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Identifying people at risk of eating disorders

Early intervention depends on early detection of symptoms. Long delays in seeking treatment for eating disorders are related to poorer long‐term health and quality of life.

People with eating disorders often do not seek help, or only seek help after a long period of illness. There is an average delay of approximately 4 years between the start of disordered eating symptoms and first treatment, and this delay can be 10 or more years. A reduction of this delay can result in improved health and quality of life.

The majority of people with eating disorders have contact with health professionals but they do not specifically talk about their eating problems. This means that many people are not diagnosed with eating disorders at an early stage because they present with apparently unrelated complaints. Common health presentations include emotional problems, weight loss, and gastro-intestinal problems.

Research suggests that the most common first points of professional contact are GPs, and for younger people, school counsellors. People involved in sports may contact a physiotherapist for their injuries. Adults with eating disorders may contact a health professional for infertility treatment.

While people may not volunteer information about their eating problems, many people would welcome questions regarding their eating behaviour as a first step towards getting help.

Screening questions

Screening questions may help people to identify and talk about their body dissatisfaction or disordered eating with a health professional leading to earlier access to treatment.

Screening can be effective for eating disorders because:

  • Eating disorders are complex illnesses with serious consequences for health and quality of life
  • Early detection and intervention can reduce the severity and impact of the illness
  • High risk groups can be identified
  • Screening tests are available

Screening questions for eating disorders can be as simple as the five questions in the Eating Disorders Screen for Primary Care (ESP) and SCOFF screening tools. The questionnaires do not diagnose eating disorders but identify the possible presence of an eating disorder and when a more detailed assessment is warranted.

Eating Disorder Screen for Primary Care (ESP)

• Are you satisfied with your eating patterns? (A “no” to this question is classified as an abnormal response).

• Do you ever eat in secret? (A “yes” to this and all other questions is classified as an abnormal response).

• Does your weight affect the way you feel about yourself?

• Have any members of your family suffered with an eating disorder?

• Do you currently suffer with or have you ever suffered in the past with an eating disorder?

SCOFF

S – Do you make yourself Sick because you feel uncomfortably full?

C – Do you worry you have lost Control over how much you eat?

O – Have you recently lost more than 6.35 kg in a three-month period?

F – Do you believe yourself to be Fat when others say you are too thin?

F – Would you say Food dominates your life?

An answer of ‘yes’ to two or more questions indicates the need for a more comprehensive assessment.

A further two questions have been shown to indicate a high sensitivity and specificity for bulimia nervosa.

       1. Are you satisfied with your eating patterns?

       2. Do you ever eat in secret?

One study found that the best individual screening questions are:

       • Does your weight affect the way you feel about yourself?

       • Are you satisfied with your eating patterns?

(Cotton, Bell & Robinson, 2003)

Screening for high risk groups

Eating disorders occur in both males and females; in children, adolescents, adults and older adults; across all socio-economic groups; and from all cultural backgrounds. Within this broad demographic however there are some groups with a particularly high level of risk.

Based on the known risk factors for eating disorders, high risk groups who may benefit from screening for eating disorders include:

  • Adolescents
    The peak period for the onset of eating disorders is between the ages of 12 and 25 years, with a median age of around 18 years
  • Women, particularly during key transition periods: from school to adult life, pregnancy and menopause
    Targeting preventive interventions at women with high weight and shape concerns, a history of critical comments about eating weight and shape, and a history of depression may reduce the risk for eating disorders
  • Women with Polycystic Ovary Syndrome or Diabetes
    Adolescents with diabetes may have a 2.4-fold higher risk of developing an eating disorder, particularly Bulimia Nervosa and binge eating, than their peers without diabetes. Polycystic Ovary Syndrome is associated with body dissatisfaction and eating disorders. Screening for abnormal eating patterns is recommended.
  • Athletes and people engaged in competitive fitness, dance and other physical activities where body shape may be perceived as affecting performance
  • People with a family history of eating disorders
    There is evidence that eating disorders have a genetic basis and people who have family members with an eating disorder may be at higher risk of developing an eating disorder themselves.
  • People seeking help for weight loss
    Eating disorders almost invariably occur in people who have engaged in dieting or disordered eating. Weight related risk factors for eating disorders include:
    • Higher BMI – current or in childhood
    • Body dissatisfaction with high weight and shape concerns
    • Dieting
    • Exposure to appearance based criticism (bullying, teasing)
    • Internalization of the thin ideal (unrealistic appearance goals)

Eating disorders in males

A focus on specific groups at high risk should not distract from the prevalence of eating disorders in other populations. In particular, there is growing awareness of eating disorders occurring amongst males. Current research suggests that males make up approximately 25% of people with anorexia or bulimia and 40% of people with binge eating disorder. In a recent study lifetime prevalence for anorexia nervosa in adolescents aged 13 – 18 years found no difference between males and females.

The number of males may be underrepresented in clinical samples, because in comparison to females, men are less likely to seek help, and more likely to be misdiagnosed with other mental health problems.

One unique difference between males and females with eating disorders is that men more typically engage in compulsive exercise as a compensatory behaviour, “meaning that male eating disorders may be oriented towards the acquisition of muscularity and not exclusively towards the pursuit of a more slender body”.

Screening for excessive exercise

Compulsive exercise describes a rigid, driven urge to exercise. This is a serious health concern that often requires the intervention of someone close to the individual, such as a family member, friend or coach who recognises these warning signs and encourages professional help.

The CET is a screening questionnaire of 24 questions (1 page) which asks people to rate their own behaviour and emotions in relation to exercise. The CET can be used with adolescents.

For more information on compulsive exercise please read the following article from the NEDC Clearinghouse:

Exercise in the Eating Disorders: Terms and Conditions
Compulsive exercise: The role of personality, psychological morbidity, and disordered eating
Sports-related correlates of disordered eating in aesthetic sports

Mental Health First Aid

For professionals who do not have a background in working with people with eating disorders, the Mental Health First Aid guidelines may provide useful starting place to support recognition and safe responses to people who are developing or experiencing an eating disorder. The guidelines provide an evidence based set of general recommendations about how you can help someone who is developing or experiencing an eating disorder.

Mental Health First Aid Guidelines

First Aid for Eating Disorders Article

Risk and early identification - information on the NEDC website

The following resources and links may be of interest:

Who is really at risk? Identifying risk factors for subthreshold and full syndrome eating disorders in a high-risk sample

Barriers to help seeking in young women with eating disorders: a qualitative exploration in a longitudinal community survey

Eating disorder risk factors

References

Cotton, M.A., Ball, C. and Robinson, P. (2003) Four Simple Questions Can Help Screen for Eating Disorders. Gen Intern Med. 2003 January; 18(1): 53–56.

Evans, E.J., Hay, P.J., Mond, J., Paxton, S.J., Quirk, F., Rodgers, B., Jhajj, A.K, and Sawoniewska, M.A. (2011) Barriers to help seeking in young women with eating disorders: a qualitative exploration in a longitudinal community survey. Eat. Disord. May 2011; 19 (3): 270-285

Fursland, A., Allen, K. L., Watson, H., & Byrne, S. M. (2010). Eating Disorders – not just an adolescent issue? Australia and New Zealand Academy of Eating Disorders (ANZAED) 8th Annual Conference, Auckland, New Zealand.

Goodwin H, Haycraft E, Taranis L, Meyer C. (2011) Psychometric evaluation of the compulsive exercise test (CET) in an adolescent population: links with eating psychopathology. European Eating Disorders Review. Special Issue: Special edition on compulsive exercise, Volume 19, Issue 3, pages 269–279, May/June 2011

Hay PJ, Mond J, Buttner P, Darby A (2008) Eating Disorder Behaviors Are Increasing: Findings from Two Sequential Community Surveys in South Australia. PLoS ONE 3(2): e1541.

Himelein, M.J., and Thatcher, S. (2006) Polycystic Ovary Syndrome and Mental Health: A review. Obstetrical and Gynecological Survey, Volume 61, Number 11

Jacobi, C. & Fittig, E. (2010). Psychosocial risk factors for eating disorders. In Agras, W.S. (Ed.), Oxford Handbook of Eating Disorders. Oxford University Press: N.Y.

Jacobi, C., Fittig, E., Bryson, S.W., Wilfley, D., Kraemer H. C. and Taylor C. B. (2011) Who is really at risk? Identifying risk factors for subthreshold and full syndrome eating disorders in a high-risk sample. Psychological Medicine 41, 1939–1949.

Luck, A.J., Morgan, J.F., Reid, F., O'Brien, A., Brunton, J., Price, C., Perry, L., Lacey, J.H. (2002), ‘The SCOFF questionnaire and clinical interview for eating disorders in general practice: comparative study’, British Medical Journal, 325,7367, 755 - 756.

Mangweth-Matzek B, Rupp CI, Hausmann A, Assmayr K, et al. (2006). Never too old for eating disorders or body dissatisfaction: A community study of elderly women. International Journal of Eating Disorders 39(7):583-586.

Newton, M. S., & Chizawsky, L. L. K. (2006). Treating vulnerable populations: The case of eating disorders during pregnancy. Journal of Psychosomatic Obstetrics & Gynecology, 27(1), 5–7.

Pereira, R. F., & Alvarenga, M. (2007). Disordered Eating: Identifying, Treating, Preventing, and Differentiating It From Eating Disorders. Diabetes Spectrum, 20(3), 141-148.

Swanson, S.A., Crow, S.J., Le Grange, D., Swendsen, J. and Merikangas, K.R. (2011) Prevalence and Correlates of Eating Disorders in Adolescents Results From the National Comorbidity Survey Replication Adolescent Supplement. ARCH GEN PSYCHIATRY/VOL 68 (NO. 7), July 2011

Taranis L, Touyz S, Meyer C. (2011) Disordered eating and exercise: development and preliminary validation of the compulsive exercise test (CET). Eur Eat Disord Rev. 2011 May-Jun;19(3):256-68.

William Jones, John Morgan, (2010) "Eating disorders in men: a review of the literature", Journal of Public Mental Health, Vol. 9 Iss: 2, pp.23 – 31

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