shame about the behavior. But, it’s still 100% within your scope to ask these questions. A reminder: PCPs can be the first clinician to recognize an eating disorder. And therefore, should always be screening for EDs.
Question 5: Is your patient bradycardic?
Bradycardia is a physical sign of an eating disorder. While not all patients may be bradycardic, this can be a very important screening tool for physicians. If a patient has a heart rate lower than 60bpm, that’s certainly a sign for concern.
But you may be thinking, “what if my patient is a runner and she is ‘fit’?” Great question! While it is common for athletes’ heart rates to be lower, in cases where an ED is involved, the low heart rate is actually due to malnutrition, NOT a “fit” heart. To test the difference, try out the “walk across the room test” with your patients.
What this means is you take a patient’s resting heart rate and then have them do a lap or 2 across the room. Take the heart rate again. A true athlete’s heart with a healthy heart should stay around the same bpm. But in cases with eating disorders, the heart rate may double or triple. This is a malnourished heart.
You can read more about physical signs of eating disorders and how physicians can screen for them in a blog by Dr. Jennifer Gaudiani. Click here. She also discusses the “walk across the room test.”
Question 6: Ask your patients: Do you feel guilty after eating? Do you feel preoccupied with food/body image?
People with eating disorders may find their thoughts focusing on food very frequently, even if the conversation changes topics. Research suggests that food restriction leads to increasing preoccupation with food. Individuals may develop food rituals or spend non-eating time thinking about food. Restriction does not have to include all food, but may involve favorite foods, foods perceived as unhealthy, or other foods the client does not feel they should be eating.
Guilt may accompany eating behaviors or body image if your patient feels that their behaviors or body image does not align with their ideal. Whether or not they act in the way they feel they “should” be acting can directly impact how they view themselves and their mood for the day. If they eat something they perceive as a “bad” food, or eat too much, or eat anything at all, this can lead to intense feelings of guilt.
Question 7: Are there lab abnormalities? Low B12, Vit D, electrolytes or iron levels?
Eating disorders can lead to a variety of lab abnormalities, including but not limited to low vitamin B12, electrolytes, iron, white blood cell count, or elevated cholesterol. The reason for these lab abnormalities could be due to low/restrictive food intake, excess water intake, compulsive exercise or purging behaviors.
Please note: Lab abnormalities may NOT be present even if a client is struggling with an eating disorder. But still, looking for these abnormalities can be an important screening tool. Lab abnormalities do not immediately indicate there is an eating disorder, as there are many medical or dietary factors that may impact lab values aside from restricted intake.
Please note: These eating disorder screening questions for physicians are not an exhaustive list of questions.
Concluding Statements on Eating Disorder Screening in Primary Care
Eating disorders are complex medical illnesses that can be difficult to diagnose. Physicians are most frequently tasked with identifying patients with eating disorders and ensuring they get the treatment they need. It’s my philosophy that it’s better to play it safe. If a client answered yes to any of the questions above, please consider referring a client to an eating disorder dietitian. The RD can do a full assessment and decide the appropriate next steps.
Having a full toolkit of resources to spot patients with eating disorders and intervene appropriately is vital in getting patients on the road to recovery.
Courage to Nourish offers a variety of resources and expertise in working with individuals with eating disorders. If you have general questions, please consider contacting us. Eating disorder recovery is possible. We will work closely with you and your client to explore their beliefs and emotions surrounding food and body image, tailor interventions to their specific needs, and support patients through interventions and situations as they arise.
For more information, check out our ED resources page! You can find these eating disorder screening questions for physicians here.
Courage to Nourish is a group of eating disorder specialized dietitians. We have in person locations in Alexandria, Virginia, Columbia, Maryland. and College Park, Maryland. We offer virtual services across the state of Virginia, Washington DC, Pennsylvania, and Colorado. We offer individual nutrition therapy. As well as support groups. We would love to guide you in building a better relationship with food.
Take one of our eating disorder quizzes:
- Binge Eating Disorder Quiz
- Anorexia Quiz
- Bulimia Quiz
- ARFID Quiz
- Body Image Quiz
- Disordered Eating Quiz
- Chronic Dieting Quiz
- PCOS Quiz
- Orthorexia Quiz
- Compulsive Exercise Quiz
- RED-S Quiz
Helping my clients cultivate meaningful connections and interests outside of their eating disorder is a true passion of mine. I like to think my clients and I are on a team to navigate recovery. I love working with high school and college students as well as athletes seeking to have a better relationship with exercise. I am a proud anti-diet dietitian and work with my clients through a Health At Every Size © and intuitive eating framework.