Original Article: Eating Disorders in Primary Care: Diagnosis and Management
Issue Date: January 1, 2021
To the Editor: We want to thank Dr. Klein and colleagues for their article highlighting the crucial role that family physicians play in the early identification of eating disorders.
The authors did not discuss the effect of weight stigma on the development of eating disorders.1 One of the strongest risk factors for the development of an eating disorder is previous weight loss attempts.2,3 For patients who are not already struggling with an eating disorder, encouragement from a physician to pursue weight loss without careful consideration could contribute to the development of disordered behaviors, including bingeing, restriction, and purging. Therefore, when patients present to a primary care clinic with the goal of weight loss, screening for disordered eating thoughts or behaviors should be a top priority. Increasing physician awareness of the risks associated with recommending weight loss or dieting to patients is crucial.
The authors emphasized the importance of objective data (i.e., body mass index [BMI]) over validated screening tools (i.e., SCOFF questionnaire), citing concerns about self-report bias on survey instruments. Unfortunately, an overreliance on BMI is likely to result in physicians failing to detect the occurrence of eating disorders in patients with larger bodies. Evidence suggests that the higher a person's BMI, the greater the likelihood that they meet the criteria for an eating disorder.4,5 For this reason, a screening process that relies heavily on BMI is likely to miss the bulk of individuals in a primary care setting who would benefit the most from early identification and intervention. Further, clinicians often praise patients with larger bodies for behaviors (e.g., calorie counting) and mindsets (e.g., a goal weight) that would be considered problematic for other people. Diagnostic criteria for eating disorders that use BMI in the definition can be explicitly harmful to people with larger bodies, delaying diagnosis and treatment and inadvertently supporting symptomatic behaviors.
Family physicians have an essential role in the prevention and treatment of eating disorders and sub-diagnostic disordered eating behaviors. Physicians must also be aware of the role they could play in the development of eating disorders and consider incorporating evidence-based practices such as weight-neutral health promotion counseling.6
In Reply: We appreciate the comments from Dr. Westby and colleagues regarding two critically important concepts in the care of persons at risk of or diagnosed with eating disorders.
We agree that weight stigma is a critical risk factor for the onset and maintenance of eating pathology,1 and that dieting attempts increase the risk of eating disorders.2 Notably, weight stigma has been associated with increased vulnerability to mal-adaptive eating during the COVID-19 pandemic.3 Although a comprehensive exploration of the etiologic role of weight stigma in eating disorders was beyond the scope of our article, we advised clinicians to assess and confront weight stigma and discussed how praise for weight loss might result in or reinforce eating pathology. We also dedicated the final section to prevention (e.g., avoiding stigmatizing language, promoting acceptance of larger body sizes, emphasizing health instead of weight or appearance-related goals).
Dr. Westby and colleagues raise essential points about the prevalence of eating pathology in individuals with larger bodies, which clinicians may fail to assess or detect. We also highlighted the importance of analyzing anthropometric trends and percentile changes, ideally in graphic form, instead of absolute measurements.
Objective data alone without psychosocial history taking (e.g., through clinical interview, screening tools) can miss important diagnoses. However, the sensitivity of screening tools such as the SCOFF questionnaire varies across populations,4 and assessments of disordered eating may not be universally feasible or prioritized across clinical settings and visit types. Therefore, following the American Academy of Pediatrics' recent clinical report on eating disorders, we advocate for multifaceted assessment approaches that can be effectively implemented.5
The U.S. Preventive Services Task Force is currently assessing techniques and outcomes of screening for eating disorders in primary care settings.6 Until further data are available, we conclude that during clinical encounters, history should be corroborated when possible, objective findings systematically reviewed, and screening tools interpreted in context.
Primary care clinicians are on the front lines in promoting health, positive body image, and quality of life. Therefore, clinicians must be mindful of weight bias and associated distress, and harmful weight control behaviors.1,2 Clinical recommendations, particularly for individuals with disordered eating, body image concerns, high body weight, or weight loss attempts, must be articulated with sensitivity and precision. Additional resources about addressing weight bias can be found at https://www.obesityaction.org/action-through-advocacy/weight-bias/. We are grateful that the importance of nonstigmatizing, size-inclusive approaches is being highlighted in American Family Physician.