Issue 55 | Theory and Practice: Screening and Assessment Tools for Eating Disorders
About this resource
Theory and Practice: Screening and Assessment Tools for Eating Disorders
Welcome to this edition of the NEDC e-Bulletin, where we delve into the NEDC’s recent and upcoming collaborations with local PHNs and then examine different practical screening and assessment tools to help you detect the possible presence of an eating disorder.
In early June this year, over 180 health care practitioners, academics and people with a lived experience converged on Sydney for the 2018 NEDC Members’ Meeting, which took place under the theme of “Eating Disorders in Primary Care”.
Over two days, participants listened to and engaged in a series of professional development, standards and integrated approaches sessions presented by passionate and knowledgeable guest speakers and experts in the field.
Power Point Slides of presentations from both days are now available on the NEDC website at: https://www.nedc.com.au/professional-development/e-learning/show/28/nedc-members
Please feel free to share these valuable new online resources, while respecting the authors’ copyrights.
Day 1 of these sessions will also soon be available as E-Learnings in the form of curated video footage, accessible on the NEDC website – watch this space.
A key objective of the NEDC is to develop and maintain a nationally consistent approach to the prevention, early intervention and management of eating disorders. In order to achieve this objective, the NEDC engages and supports a collaboration of key stakeholders, develops intersectoral and interdisciplinary coordination and evidence sharing on eating disorders, and fosters professional learning.
As such the NEDC is delighted to be working in collaboration with Primary Health Networks (PHNs) across the country to disseminate information and resources to increase awareness of safe evidence based practices in professional groups, families, young people and the general community.
Some of the recent and current collaborations include:
1) Murrumbidgee Primary Health Network
During the last week of July over 60 people attended three sessions on “Addressing Eating Disorders: An Introduction for Health Professionals” in Leeton, Wagga and Deniliquin.
The workshops were conducted by the NEDC and the Murrumbidgee PHN in collaboration with the local Eating Disorder coordinator for the Murrumbidgee Local Health District (MLHD). Sessions covered: Signs & Symptoms; Common Misconceptions; Screening & Management; Treatment Options; Working with Carers, Families and Friends; Recovery & Essential Elements of Care; Referral Pathways & Support Services.
2) Northern Queensland Primary Health Network (NQPHN)
On 1-2 September, Northern Queensland PHN is hosting the My PHN Conference 2018, under the theme “Connecting our health care together”. The NEDC will also be presenting at the conference on the topic of “Developing competency to identify, respond, and support clients with eating disorders”.
The NEDC is delighted to be returning and participating again in the myPHN conference to freely provide the primary care workforce with evidence based resources and tools to support professional development practice, and professional and service development.
3) South Western Sydney Primary Health Network (SWSPHN)
As the NEDC continues to engage with Primary Health Networks throughout Australia, we look forward to collaborating with the South Western Sydney PHN and other local service providers to present the workshop: “Addressing Eating Disorders in General Practice: an Introduction”. The workshop will take place on 16th October in Fairfield, Sydney.
Please keep an eye on the “Upcoming Events” section of our website for this and other relevant events in your region.
For further information or to enquire about activities in your local PHN please contact us at: firstname.lastname@example.org
It’s a recurring question at any workshop introducing eating disorders for health professionals: How do we know that someone has an eating disorder? If we suspect someone has an eating disorder, what is the next step?
In other words, how can we be helpful in practice, how do we implement the practical aspects of the theories discussed or known?
Screening and assessment tools are particularly vital as early intervention depends on early detection of symptoms. There is an average delay of approximatively 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 for the person you are caring for.
The delay in the commencement of treatment can be for a number of reasons. We do know the majority of people with eating disorders have contact with health professionals. They present with apparently unrelated complaints and do not disclose their eating problems. While people may not volunteer information about their eating problem, asking questions and allowing the person to see that their eating habits are important may offer a non-judgemental environment for them to start seeking help.
For many people with eating disorders, their first attempt at seeking treatment is a test of attitudes and responses from the health professional. If the first help seeking is a positive experience then the person is more likely to engage successfully with future treatment.
Common health presentations include:
• emotional problems
• weight loss
• gastro-intestinal problems
• infertility issues
• injuries caused by overexercising
• fainting or dizziness
• feeling fatigued or not sleeping well
• feeling cold most of the time regardless of the weather
• swelling around the cheeks or jaw, calluses on knuckles, damage to teeth and bad breath (signs of vomiting).
The full list of the physical, psychological and behavioural warning signs of an eating disorder is available under the Mental Health First Aid Guidelines:
Screening questions help to initiate a certain level of disclosure which may then lead to earlier access to treatment for individuals with eating disorders (Gilbert et al., 2012). Screening for eating disorders involves asking a small number of evidence based questions posed on an opportunistic basis when the patient presents for other reasons (e.g. weight related concerns, depression or anxiety). The questionnaires do not diagnose eating disorders but detect the possible presence of an eating disorder and identify when a more detailed assessment is warranted. Screening questions can be used by many different professionals, including teachers, sports and fitness professionals, mental health practitioners and other health care professionals in primary care.
Examples of screening questions:
An effective and commonly used tool for screening eating disorders is SCOFF. It is not prescriptive and does not have to be read out word for word.
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. For further details regarding this, see the RANZCP Treatment Guidelines.
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?
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?
Cotton, Ball & Robinson, 2003 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?
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 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: People engaged in competitive fitness, dance and other physical activities where body shape may be perceived as affecting performance have a high level of risk of eating disorders.
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.
Eating disorders in males
Population studies have suggested 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.
One unique difference between males and females with eating disorders is that men more typically engage in compulsive exercise as a compensatory behaviour, often with the aim of achieving a more muscular, and not just slender, body type. Compulsive exercise describes a rigid, driven urge to exercise, which is a serious health concern.
The Compulsive Exercise Test (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. You can download the CET at:
Physical assessment can also be useful in the identification of compulsive exercise.
Patients must be screened for physical health risks and risk of suicide. Medical stabilization, where required, must be provided before or simultaneously with other interventions. Eating disorders can impair a person’s insight and ability to make informed decisions. Decisions regarding treatment must always take into consideration the person’s capacity to make decisions for their own safety.
When taking the patients general history and conducting physical examinations assess their general state (eg. well/unwell), alertness/somnolence, height and weight history, disproportion in weight for height (>1standard deviation apart), menstruation pattern/menstrual history, hydration (tongue, lips, skin, sunken eyes), ketones on breath, deep, irregular, sighing, breathing seen in ketoacidosis, temperature <36°C, pulse rate <60 beats per min, regular or irregular, BP – lying and standing (postural drop in BP > 20mmHg), limbs – peripheral circulation, cold peripheries, ankle oedema, abdomen scaphoid, symptoms of electrolyte disturbance (thirst, dizziness, fluid retention, swelling of arms and legs, weakness and lethargy, muscle twitches and spasms) and alkaline urinary pH.
More information about medical assessments can be found in the resource ‘Eating Disorders: An Information Pack for General Practitioners’ produced by The Eating Disorders Association Inc (Qld)
Eating Disorders: A Professional Resource for General Practitioners (NEDC)
Therapist adherence to family-based treatment for adolescents with anorexia nervosa: A multi-site exploratory study.
OBJECTIVE: This exploratory study is the first to examine family-based treatment (FBT) adherence and association to treatment outcome in the context of a large-scale, multi-centre study for the treatment of adolescents with anorexia nervosa.Read more
Effects of starvation and short-term refeeding on gastric emptying and postprandial blood glucose regulation in adolescent girls with anorexia nervosa.
Postprandial glucose is reduced in malnourished patients with anorexia nervosa (AN), but the mechanisms and duration for this remain unclear.Read more
Oral mucosal lesions in Anorexia Nervosa, Bulimia Nervosa and EDNOS.
OBJECTIVES: The aim of this study is to describe oral lesions in patients with eating disorders (ED), including Anorexia Nervosa (AN), Bulimia Nervosa (BN) and eating disorders not otherwise specified (EDNOS).Read more
Neurosurgical treatment of anorexia nervosa: Review of the literature from leucotomy to deep brain stimulation
This paper reviews the literature on the surgical treatment of refractory anorexia nervosa (AN) and examines how this literature can inform current circuit models of the disease.Read more