Eating Disorders in Primary Care: Diagnosis and Management

 

Editor's Note: This article has been updated to incorporate the January 2021 guidelines from the American Academy of Pediatrics.

Am Fam Physician. 2021 Jan 1;103(1):22-32.

Related letter: The Role of Weight Stigma in the Development of Eating Disorders

  Patient information: See related handout on eating disorders.

Author disclosure: No relevant financial affiliations.

Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behaviors that impair physical health and psychosocial functioning. Early intervention may decrease the risk of long-term pathology and disability. Clinicians should interpret disordered eating and body image concerns and carefully monitor patients' height, weight, and body mass index trends for subtle changes. After diagnosis, visits should include the sensitive review of psychosocial and clinical factors, physical examination, orthostatic vital signs, and testing (e.g., a metabolic panel with magnesium and phosphate levels, electrocardiography) when indicated. Additional care team members (i.e., dietitian, therapist, and caregivers) should provide a unified, evidence-based therapeutic approach. The escalation of care should be based on health status (e.g., acute food refusal, uncontrollable binge eating or purging, co-occurring conditions, suicidality, test abnormalities), weight patterns, outpatient options, and social support. A healthy weight range is determined by the degree of malnutrition and pre-illness trajectories. Weight gain of 2.2 to 4.4 lb per week stabilizes cardiovascular health. Treatment options may include cognitive behavior interventions that address body image and dietary and physical activity behaviors; family-based therapy, which is a first-line treatment for youths; and pharmacotherapy, which may treat co-occurring conditions, but should not be pursued alone. Evidence supports select antidepressants or topiramate for bulimia nervosa and lisdexamfetamine for binge-eating disorder. Remission is suggested by healthy biopsychosocial functioning, cognitive flexibility with eating, resolution of disordered behaviors and decision-making, and if applicable, restoration of weight and menses. Prevention should emphasize a positive focus on body image instead of a focus on weight or dieting. .

Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behaviors that impair physical health and psychosocial functioning.13 Adolescence and early adulthood are vulnerable periods for the development of eating disorders; however, up to 8% of females and 2% of males are affected during their lifetimes, including persons of all ages, sizes, sexual and gender minority groups, races, ethnicities, socioeconomic strata, and geographic locations.1,46  Diagnostic characteristics of specific eating disorders are presented in Table 1.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

In patients with eating disorders, early intervention and symptom improvement decrease the risk of a protracted course with long-term pathology.1,3,11,12,14,15,20,21

C

Observational studies and a meta-analysis of observational studies

Most patients with eating disorders receive optimal care in an outpatient setting. The outpatient care team should include an experienced therapist, a dietitian, and a clinician knowledgeable about eating disorder–specific medical evaluations.3,33

C

Expert opinion

Family-based therapy should be a first-line treatment for youths with anorexia nervosa and bulimia nervosa.1,3,17,34,36,39,41

A

Randomized controlled trials (patient-oriented outcome)

Medications should not be used as monotherapy in the treatment of anorexia nervosa or bulimia nervosa.17,34,37,45,47

B

Randomized controlled trials (limited-quality patient-oriented outcome)

Lisdexamfetamine (Vyvanse) can be effective in reducing binge-eating behaviors.38,46,50

B

Randomized controlled trials (patient-oriented outcome)

Contraceptives should be offered to patients with disordered eating who want to prevent pregnancy, but they have not been associated with improved bone mineral density and may mask resumption of menses.31,52,53

C

Randomized controlled trial (disease-oriented outcome) and a systematic review of observational studies

Caregivers and clinicians should focus on positive body image instead of weight or dieting to prevent disordered eating.5

C

Expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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DAVID A. KLEIN, MD, MPH, FAAFP, is the Chief of Medical Staff, 316th Medical Group, Joint Base Anacostia-Bolling, Washington, DC, and an associate professor in the Departments of Family Medicine and Pediatrics at the Uniformed Services University of the Health Sciences, Bethesda, Md....

JILLIAN E. SYLVESTER, MD, CAQ, FAAFP, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, an adjunct assistant professor in the Department of Family Medicine at Saint Louis University, and a member of the teaching faculty at the Southwest Illinois Family Medicine Residency at Saint Louis University.

NATASHA A. SCHVEY, PhD, is an assistant professor in the Department of Medical and Clinical Psychology at the Uniformed Services University of the Health Sciences, and a research collaborator for the Section on Growth and Obesity at the National Institutes of Health, Bethesda, Md.

Address correspondence to David A. Klein, MD, MPH, 316th Medical Group, Joint Base Anacostia-Bolling, 238 Brookley Ave. SW, Washington, DC 20373 (email: david.a.klein26.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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