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While eating disorders affect about one in 20 people, persistent stereotypes can make them difficult to recognise—and patients themselves may be reluctant to seek care. Following a practical framework can facilitate early identification and appropriate treatment, say experts involved in developing a new resource hub that provides specific guidance for Australian GPs.
Many people still associate eating disorders with adolescent girls, restrictive patterns and significant weight loss, but the reality is much broader, says Dr Karen Spielman, a GP and senior research associate at the InsideOut Institute for Eating Disorders. People of any age, gender, body size or background can be affected, she stresses.
Given their prevalence, GPs should maintain a high level of clinical suspicion for eating disorders, particularly in high-risk groups, she says. These include:
Rapid weight changes, mood disturbance, social isolation and suicidality should all prompt consideration of disordered eating, she adds.
Pheobe Ho, a lived experience advocate and clinical psychologist, says stereotypes can prevent people from accessing treatment.
“In mainstream health messaging in society and the media, eating disorders are often portrayed as a diet gone wrong or only affecting teenaged females who live in smaller, thin bodies—but we actually know that’s not the case.”
“I had the idea that you had to be thin or look a certain way, and the health messaging in society is if you just lose weight and if you’re thin, then you’re going to be healthy.”
In fact, eating disorders can affect people of all weights and sizes. People with eating disorders often have a BMI in the average or higher range, and often still experience significant adverse medical and psychological outcomes.
Stigma and shame are also “really huge barriers” to accessing care, she adds.
“A lot of people coming in seeking help for the first time don’t think that they’re sick enough or that they’re deserving of help.”
It’s essential to approach discussions about disordered eating sensitively, Dr Spielman stresses. The InsideOut Institute Screener, developed in consultation with the lived experience community, is specifically designed for this purpose, she explains.
“There’s no stigmatising language and the range of eating disorder behaviors are covered. It’s a validated, easy to ask, and easy to score questionnaire.”
The six-question tool starts by asking “How is your relationship with food?”, which is a “really beautiful way to open up the conversation,” she says.
The other five questions explore body image concerns, the extent to which thoughts about food or weight dominate daily life, anxiety around eating, experiences of loss of control with food, and compensatory behaviours after eating.
If concerns are identified, the next step involves determining their severity and the urgency of treatment, Dr Spielman explains.
History should cover eating patterns, exercise behaviours, binge eating, purging, psychological symptoms, and menstrual history. It’s also important to understand how the illness is affecting the patient’s daily life, relationships, study or work.
Physical assessment should be conducted with care, she advises.
“It’s particularly important when we’re dealing with these sensitive issues to make people feel comfortable and not cause danger in terms of the examination. If patients do have discomfort around body shape or function, then we have to be super sensitive.”
She recommends asking a patient’s permission before weighing them, emphasising “that’s not necessarily the first thing we want to do.” She typically offers a blind weight by asking patients to step backwards onto the scales.
Other key components include:
Routine investigations typically include full blood count, kidney and liver function tests, glucose and electrolytes, magnesium and phosphate levels. Additional investigations may include iron studies, vitamin B12, folate, zinc, hormonal assessment and coeliac testing where clinically indicated.
Do an ECG if you have concerns about cardiovascular stability.
Indications for hospital admission vary slightly between states and territories, and cardiovascular complications are among the most important, Dr Spielman says.
“If somebody’s heart is struggling with malnutrition at any body size, shape or weight, you’re going to get some impact on their cardiovascular health.”
A postural heart rate increase of more than 20 beats per minute in younger patients or 30 beats per minute in adults warrants concern.
Finger prick testing can provide important information if you are concerned about a patient’s immediate safety, and rapid weight loss (about a kilo per week over a few weeks) is a red flag.
“If I’m seeing a young person who’s losing weight rapidly, then I would class that as a medical emergency,” she says.
Eating disorders affect numerous body systems, and Dr Spielman suggests thinking systematically about potential complications.
Gastrointestinal symptoms are common and may include bloating, abdominal pain, constipation, diarrhoea and altered gut motility. “And unfortunately eating disorders can occur with or can be caused by issues with digestion, so it’s really important to tease out.”
Dermatological changes such as hair loss and brittle nails can occur, while dental erosion and salivary gland enlargement are frequently seen in patients who engage in purging behaviours.
Menstrual irregularities are common with malnutrition, and prolonged oestrogen suppression may contribute to reduced bone density and osteoporosis—which can sometimes be irreversible.
Haematological abnormalities can occur as well, including neutropenia associated with bone marrow suppression.
Importantly, recovery is not only identified by weight restoration or the return of menstruation, Dr Spielman notes.
“Some of our patients will continue to menstruate at lower weight. It’s actually quite a subtle marker. So holistically, we’re looking at restoration of cognition. When people are malnourished, that really impacts flexibility of thinking and cognition and concentration. And personality coming back, those kinds of things, can be a really beautiful marker of when somebody’s recovered.”
Many patients present after months or years of shame and self-doubt, and “just actually being heard and seen and validated” can have a profound impact, Ms Ho says.
To help patients with eating disorders feel safe and comfortable, she recommends:
Eating disorders almost always require multidisciplinary management. Along with ongoing medical monitoring, GPs will often be involved in care planning and coordinating referrals (e.g. to psychologists, dietitians, psychiatrists and other specialists as required).
Treatment can feel overwhelming for patients, Ms Ho notes, especially when multiple appointments and health professionals are involved. Effective coordination helps reduce that burden.
InsideOut Screener | Validated screening tool
InsideOut eClinic | Free online CBT-based activities, progress tracking, carer resources
InsideOut GP Hub | Eating disorder information and resources for GPs
This article was developed from a podcast proudly brought to you by InsideOut and Healthed.
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