Eating disorders are complex, potentially life-threatening conditions characterised by significant disturbances in eating behaviour that result in serious medical, psychiatric and psychosocial consequences. Eating disorders are formally classified on the basis of the Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5) criteria (Table 1).1
Table 1. Summary of DSM-5 diagnostic criteria for eating disorders
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Anorexia nervosa
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Bulimia nervosa
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- Restriction of energy intake resulting in a significantly low body weight; or a less than minimally expected weight (based on age, sex or developed trajectory)
- Intense fear of gaining weight; or persistent behaviour that interferes with weight gain, despite low weight
- Disturbance in body image; or persistent lack of recognition of the seriousness of the current low body weight
Subtypes: Restricting type, binge-eating/purging type
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- Recurrent episodes of binge eating (this involves eating an excessive amount of food in a discrete period of time AND a sense of lack of control)
- Recurrent inappropriate compensatory behaviours to prevent weight gain, such as vomiting, laxatives, diuretics, fasting or excessive exercise
- Frequency of at least once per week for three months
- Self-evaluation unduly influenced by body shape and weight
- Absence of anorexia nervosa
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Binge eating disorder
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Other specified feeding or eating disorder (OSFED)
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- Recurrent episodes of binge eating
- Associated with symptoms such as eating more rapidly, feeling uncomfortably full, not feeling hungry, eating alone due to embarrassment and/or feelings of self-disgust
- Marked distress regarding binge eating
- Frequency of at least once per week for three months
- Absence of compensatory behaviours, anorexia nervosa and bulimia nervosa
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Eating disorders causing significant distress but not meeting criteria for other diagnostic categories
Examples:
- Atypical anorexia nervosa – ‘normal weight anorexia nervosa’
- Bulimia nervosa (of low frequency and/or limited duration)
- Subthreshold binge-eating disorder
- Purging disorder
- Night eating syndrome
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Avoidant/restrictive food intake disorder (ARFID)
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Unspecified feeding or eating disorder (UFED)
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- Eating or feeding disturbance with persistent failure to meet nutritional needs associated with either significant weight loss (or growth failure), significant nutritional deficiency, dependence on enteral/supplemental feeding or marked interference with psychosocial functioning
- Not explained by lack of available food or culturally sanctioned practice
- Absence of anorexia nervosa, bulimia nervosa or body image disturbance
- No intercurrent medical illness
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Presentations in which clinically significant symptoms occur but do not meet full criteria for other eating disorders. Includes situations where the clinician chooses not to specify the reason criteria are not met or where this may be unknown (eg emergency room setting)
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DSM-5 classification and criteria
The diagnostic criteria for anorexia nervosa and bulimia nervosa were updated in the DSM-5. Other eating disorders, including binge-eating disorder (BED), pica, rumination and avoidant/restrictive food intake disorder (ARFID), have also been added in the DSM-5. In addition, atypical presentations are now included under the newly named categories of other specified feeding or eating disorder (OSFED), and unspecified feeding or eating disorder (UFED); these replace eating disorder not otherwise specified (EDNOS).
Some of the significant revisions are the removal of amenorrhoea as a diagnostic criterion for anorexia nervosa in female patients, and reduction of binge frequency to an average of once per week for bulimia nervosa.2 The modifications were anticipated to better represent the symptoms and behaviours of patients dealing with these conditions, and enable more specific eating disorder diagnoses, thereby facilitating initiation of appropriate and timely management.2–4 In theory, these modifications broaden the criteria for specific eating disorders such as anorexia nervosa and bulimia nervosa, but also more precisely categorise the previous diagnostic category of EDNOS. Patients who lose significant amounts of weight and meet the other diagnostic criteria for anorexia nervosa, but who are not underweight, will now be diagnosed with atypical anorexia nervosa.4
Magnitude of the problem
The prevalence of eating disorders in Australia is conservatively estimated to be 9% of the adult population, and this figure continues to increase.5 In fact, a 2015 study of older adolescents and adults found a point prevalence as high as 16.3%, where BED accounted for 6.3% and subthreshold BED 7%. By contrast, anorexia nervosa and bulimia nervosa each occurred in less than 1% of the population.6
In spite of the seemingly low prevalence rate in the general population, anorexia nervosa and bulimia nervosa are of great significance because of their incidence in adolescent female patients and their mortality rate.7 These conditions represent the third most common chronic illness (after asthma and obesity) in adolescent female patients.7 In addition, anorexia nervosa has the highest mortality rate of all psychiatric disorders;8 long-term studies report mortality rates of approximately 20%.9 It has been noted that ‘compared with their peers without the illness, the risk of premature death is approximately tenfold higher in a person with anorexia nervosa’.10
In addition, these illnesses represent a significant socioeconomic cost to the community. In 2012, Deloitte Access Economics estimated the figure to be $69.7 billion. Of this amount, the direct healthcare cost is $99.9 million and the remainder is due to productivity loss and loss of healthy years of life.11
Importance of early identification
To limit the impact of these disorders in terms of physical, psychiatric and economic outcomes, it is essential that general practitioners (GPs) are able to identify and initiate management in such patients, as primary care is the context of most presentations. Given that early intervention may limit the progression and improve outcomes of eating disorders, early recognition is imperative.12–15 Hence, it is appropriate to commence medical management before a patient fulfils all of the diagnostic criteria of a particular eating disorder,14 thereby limiting or reversing symptom progression and optimising prognosis.
General practice consultation
GPs face a number of challenges in the early identification of patients with an eating disorder;15,16 this is particularly the case when the presentation does not relate to dietary intake or weight. Conversely, the classic presentation of the adolescent brought in by a parent who is concerned about their child’s nutritional intake, behaviours surrounding food and/or weight, should alert the GP to the possibility of an eating disorder with a more directed history and examination protocol.
However, far more challenging from a detection and therefore diagnostic standpoint is a patient who presents with seemingly ‘unrelated complaints’.15 These complaints include psychological issues such as stress, depression or anxiety; physical complaints such as fatigue, dizziness, gastrointestinal problems (especially constipation and bloating) and, for female patients, menstrual irregularities; chronic health problems such as osteoporosis; and socioeconomic consequences such as financial insecurity due to inability to sustain employment.17–19
Of course, the other impediment to early identification is delayed presentation. Patient factors contributing to this include:15,20
- ambivalence about recovery
- stigma and shame
- denial of, and failure to, perceive the severity of the illness
- low motivation to change
- negative attitudes towards seeking help
- lack of knowledge about available resources
- practical issues (eg distance, cost).
There are a number of screening tools that can be used in the primary care setting to assist in the detection and diagnosis of eating disorders. The best known of these is the SCOFF questionnaire, which consists of five questions:21
1. Do you make yourself Sick because you feel uncomfortably full?
2. Do you worry you have lost Control over how much you eat?
3. Have you recently lost more than One stone (6.35 kg) in a 3 month period?
4. Do you believe yourself to be Fat when others say you are too thin?
5. Would you say that Food dominates your life?
Each ‘yes’ answer scores one point and a score of ≥2 indicates a likely diagnosis of anorexia nervosa or bulimia nervosa.21 However, the most poignant comment on diagnosis is conveyed in this quote from the National Institute for Health and Clinical Excellence (NICE) guidelines: ‘The most effective screening device probably remains the general practitioner thinking about the possibility of an eating disorder’.19
In addition to screening tools, there are a number of ‘warning signs’ that can aid in the detection of eating disorders. Some of these warning signs can be difficult to detect because of the patient’s secrecy, deception or shame surrounding their behaviours.14,19 However, other signs can be readily observed in the consultation or described by family members. The warning signs include psychological manifestations, commonly anxiety; behaviours such as avoiding meals; and physical issues that include menstrual irregularity or cessation in female patients. A detailed list of these features is shown in Table 2.
Hence, a detailed history is paramount in the assessment process. When a detailed history is performed in an empathic and non-judgemental manner, it provides an ideal opportunity for engagement with patients and a greater likelihood that they will accept the medical care they require.14,18 There are only a few other medical conditions where the therapeutic alliance between doctor and patient is so critical.19
Table 2. Eating disorder warning signs1,2,7,14,18,24
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Behavioural
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- Avoiding eating in public
- Fussy eater/banned foods
- Cooking for others yet not eating
- Frequent weighing
- Excessive exercise
- Stressed when unable to exercise
- Trains through injury
- Restricted/rigid diet
- Wears baggy clothing
- Avoiding meals
- Raiding the refrigerator
- Eating low-calorie foods
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- Excessive use of the toilet
- Body checking
- Constant focus on food, diet and exercise
- Has different meals to rest of family
- Social isolation
- Calorie counting
- Use of diet pills, laxatives, supplements
- Throws away food
- Denies problem
- Slow eating/picking at food
- Developing ‘allergies’ to food
- Eating in secret
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Psychological
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- Anxiety, especially in regards to food/eating
- Depression
- Social phobia/withdrawal
- Distorted body image
- Negative body image
- Feelings of lack of control
- Suicidality
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- Poor concentration
- Perfectionism
- Low self-esteem
- Guilt, especially around food
- Obsessiveness
- Subtle cognitive changes
- Hopelessness
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Physical
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- Sensitivity to the cold
- Brittle nails
- Dorsal finger callouses
- Stress fractures
- Muscle cramps
- Dental caries
- Parotid enlargement
- Irregular or cessation of menstruation
- Gastrointestinal symptoms – bloating, nausea
- Anaemia
- Insomnia
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- Dry hair or skin
- Lanugo
- Feeling faint, cold or tired
- Bone pain
- Injuries due to over-exercising
- Gingivitis
- Self harm
- Abdominal pain/distension
- Early satiety
- Hypercarotenaemia
- Halitosis
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A thorough history will also eliminate many of the other potential differential diagnoses of weight loss or symptoms (eg amenorrhoea in female patients). GPs’ failure to identify that certain symptoms and signs may represent an eating disorder may preclude early detection. NICE guidelines note that ‘diagnosis is often delayed when doctors inadvertently collude by over-investigating and referring to other specialties rather than confronting the possibility of an eating disorder’.19
Physical examination and investigation are the next steps in assessment, but there may not be any abnormal physical findings and, often, laboratory results are normal.7 Table 3 summarises a relevant assessment for a patient with a suspected eating disorder.
Table 3. Assessment of the patient with a suspected eating disorder7,14,18,19,22–25
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The initial physical assessment should include:
- Height, weight, body mass index (BMI; adults), BMI percentile for age (children)
- Pulse and blood pressure, with postural measurements
- Temperature
- Assessment of breathing and breath (eg ketosis)
- Examination of periphery for circulation and oedema
- Assessment of skin colour (eg anaemia, hypercarotenaemia, cyanosis)
- Hydration state (eg moisture of mucosal membranes, tissue turgor)
- Examination of head and neck (eg parotid swelling, dental enamel erosion, gingivitis, conjunctival injection)
- Examination of skin, hair and nails (eg dry skin, brittle nails, lanugo, dorsal finger callouses [Russell’s sign])
- Sit-up or squat test (ie a test of muscle power)
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Useful laboratory investigations include:
- Full blood count
- Urea and electrolytes, creatinine
- Liver function tests
- Blood glucose
- Urinalysis
- Electrocardiography
- Iron studies
- B12, folate
- Calcium, magnesium, phosphate
- Hormonal testing – thyroid function tests, follicle stimulating hormone, luteinising hormone, oestradiol, prolactin
- Plain X-rays – useful for identification of bone age in cases of delayed growth
- Bone densitometry – relevant after 9–12 months of the disease or of amenorrhoea and as a baseline in adolescents. The recommendation is for two-yearly scans thereafter while the DEXA scans are abnormal.
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Other investigations may be indicated in certain clinical presentations to exclude other differential diagnoses (eg coeliac autoantibodies).
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Management
The first priority in the management of a patient with an eating disorder is securing medical and psychiatric safety.2,18 It is prudent to remember that a patient’s visible habitus is not a reliable indicator of their medical risk. For example, a patient can have a normal body mass index (BMI) but also have a potassium level of 2.5 mmol/L due to their purging behaviours. In addition, BMI may be normal, but the patient might be at risk because of rapid weight loss or, in children, there may be failure to gain weight.7,18,22 The criteria for admission to hospital are listed in Table 4.22
Table 4. RANZCP clinical practice guidelines for the treatment of eating disorders 2014
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Psychiatric admission indicated*
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Medical admission indicated†
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Weight
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Body mass index (BMI) <14 kg/m2
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BMI <12 kg/m2
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Rapid weight loss
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1 kg per week over several weeks or grossly inadequate nutritional intake (<100 kcal daily) or continued weight loss despite community treatment
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Systolic blood pressure
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<90 mmHg
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<80 mmHg
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Postural blood pressure
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>10 mmHg drop with standing
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>20 mmHg drop with standing
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Heart rate
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≤40 bpm or >120 bpm or postural tachycardia >20 bpm
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Temperature
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<35.5°C or cold/blue extremities
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<35°C or cold/blue extremities
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12-lead electrocardiogram
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Any arrhythmia including QTc prolongation, non-specific ST or T-wave changes including inversion or biphasic waves
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Blood sugar
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Below normal range‡
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<2.5 mmol/L
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Sodium
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<130 mmol/L‡
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<125 mmol/L
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Potassium
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Below normal range‡
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<3.0 mmol/L
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Magnesium
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Below normal range‡
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Phosphate
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Below normal range‡
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Estimated glomerular
filtration rate
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<60 ml/min/1.73m2 or rapidly dropping (25% drop within a week)
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Albumin
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Below normal range
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<30 g/L
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Liver enzymes
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Mildly elevated
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Markedly elevated (AST and ALT >500)‡
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Neutrophils
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<1.5 × 109/L
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<1.0 × 109/L
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Risk assessment
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Suicidal ideation
Active self-harm
Moderate to high agitation and distress
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*Patients who are not as unwell as indicated above may still require admission to a psychiatric or other inpatient facility. †Medical admission refers to admission to a medical ward, short-stay medical assessment unit or similar. ‡Please note, any biochemical abnormality that has not responded to adequate replacement within the first 24 hours of admission should be reviewed by a medical registrar urgently.
ALT, alanine aminotransferase; AST, aspartate aminotransferase
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Admission criteria for children
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Indicators for admission* and specialist consultation
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Medical status
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Heart rate: <50 bpm
Cardiac arrhythmia
Postural tachycardia: >20/min
Blood pressure: <80/50 mm
Postural hypotension: >20 mm
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QTc: >450 msec
Temperature: <35.5℃
Hypokalaemia
Neutropaenia
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Weight
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Children <75% of expected body weight or rapid weight loss
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Note: These are a guide only and do not replace the need for individual clinical judgement
*For children, admission would generally be to a medical ward. †People may also require admission for:
- uncontrolled eating disorder behaviour
- failure to respond to outpatient treatment
- severe psychiatric comorbidity
Reproduced with permission from the Royal Australian and New Zealand College of Psychiatrists. Clinical practice guidelines for the treatment of eating disorders. Melbourne: RANZCP, 2014.
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For most patients who will not need immediate hospitalisation, treatment should be individualised and take place initially in an outpatient community setting, if possible.14 Decisions surrounding management options are dependent on:2
- age of the patient
- symptom severity
- course of illness
- medical stability
- patient motivation
- psychosocial or family support
- regional availability of specialised inpatient/outpatient programs
- associated psychiatric comorbidity.
Other significant factors that influence the necessary treatment interventions are whether identification or presentation occurs early, and the competence of the GP in the field of eating disorders.16
A multidisciplinary team approach is often required to manage the physical and psychosocial consequences of the condition. The team could include a psychiatrist, psychologist, paediatrician, dietitian, social worker, psychiatric nurse, community support organisations and other medical specialists (eg endocrinologist, gastroenterologist).18 The role of the GP includes:14,18,22,23
- assessment and initial diagnosis (including urgent referral to the emergency department, if indicated)
- treatment of medical complications (eg iron deficiency)
- nutritional/weight assessment
- referral to appropriate health professionals
- involvement of community or hospital-based mental health services
- education for the patient and their family
- provision of regular ongoing medical monitoring.
The more detailed aspects of management are beyond the scope of this article, but are provided in the list of resources supplied. Certainly, in the scenario of early presentation and diagnosis (or prior to the patient fulfilling diagnostic criteria), education and regular monitoring in the primary care setting may be all that is required to prevent symptom progression.
Conclusion
Eating disorders are serious, life‑threatening conditions with significant physical, psychiatric, psychosocial and financial outcomes. The impact of these consequences can be minimised or avoided by early identification and management in the general practice setting. This article outlines an approach to assessment in the primary care setting with an emphasis on early detection. Ideally, this is achieved by a thorough history, a trusting therapeutic relationship between doctor and patient, and intervention before a patient fulfils all of the diagnostic criteria of a particular eating disorder.
Resources for GPs
Author
Elizabeth Rowe MBBS, FRACGP, General Practitioner, Airlie Women’s Clinic, Malvern, Vic. drlibby.rowe@gmail.com
Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.