Assessment of Eating Disorders: Getting Started

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.

Why Assess?

- 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: