Guidelines for preventive activities in general practice

Mental health and substance use

Eating disorders

      1. Eating disorders

Mental health and substance use | Eating disorders

 

There are approximately 1 million Australians living with eating disorders, comprising approximately 25,000 with anorexia nervosa, 100,000 with bulimia nervosa, 500,000 with binge eating disorder and 350,000 with other forms of eating disorders.1 Anorexia nervosa has one of the highest mortality rates of any mental illness, with approximately 450 deaths from anorexia nervosa every year in Australia.1 The prevalence of eating disorders is higher among athletes, women, younger adults aged 18–29 years and transgender individuals. It is also important to understand that eating disorders in men and individuals from diverse or minority populations (eg LGBTQIA+/gender diverse, ethnic minority groups, Aboriginal and Torres Strait Islander people) are often missed and that they may face poorer outcomes due to delayed diagnosis and a lack of access to services.2,3 Various biological, psychological, social and environmental factors, such as genetics, the presence of other mental health conditions, trauma, perfectionism, rigidity, social pressure related to appearance and childhood adversity, are associated with a higher risk of developing an eating disorder.
 
Eating disorders are serious and potentially life-threatening mental illnesses with complex aetiology that can present to primary care in myriad ways. Patients will more often present with an eating disorder than for an eating disorder, and, as such, GPs with their skilled generalist approach are ideally placed with curious questioning to provide a safe space for patients to explore help seeking at any stage.4
 
There is an opportunity to improve the detection and management of eating disorders in Australian primary care settings, particularly when patients present for ‘other’ issues or with unexplained low body mass index (BMI) and one or more symptoms related to an eating disorder.5
 
Although the evidence for screening is insufficient,4 implementing opportunistic case finding in high-risk groups is likely to improve access to early intervention, accurate diagnosis and treatment, which will improve outcomes for individuals and the community.2

Screening

Recommendation Grade How often References
Screening for eating disorders (eg binge eating disorder, bulimia nervosa and anorexia nervosa) is not recommended in adolescents and adults. Not recommended (Strong) N/A 6
 

Case finding

Recommendation Grade How often References
Assess the risk of eating disorders.
When assessing for an eating disorder or deciding whether to refer people for assessment, consider the information in Box 1.
Practice point N/A 7
 
 
 

Preventive activities and advice

Recommendation Grade How often References
GPs have a vital role in prevention by educating about the risks of dieting, which is a risk factor for the development of both eating disorders and obesity, by:
  • discouraging unhealthy dieting; instead, encourage and support the use of positive eating and physical activity behaviours that can be maintained on an ongoing basis
  • promoting a positive body image among all adolescents
  • encouraging families to have body-positive conversations that do not focus on weight but celebrate health
  • encouraging families to engage in family-centred/led activities such as healthy family meals and routine and regular physical activity
Practice point N/A 6,8
 

Screening for eating disorders has the potential to improve health outcomes, such as quality of life or function, if it leads to early detection and effective treatment. However, the current evidence on whether screening improves health outcomes is unclear.6 

GPs can also implement sensitive weighing practices at every opportunity, being mindful of the Academy of Eating Disorder position statement on preventing Childhood Obesity,9 which states:

Weighing [children] should only be performed when there is a clear and compelling need for the information. The height and weight of a child should be measured in a sensitive, straightforward and friendly manner, in a private setting. Height and weight should be recorded without remark.

Refer to the Preventive activities in childhood chapter for information on measuring the height and weight of a child. Further, BMI assessment should be considered just one part of an overall health evaluation and not as the single marker of a child’s health status.

Box 1. Assessing for an eating disorder7

Potential indicators of an eating disorder include:
  • an unusually low or high BMI or body weight for age
  • rapid weight loss
  • dieting or restrictive eating practices
  • family members or carers reporting a change in eating behaviour
  • social withdrawal, particularly from situations that involve food
  • other mental health problems
  • a disproportionate concern about weight or shape
  • problems managing a chronic illness that affects diet, such as diabetes or coeliac disease
  • menstrual or other endocrine disturbances, or unexplained gastrointestinal symptoms
  • physical signs of:
    • malnutrition, including poor circulation, dizziness, palpitations, fainting or pallor
    • compensatory behaviours, including laxative or diet pill misuse, vomiting or excessive exercise
  • abdominal pain that is associated with vomiting or restrictions in diet and cannot be fully explained by a medical condition
  • unexplained electrolyte imbalance or hypoglycaemia
  • atypical dental wear (eg erosion)
  • taking part in activities associated with a high risk of eating disorders (eg professional sport, fashion, dance, or modelling).

There are no specific recommendations or advice for Aboriginal and Torres Strait Islander people.

It is important to understand that men and individuals from diverse or minority populations (eg LGBTIQA+/gender diverse, ethnic minority groups) with eating disorders are often missed and may face poorer outcomes due to delayed diagnosis and a lack of access to services.2

Eating disorders: A professional resource for general practitioners | National Eating Disorders Collaboration
Weighing an individual with an eating disorder | Inside Out Institute for Eating Disorders
Weekly weighing | Centre for Clinical Interventions
  1. Inside Out Institute for Eating Disorders. About eating disorders. Inside Out Institute for Eating Disorders, 2023 [Accessed 23 May 2023].
  2. Bryant E, Spielman K, Le A, et al. Screening, assessment and diagnosis in the eating disorders: Findings from a rapid review. J Eat Disord 2022;10(1):78. doi: 10.1186/s40337-022-00597-8.
  3. Burt A, Mitchison D, Doyle K, Hay P. Eating disorders amongst Aboriginal and Torres Strait Islander Australians: A scoping review. J Eat Disord 2020;8(1):73. doi: 10.1186/s40337-020-00346-9.
  4. Rowe E. Early detection of eating disorders in general practice. Aust Fam Physician 2017;46(11):833–38.
  5. Ivancic L, Maguire S, Miskovic-Wheatley J, Harrison C, Nassar N. Prevalence and management of people with eating disorders presenting to primary care: A national study. Aust N Z J Psychiatry 2021;55(11):1089–100. doi: 10.1177/0004867421998752.
  6. U.S. Preventive Services Task Force (USPSTF). Depression and suicide risk in adults: Screening. USPSTF, 2023 [Accessed 5 March 2024].
  7. National Institute for Health and Care Excellence (NICE). Eating disorders: Recognition and treatment. NICE, 2020 [Accessed 5 March 2024].
  8. Neumark-Sztainer D. Preventing obesity and eating disorders in adolescents: What can health care providers do? J Adolesc Health 2009;44(3):206–13. doi: 10.1016/j.jadohealth.2008.11.005.
  9. Academy for Eating Disorders. Position statements: Guidelines for childhood obesity prevention programs. Academy for Eating Disorders [Accessed 23 May 2023].
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