BY JONATHAN CHEVINSKY, MD, NUTRITION AND PHYSICAL ACTIVITY COMMITTEE MEMBER
Dr. Jonathan Chevinsky
Eating disorders are a significant and often overlooked public health crisis, impacting nearly 30 million Americans at some point in their lives, with even higher rates among children and adolescents. Anorexia nervosa is commonly cited as the psychiatric condition with the highest overall mortality,
due to the combination of physical effects of starvation and comparatively high rates of suicide. Current estimates suggest that 10,000 deaths per year can be directly attributed to eating disorder pathology.
The statistics surrounding eating disorder pathology in minoritized groups are even more alarming. Although estimates suggest that around 75 percent of women with eating disorders will never
receive treatment, individuals who identify as Black, Indigenous, and other people of color (BIPOC) are half as likely to be diagnosed despite similar prevalence rates. Youth who identify as LGBTQIA+ are approximately three times more likely
to have an eating disorder compared to their heterosexual counterparts; moreover, transgender youth have around four times higher risk compared to cisgender youth. Given the magnitude
of this disparity, the key challenge for physicians in Massachusetts is determining the most effective way to address it. Familiarizing ourselves with eating disorders guidelines is an essential first step in recognizing when our patients
may need further assessment or treatment.
In terms of primary care assessment, the United States Preventive Services Taskforce (USPSTF)
on eating disorders concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for eating disorders in asymptomatic adolescents and adults. Still, they caution physicians to watch out for signs
and symptoms of eating disorders such as rapid weight changes or pronounced deviation from growth trajectory, pubertal delay, bradycardia, oligomenorrhea, and amenorrhea. However, the American Psychiatric Association’s (APA) Guideline Summary Statement for eating disorder assessment includes several recommendations for physicians and other clinicians. They recommend that any initial psychiatric evaluation should involve a screen for eating disorders. This would include an evaluation of the
patient’s recent height and weight history, patterns or changes in eating behavior and compensatory behavior, psychosocial impairment related to eating or body image, and personal and family history of eating disorders. They also recommend
vital signs and body mass index (BMI) measurement, with evaluation for signs of malnutrition or purging behaviors (e.g., callouses on knuckles or the back of the hand due to repeated purging behavior). If there is a possible eating disorder,
relevant laboratory monitoring would include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests. Due to the combination of structural, geographic, economic, and social
barriers, underserved communities are least likely to have access to psychiatric evaluations by specialist physicians. As such, primary care physicians should be aware of these screening standards, particularly in patients suspected of having
severe eating disorders.
simplehappyart /iStock/Getty Images.
Additionally, the APA offers more specific recommendations for the three most common eating disorders:
While barriers to care do exist for economically disadvantaged individuals, psychotherapy and generic medications in these classes are typically covered by MassHealth.
With the shortage of resources nationwide for eating disorder treatment, particularly for the disproportionately affected racial and sexual minority groups, more of an onus will fall on clinicians in the community for management of these disorders.
As such, APA guidelines recommend a “documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary
team.”
While eating disorders represent both a diagnostic and treatment challenge, clinical interventions and appropriate referrals to care can help address this challenge. If physicians, especially primary care physicians, focus on socioculturally sensitive
diagnosis and treatment, we can more effectively triage and refer patients to the appropriate treatment.
