Editor’s Note: This post is part of a series to explore how we can utilize research, clinical experience, and policy levers to prevent and enhance treatment of eating disorders in children and teens at a time when behavioral health concerns, including eating disorders, in youth are demanding attention and resources.
Eating disorders are serious, life-threatening illnesses that impact at least 9% of the world’s population. Despite significant mortality rates, eating disorders can be easily overlooked in the primary care setting.
Early diagnosis of eating disorders is critical and has been shown to improve outcomes and shorten the course of illness. However, many primary care providers (PCPs) are not trained to recognize early warning signs of eating disorders. Complicating this issue is the prevalent belief that people at higher weights cannot develop eating disorders, which is a form of weight stigma. In this way, weight stigma may even further contribute to a lack of early diagnosis and treatment of eating disorders.
In order to increase access to eating disorder treatment for all children and adolescents, it is essential to implement effective screening and diagnostic practices in the primary care setting.
Identifying Eating Disorders in Primary Care
The primary care office is often the first stop for patients and families with eating disorder concerns. When concerns arise, it is important that children and adolescents are evaluated for eating disorder signs and symptoms such as weight loss, dizziness, fatigue, loss of menstrual period, low heart rate, and preoccupation with food, weight or shape.
Alternatively, individuals with eating disorders may recognize the gravity of their illness and may not overtly report eating disorder symptoms or cognitions to a provider. This can complicate diagnosis and may require PCPs to proactively screen for eating disorders. Given that parents and family members play a crucial role in the diagnosis and treatment of children and adolescents with eating disorders, PCPs should ask parents about changes in their child’s eating, exercise, and body image behaviors, and should monitor growth curves for deviations.
Early eating disorder identification and treatment greatly improves overall outcomes both physically and psychologically. Adolescents who receive diagnosis and treatment at their first eating disorder presentation are less likely to carry the illness into adulthood. Eating disorders become stronger and less receptive to treatment the longer they are left untreated, and therefore early intervention is imperative.
Additionally, it is critical to expand recognition that eating disorders can occur in individuals of any body size. Since patients who drop from a higher body weight face the same detrimental health consequences as their lower weight counterparts, any significant drop in a patient’s typical growth curve should be an immediate cause for concern. However, this demographic often cannot access diagnosis and treatment services due to the widespread notion that eating disorders occur only in a small subset of adolescents (such as thin, White, affluent, able-bodied, cisgender females). In fact, adolescents consistently receive messaging that stigmatizes those in larger bodies, and the prevailing medical approach emphasizes that weight loss in adolescents at higher weights should be praised.
Next Steps: Increasing Access to Identification & Treatment
Primary care is an important venue to increase access to and engagement in pediatric behavioral health care, including for eating disorders. It is vital to implement reliable eating disorder screening tools in the primary care office. Experts recommend that all children as young as ten years old should be screened for eating and body image concerns at well-child appointments. Appropriate screening questionnaires can help PCPs in clinical decision-making regarding diagnosis and referrals to appropriate resources, but there is not consensus about which screening tool is best, and the implementation of those that exist has been sporadic. To close this gap, research to identify an evidence-based, effective screening tool is needed.
Additionally, integrated behavioral health programs may be an important avenue to increase equitable access to assessment and treatment of eating disorders. In these programs, behavioral health professionals are embedded into the primary care team, allowing PCPs to access consultation, or request a warm handoff and instant or expedited access to a behavioral health provider. Programs like this can offer PCPs important access to an expert second opinion; unfortunately, they are not ubiquitous and require policy changes such as improved payment structures, institutional resources and a larger behavioral health workforce.
PCPs, patients and families can all benefit from broadening access to eating disorder identification and treatment. The integration of behavioral health providers into primary care teams—as well as thoughtful coordination across multiple levels of care—can support PCPs in the implementation of screening tools and subsequently in accessing specialty care for youth when warranted.