Monday, January 12, 2015

Uncovering eating disorders: history-taking tips

- Jennifer Middleton, MD, MPH

Eating disorders affect up to 24 million U.S. teens and adults, and an article in the January 1 AFP discusses the "Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa." The well-known clinical signs of eating disorders, including marked weight change, amenorrhea, edema, and arrythmia, are reviewed in Table 3 of this article. Identifying eating disorders in patients whose disease has not yet progressed to this level of severity is more challenging, yet identifying eating disorders earlier in their course is associated with better outcomes for patients.

Since we often enjoy long-term relationships with patients and their families, family physicians can be well-attuned to subtle changes or concerns in patients that may raise our suspicion of an eating disorder prior to any obvious physical complaints or symptoms. Finding the right words or language to investigate further, however, may feel challenging.

An article from 2012 in Current Problems in Pediatric and Adolescent Health Care provides a comprehensive guide to history-taking in adolescents with suspected eating disorders that is also applicable to adults. Directed questioning regarding specific behaviors, done in a supportive and non-judgmental manner, is most likely to be effective. Examples of how to word these questions include:
  • What has been going on with your health and your body? What are your biggest concerns?
  • What do you think you ought to weigh?
  • How much of your day is spent on food/body thoughts?
  • Have you ever tried to change your weight or body? What have you tried?
  • How stressed are you if you miss a workout?
  • What foods do you avoid? Any taboo or fear foods (ones you used to eat that you now avoid)?
  • Do you count calories and/or fat grams? If so, how many do you allow yourself of each?
  • Has anyone ever bullied or teased you? 
A Curbside Consultation from AFP published in 2008 provides additional tips for dealing with challenging parent-adolescent interactions related to eating disorders. The author recommends beginning the visit with both the parent and the adolescent patient, as parents may, initially, be more likely to share details related to disordered eating behaviors than teens. Speaking with the adolescent privately is also of importance, though; asking direct questions like those outlined above may yield additional information that teens may be unwilling to discuss in front of their parents. 

It's estimated that only 10% of individuals with eating disorders receive treatment. Most patients with eating disorders are reluctant to seek help, yet individuals with eating disorders have increased health-care utilization before their diagnosis. Patients with undiagnosed eating disorders are in our offices and hospitals; sensitive history taking can not only uncover the presence of an eating disorder but also build patient-clinician rapport toward effective treatment.

What challenges and successes have you experienced with caring for patients with eating disorders?

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