PCPs are 'on the front lines' in diagnosing eating disorders like anorexia

Key takeaways:

• Diagnosing and managing anorexia nervosa can be complicated for primary care providers, partially due to treatment hesitancy.
• However, PCPs can also be the keystone of a multidisciplinary treatment team.

Primary care providers are on the front lines of diagnosing and treating anorexia nervosa — a particularly complex eating disorder, according to experts.

Previous research has indicated that eating disorders are on the rise in the United States — a report from the health care claims repository FAIR Health revealed that, from 2018 to 2022, eating disorder claims in the United States rose 65% as a percentage of all medical claims. Because primary care providers have been seeing more and more patients with eating disorders, researchers have created tools that help PCPs screen for them and counsel patients in need.

However, PCPs can still struggle with diagnosing and managing anorexia nervosa — a mental health condition characterized by fear of weight gain, body image distortion and calorie restriction that “can lead to profound health consequences,” David Klein, MD, MPH, a colonel in the U.S. Air Force, a family and adolescent medicine physician and a member of the American Academy of Family Physicians, told Healio.

Potential causes of anorexia

The eating disorder can present for a variety of reasons, including environmental factors and a family history, Ashley Denmark, DO, an osteopathic physician specializing in family medicine and a member of the American Osteopathic Association, said in an interview.

Klein said that in many cases, the cause of a patient’s anorexia “is not apparent or may require extensive therapy to begin to understand.”

“It is likely that eating disorders develop through the interplay between predisposing genetic vulnerabilities, environmental factors occurring at the onset of the disorder, and perpetuating factors that maintain the disorder,” he added.

Other factors that likely play a role in anorexia include:

• behavioral (eg, perfectionism coping and overcontrol of eating);
• biological (eg, genetic predisposition);
• psychological (eg, personality traits); and
• psychosocial (eg, culture, stress or trauma).

Notably, a study that was recently published in JAMA Network Open pointed to associations between anorexia and sleep and circadian rhythms.

Hannah Wilcox, BS, a research assistant at Massachusetts General Hospital, and colleagues conducted a genetic association study evaluating these associations through mendelian randomization. Wilcox and colleagues found that anorexia genetic liability was associated with a morning chronotype ( = 0.03; 95% CI, 0.00-0.07), and vice versa, with morning chronotype genetic liability associated with an increased risk for anorexia nervosa ( = 0.17; 95% CI, 0.04-0.31).

“Our findings suggest the role of morningness as an underrecognized risk factor for anorexia nervosa whose importance should be further investigated in the context of other established risk factors,” Wilcox and colleagues wrote. “If deemed a relevant risk factor, interventions promoting later sleep schedules may be considered to ameliorate risk conferred by a morning chronotype.”

Although research can help identify patients who are more likely to be at a higher risk, Klein and Denmark stressed that the eating disorder can appear in anyone.

“I have seen many patients with forms of anorexia nervosa in all body types, sociodemographic backgrounds, and age ranges,” Klein said. “In many cases, the affected person perceives benefit from the condition, making the process of getting buy-in for treatment very difficult.”

Treating anorexia in practice

Recently, Klein found himself speaking with a boy aged 16 years who had dropped from the 90th percentile of weight based on his age and height to the 35th percentile relatively quickly.

“He was focused on achieving a muscular and trim appearance and had a disordered relationship with food and exercise,” Klein said. “This seemed to start after multiple people in his life complimented him on a noticeable weight loss.”

The patient refused to even sit in the car without tensing his legs to burn fat, Klein said. But even so, “getting the parents on board with a treatment plan was particularly challenging,” because they thought he was simply “taking important steps to get ‘in great shape’ for the athletic season.”

It was also tough to convince the patient of a treatment plan, Klein said, becaseu he “was invested in the positive attention he received from his peers from posting weight loss posts on social media.”

Social media was also a challenge in Klein’s treatment of a woman aged 22 years, he said. During one visit, she showed him her feed, which featured “endless revealing images of thin women, which she regularly compared to her own body shape.”

“Her parents had previously struggled to implement the recommended family-based therapy approach because she would not relinquish control of her rigid and unhealthy routines, including body checking and adhering to strict calorie counts, at home,” he said. “She ended up with profound weight loss and abnormal vital signs requiring inpatient hospitalization. I worry that she may be in the significant percentage of people with eating disorders who have lifelong symptoms and have a very high risk for medical complications (eg, cardiac, bone health) or suicidality.”

Had other clinicians who had seen the patient, like her PCP, identified her condition earlier, “I believe her course would be different,” Klein said.

Challenges in diagnosis

The U.S. Preventive Services Task Force decided in 2022 that that there was insufficient evidence to recommend screening for eating disorders in primary care.

Still, Klein said, PCPs “are on the front lines in detecting eating disorders.”

When they are concerned about a patient’s eating habits, he said PCPs should ask for permission to address the sensitive topic to kick off a conversation. He suggested using specific phrases like “I’m concerned about your eating. Would it be okay if we talk about your eating habits?” and then asking questions that are more personal, such as: “Some of my patients tell me their weight or body shape causes stress. Tell me about any experiences you have had.”

“To avoid disordered eating behaviors and unhealthy psychosocial functioning becoming entrenched, making treatment very difficult, clinicians should quickly pursue worrisome findings found on psychosocial history taking or physical exam, and understand the timeliness in making a diagnosis or referral to prevent treatment delays,” Klein said. “Because some patients minimize symptoms, the clinician evaluating a patient with worrisome findings may try to seek the help of family members or friends to further support the person’s care and gain understanding.”

PCPs who know a patient’s baseline are “very critical in the diagnosis of eating disorders,” according to Denmark.

“PCPs can play a crucial role in early detection and initial management,” she said. “We provide education, support and monitoring of physical and emotional health.”

However, Denmark noted that there is a common misconception that one can diagnose an eating disorder like anorexia based on BMI or appearance alone. She said this misconception is harmful and can lead to delayed diagnosis and treatment as well as patient suffering.

“Eating disorders like anorexia thrive in secrecy because they can affect people even with higher BMIs,” she said. “Using BMI-based criteria or appearance-based assessments is limiting and leads to delays in diagnosis. PCPs should expand beyond those assessments and dive deeply into family history and emotional symptoms as a comprehensive diagnostic approach.”

Klein also said that eating disorders can present in patients who have all kinds of body types, so, “to avoid missing worrisome findings, clinicians should analyze weight and BMI trends and changes over time.”

“The clinician can miss diagnoses using physical measurement alone without psychosocial history taking, including questions about eating behaviors, body image and mood, through clinical interview and/or validated screening tools,” Klein said.

Unfortunately, “effective, comprehensive screening is not always feasible in short visits,” and screening questionnaires are not always accurate — barriers that can “complicate matters,” Klein said.

“Until more effective screening tools become available, clinicians should use assessment approaches that can be effectively implemented in their practices,” he said.

Treatment

Once diagnosed, treatment for patients with anorexia must be multidisciplinary and address their physical, emotional and psychological health, Denmark said.

“As a physician, I have treated anorexia in my clinic, and the complexities of these patients go beyond BMI/health and weight measurements,” Denmark said. “These patients have a host of comorbid mental health conditions that are giving rise to physical symptoms, which only worsen patient eating disorders if not appropriately managed.”

Anorexia management can be particularly complicated because patients often resist treatment, partially because of the perceived benefits from restrictive eating, Klein said.

“Most medical complications associated with anorexia nervosa resolve with weight restoration, making this a priority early in the treatment course,” he said. “These complications include the inattention, fatigue or dizziness that many people experience, but also the dangerous symptoms including but not limited to cardiac and bone health.”

Denmark said treatment for anorexia can include nutritional rehabilitation, cognitive behavioral therapy and antidepressant medication to address underlying mental health problems. However, “providing continuity in care while patients seek outpatient treatment can be difficult depending on availability, access to therapy, and affordability.”

When PCPs are making treatment decisions, Denmark said guidance, including referrals to specialists, “is often necessary for comprehensive treatment, especially in severe cases or when specialized psychological therapies are required.”

“I emphasize the holistic approach when dealing with eating orders and not limit to appearance-based or BMI-based metrics,” Denmark said. “Anorexia is a mental health condition that requires addressing just as much as the physical [aspects]. Listen to your patients and their needs. Often, these are complex cases, and far too often, concerns are not believed or given complete evaluation because they may not believe they have an eating disorder based on appearance.”

Klein also emphasized the importance of multidisciplinary care.

“A basic multidisciplinary outpatient treatment team includes a clinician who is knowledgeable about eating disorder care (who can be a PCP), a dietician and a therapist,” he said. “The team’s physician ... helps to determine healthy weight goals, recommends an appropriate level of care (eg, outpatient, hospitalization, intensive outpatient), reinforces the treatment strategy agreed upon by the treatment team and evaluates for medical or psychiatric changes in health status.”

References:

• Eating disorders in adolescents and adults: screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-eating-disorders-adolescents-adults. Published March 15, 2022. Accessed Jan. 16, 2024.
• Wilcox H, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2023.50358.