Eating Disorders: A Family Physician's Perspective

Educational Objectives

The goal of this program is to improve treatment of eating disorders. After hearing and assimilating this program, the clinician will be better able to:

1. Assess laboratory findings in patients with eating disorders.
2. Refer patients to appropriate eating disorder treatment programs.

Summary

Clinical Signs and History

Clinical signs of an eating disorder (ED): unexplained weight loss — can have a wide differential diagnosis ranging from cancer to disordered eating; one should consider EDs in patients who have lost a significant amount of weight over a short period, eg, during the social isolation period of the COVID-19 pandemic; irregular menses — one should evaluate the nutritional status of women with irregular menses; performance issues — EDs may cause performance issues at school, at work, or in athletics; a new environment, its stressors, and lack of access to knowledge can lead to disordered eating behaviors; injuries — patients with recurrent simple injuries, eg, ankle sprains or irritated tendons, and stress fractures may have disordered eating; personality and social changes — can be caused by different factors, eg, primary psychiatric disorder, drugs, disordered eating

Patient history: one should start with a detailed history; the chief complaints may vary, eg, feeling tired, hair loss, or irregular periods; one should obtain information about the reason for sudden weight loss from everyone around the patient, eg, parents, coaches, athletic trainers, peers

Pediatric population: access to their growth charts can give some perspective on their relative weight loss or body mass index; information regarding prematurity, failure to thrive, other medical diagnoses, food aversions to different textures, and oral motor issues with feeding aids in diagnosis

The onset of symptoms and behaviors: the most common and the first symptom is food restriction; individuals start eliminating a type or category of food, eg, carbohydrates, which leads to certain behaviors

Medications: one should ask about the use of medications for weight loss, whether prescribed, borrowed from friends or family members, or picked up in the pharmacy (an over-the-counter diuretic or laxative); many people use weight-loss medications off-label for cosmetic weight loss as opposed to obesity treatment, eg, semaglutide (Ozempic, Wegovy)

Purge behaviors: one should check for the presence of purge behaviors, ie, purposefully vomiting or over-exercising (in athletes)

Body weight details: one should try to get a picture of their high and low body weights; for some people, talking about weight may be triggering; obtaining at least a 24-hr diet log during the visits can give an idea about the patient’s behavior; 90% of patients with a new ED may not have eaten before the visit (because of patterns that perpetuate themselves)

Menstrual history: one should ask about menstrual history, menarche, regularity of menses, and duration of irregularity; changes in training regimen often lead to irregular menses

Injuries: one should ask about injuries, long-standing sprains, and strains, eg, patellofemoral arthralgia; patients with EDs have a higher risk for stress fractures in uncommon areas, eg, sacral alar fractures because of continued running despite a femoral neck fracture

Psychiatric and family history: one should obtain a comorbid psychiatric history (anxiety, depression, bipolar disorder, or a history of counseling) and ask about family dynamics, as they determine the ways people cope with stress, eg, food intake or exercise output may be a coping mechanism; a family history of psychiatric disorder (a parent with disordered eating) is almost always present; there may be some genetic penetrance, eg, a parent or an aunt with a history of anorexia

Changes in performance: one should ask about school, sport, or work performance; children with anorexia may start to do more poorly in school or get straight As (bimodal distribution)

Physical Examination and Laboratory Evaluation

Physical examination: one should obtain the patient’s blind weight, height, orthostatic blood pressure, and heart rate, and perform a detailed physical examination (time-consuming); one should perform an oral examination for dental decay, examine the hands (to check for signs of inducing vomiting), and examine the thyroid and lymph nodes (for enlargement; to rule out primary cancer); bradycardia is one of the key signs of a severely restricted ED; vitals should be checked after the patient is made to sit for 10 min; one should look for vellus hair growth on the face and arms and for signs of self-harm (eg, on the wrists or thighs)

Laboratory testing: patients with suspected disordered eating may have a different primary medical diagnosis; a complete blood count (to look for anemia or iron deficiency), a comprehensive metabolic panel with prealbumin (often low in severe restriction), and a complete thyroid panel should be obtained; in patients with ED, thyroid-stimulating hormone level on the lower end of normal range occurs in the setting of low triiodothyronine (abnormal pituitary response); a lipid panel may be highly abnormal; a urine analysis is helpful to assess their hydration status; electrocardiography should also be obtained; consider hospital admission for a patient with bradycardia and a heart rate of <45 bpm with suspected ED; a complete panel, ie, prolactin, estradiol, progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone should be obtained for patients with amenorrhea or oligomenorrhea; in the typical restricted patient, FSH, LH, estradiol (nonexistent), progesterone, and testosterone levels are low; food choices, eg, being vegan or vegetarian, may lead to restrictive behaviors; vitamin B, iron (panel), ferritin, vitamin B₁₂, folate, magnesium, and phosphorus levels should be obtained

Care and Referral

The first visit: speaker’s method — it may be difficult to arrive at a definitive diagnosis at the first visit because of time limitations; the term “ED not otherwise specified” may be used initially; the goal of the first visit is to identify if the patient is medically stable enough or has a reliable parent to direct care at home; severe anorexia can be compared with leukemia, and the patient can be sent to the emergency department because of the acuity of the diagnosis and the potential outcome; one should ensure that the patients understand the seriousness of their condition and create a safe environment for their care

Referral for care: stable patients can be referred to specialists who feel comfortable managing stable outpatient ED care (complex and time-consuming); the medically unstable patients require acute care and should be referred to the emergency department, directly admitted, and safely handed to a medically monitored nutritional re-entry program (with access to the necessary services); patients can be motivated to enter organized ED programs, eg, a partial hospitalization program; they can step down to an intensive outpatient program for EDs and be referred to an ED dietitian, psychologist, and psychiatrist; patients can also be referred to an online platform called “Equip” (can be individualized), enabling them to manage their visits; the patients who are not willing to enter a program can be discharged but monitored continuously to plan further management

Final points: further testing might be required, eg, dual-energy X-ray absorptiometry imaging for patients with a stress fracture history, echocardiography for patients with cardiac symptoms or a history of syncope; patients with an ED may have a primary gastrointestinal (GI) disorder or may have developed the GI disorder from the disordered eating behavior

Readings

Keski-Rahkonen A. Eating disorders: etiology, risk factors, and suggestions for prevention. Cur Opin Psychiatry. 2024;37(6):381-387. doi: 10.1097/YCO.0000000000000965; Mills R, Hyam L, Schmidt U. Early intervention for eating disorders. Curr Opin Psychiatry. 2024;37(6):397-403. doi: 10.1097/YCO.0000000000000963; Owens RA, Attia E, Fitzpatrick JJ, et al. Eating disorders. J Am Psychiatric Nurses Assoc. 2023;29(3):241-251. doi: 10.1177/1078390321999713; Schorr M, Miller KK. The endocrine manifestations of anorexia nervosa: mechanisms and management. Nat Rev Endocrinol. 2017;13(3):174-186. doi: 10.1038/nrendo.2016.175; Shook J, Brady-Olympia J. The inpatient management of adolescents with eating disorders. Pediatr Ann. 2024;53(8):e283-e287. doi:10.3928/19382359-20240605-03; Yahalom M, Spitz M, Sandler L, et al. The significance of bradycardia in anorexia nervosa. Int J Angiol. 2013;22(2):83-94. doi:10.1055/s-0033-1334138.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Myers was recorded at the 67th Annual Postgraduate Symposium, held June 28-30, 2024, in San Diego, CA, and presented by the San Diego Academy of Family Physicians. For information on upcoming CME activities from this presenter, please visit sandiegoafp.org. AudioDigest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

PS541602

Qualifies for:

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.