Every 62 minutes someone dies as a direct result of their eating disorder (ED). Yet, despite high rates of mortality and
morbidity, eating disorders are underdiagnosed and often missed by healthcare practitioners. Part of the problem is that many clinicians have never had comprehensive training in the assessment or treatment of EDs, therefore proper screening measures are excluded in many treatment settings.
Whether you plan to treat the ED or not, I believe it is our responsibility to assess for them as part of a standard intake process.
- Eating disorders have the highest mortality rate of all psychiatric illnesses, yet the average length of time between the onset of symptoms and the first evidence-based treatment is seven years. Training more clinicians to properly assess EDs will translate to a shorter duration of time between onset and treatment, and will save lives.
- Eating disorders are common and highly co-occur with mood and anxiety disorders, substance use, trauma, and personality disorders. If missed, an ED will interfere with emotion regulation and/or with a client’s ability to learn and retain treatment material (e.g., problems with attention or cognitive capacity secondary to malnutrition).
- Early detection can reduce the need for high levels of care. If we can assess and help individuals get proper ED treatment earlier, we may be able to circumvent the worsening of symptoms that will need inpatient or residential treatment.
- While there has always been a crisis in terms of the number of trained clinicians and access to services in general, Covid-19 has exacerbated the field. Over the last two months alone, there have been numerous media reports of individuals with EDs presenting for adolescent and adult care in substantial numbers, in a system that cannot meet those demands. It is essential that clinicians in private practice and other community-based settings receive ED education and training.
Where do I start?
Eating disorder assessments are comprehensive in nature because multiple domains need to be evaluated, as follows:
1. Daily food and fluid intake. In order to get an accurate picture of what a person consumes in a day, it is essential to ask the client what a typical day of eating involves. I often ask them to report what they ate or drank the day before the appointment, starting from the time they woke up until the time they go to bed. Get specific details about quantity and type of food eaten (e.g., “lite” yogurt vs regular, cereal or pasta quantities, what exactly was in the sandwich, type of soup). Ask whether weekends are different from week days. Assess whether hunger and fullness cues have been disrupted by the ED; a common adaptation the body makes during periods of underfeeding. If a client is having difficulty recalling intake, ask them to do a food and fluid log for a week to bring to the next session. Having the client be assessed by a dietitian who is trained in eating disorders is also very helpful.
2. Behaviours that impact weight and shape. Collect information on the types of behaviours clients engage in to control (or that impact) weight or shape. It is important to remember that not all ED behaviours are done with the intent to lose weight. For example, people who struggle with Avoidant Restrictive Food Intake Disorder (ARFID) may not eat enough food due to a fear of choking or a dislike of food textures. Ask about the presence and frequency of dieting or restrictive eating patterns, binge eating episodes, purging, laxative use, excessive exercise, misuse of insulin, eating non-nutritive substances, and other related behaviours.
3. Medical health and stability. Standard ED assessments must include up-to-date labwork. You cannot tell how ill someone is by looking at them and many individuals who look “healthy” are very unwell. ED symptoms are related to numerous and potentially life-threatening complications including electrolyte imbalances, heart arrythmias, dangerously low heart rates, and kidney and pancreatic problems. Anyone being assessed for an eating disorder requires an ECG and a full blood panel. The one my Clinic uses includes:
CBC and differential
AST, ALT, GGT, Alkaline Phosphatase, Bilirubin Amylase
RBC Folate, Vitamin B12 Albumin FSH,LH, estradiol (Halton referrals only)
Urea, Creatinine Magnesium, Phosphate
Na+, K, Ca2+ Ferritin
These tests results are essential in determining the medical severity of the ED and direct treatment recommendations (e.g., outpatient versus inpatient). Those using a DBT for ED model rely on these data for proper targeting (e.g. life threatening ED behaviours vs therapy interfering behaviours vs quality of life interfering behaviours).
4. Body weight. In addition to assessing current body weight and height, it is important to ask clients about their weight over time. Ask about weight during childhood, through the teenage years, lowest and highest adult weights, whether they have an “ideal” body weight, and what their weight does during periods (if any) in which there were no eating disorder symptoms. Data on weight gain and loss is important and any precipitous weight loss should be investigated for the presence of an ED. In children and adolescents, obtaining growth charts is especially helpful in trying to determine genetic factors in weight and shape. We also typically ask about weight and shape of biological relatives.
5. Thoughts, beliefs, and sensations about weight, shape, and food: Assess the degree to which the client bases their self-worth and self-esteem on weight and shape. Ask about the presence of food rules (e.g., can’t eat after a certain time, clean eating), feared foods, and how they would feel if their weight and shape changed. Most individuals who struggle with EDs experience excessive and difficult-to-control thoughts about eating, food, weight, and shape. Many also experience sensory issues that disrupt how they experience and perceive their bodies (e.g., perceiving the body as larger than it actually is, noticing very subtle changes in the body).
Your assessment can be supplemented with some of the following measures (all within the public domain).
The Eating Disorder Examination Questionnaire (EDE-Q, 17.0) is a commonly used self-report measure that assesses ED related cognitions and behaviours. This tool can be used to generate DSM-5 eating disorder diagnoses and provides four subscales: restraint, eating concern, shape concern, and weight concern. The EDE-Q is offered in the measures section of Owl Practice for easy administration and scoring
The Eating Attitudes Test (EAT-26) is another commonly used measure of disordered eating and behaviours. It is designed as a screening tool to help identify those who may have an eating disorder.
The Children’s Eating Attitudes Test (ChEAT) is a modified version of the EAT-26 that can be used in children ages 8 and above. This measures captures dieting behaviours, as well as attitudes about body image and weight.
The more we can assess for the presence of an eating disorder, the faster we can make a difference and the more lives can be saved!
Interested in learning more? Join Dr. Federici on October 20th for a 2 hrs. presentation:
Eating Disorders Primer: What every practitioner needs to know
Info & Registration: