Eating disorders facts
Eating disorder screener
What to say or not say
Medical stabilization criteria
How Does Equip Treatment Work?
A note from
Dr. Derenne and Dr. Hill
Rates of eating disorders have skyrocketed and hospital admissions for eating disorders have doubled since before the pandemic.1,2 Between the isolation of the pandemic, mental health struggles, and more social media exposure, adolescents are particularly vulnerable to developing eating disorder symptoms. Eating disorders are the second deadliest mental illness with a mortality rate of 4-5 percent.3 The good news, however: eating disorders are very treatable with early detection and proper treatment. Unfortunately, most medical schools and residency programs don’t provide adequate education on eating disorders.
Below you'll find educational materials and resources to help with appropriate screening, workups, and referral options for proper treatment. We welcome your feedback and questions so we can continue to improve – please don’t hesitate to reach out.
Katherine Hill, MD
VP, Medical Affairs
Jennifer Derenne, MD
VP, Clinical Care Delivery and Head Psychiatrist
Important Facts About Eating Disorders
- 30 million Americans (10% of the population) will be affected by an eating disorder in their lifetime 4
- 5 million Americans will develop an eating disorder this year 4
- 80% of Americans will never receive treatment and less than 20% of those will receive evidence-based treatment that works 5
- Eating disorders have the 2nd highest mortality rate of all mental illnesses, following opioid addiction 3
- Families don’t cause eating disorders but are critical in helping loved ones recover
- Eating disorders don’t have a “look” and affect people across genders, races, ages, ethnicities, and body sizes
How to Screen for Eating Disorders
A Guide for Primary Care Physicians
Signs in the history
- Changes in food intake and behavior: Food restriction, binging, new diets, wearing baggy clothing, avoiding family meal time, becoming vegetarian/vegan/gluten free, disappearing to bathrooms/showers after meals
- Overexercise or compulsive exercise: Is your patient exercising when sick, tired, or injured? Do they never take a day off?
- Physical complaints: Fatigue, hair loss, fainting or near-fainting spells, abdominal pain, constipation, cold hands and feet
- Mood changes: worsening depression or anxiety, poor concentration, irregular or absent menses
- Noticeable weight changes
- Temperament traits: perfectionism, overachievement
Clues in the growth chart, vital signs, and physical exam
- Rapid weight loss or weight gain can both be indicative of an eating disorder
- In growing children, slowed height velocity or falling off growth curve (regardless of where on BMI chart)
- Do vital signs suggest any medical instability?
- Common physical exam findings: bradycardia, alopecia, cold or bluish extremities, enamel erosion or enlarged parotid glands (signs of purging), lanugo, Russell sign (callous on knuckles from purging), decreased bowel sounds or palpable stool
How to Do a Medical Workup
Take a closed (formerly known as blind) weight
Weight numbers can be triggering for patients with eating disorders. We recommend weights are taken in a gown standing backwards on the scale.
Tip: Sometimes, patients with eating disorders may hide weights in their clothes, hair, or drink a lot of water to artificially increase their weight. If this is a concern, consider testing the patient’s urine – if it is very dilute, they might be water loading.
- The weight number should not be shared with the patient. Instead, discuss general trends – up, down, stable. A height should be obtained to calculate BMI.
Take orthostatic vital signs:
- Lie for 5 minutes: The patient should lie flat and still for 5 minutes – check and record heart rate and blood pressure
- Stand for 2 minutes: Patient should stand for 2 minutes – check heart rate and blood pressure
Baseline Labs & Screening Tests
When an eating disorder is suspected, the following labs are recommended for an initial workup:
1.CBC + differential
- It is common to see leukopenia, anemia, and thrombocytopenia in states of malnutrition due to bone marrow suppression or iron or vitamin deficiencies (B12, folate)
2.Comprehensive metabolic panel with magnesium and phosphorus
- Ensure potassium is > 3.5, magnesium is > 1.8, and phosphorus is > 3.0
- An elevated bicarbonate level may suggest purging behaviors
- AST and ALT can be elevated in states of malnutrition
3.TSH, Free T4, optional: Total T3
- A low T3 with normal TSH and Free T4 is not a problem with the thyroid, but a marker of malnutrition
4.Vitamin D 25-hydroxy
- If Vitamin D 25-hydroxy level is under 30, treat with ergocalciferol 50,000 I.U. once a week for 8 weeks
5.In bio females with irregular or absent periods: LH, FSH, estradiol
- LH, FSH, and estradiol are often suppressed in states of malnutrition – estradiol needs to be above 30 for regular menses
6.EKG: assess for arrhythmias, prolonged QTc, bradycardia
- Celiac disease screen if patient reports GI distress, bloating, fatigue, unexplained rashes
- PCOS screen, pregnancy test if irregular or absent periods
- Fecal calprotectin if significant GI distress to look for IBD (inflammatory bowel disease)
- If prolonged amenorrhea (>6-12 months) or significant fracture history: DXA scan to assess bone density
What To Say or Not Say
Language is Important
If you’ve noticed a patient has lost weight: It may be reinforcing to hear “wow, you look great, what have you been doing?” Instead, consider saying, “I’m noticing that your weight has changed since you were last here. Tell me what's been going on.”
Modeling body positive attitudes is important: When interacting with kids and teens, consider commenting on a bright smile, the sparkle in their eyes, or their excitement when they're passionate about something rather than focusing on image or appearance. Ask their opinions, be interested in their ideas, and make it clear who they are is more important than what they look like.
Don’t make disparaging comments about your own weight, shape, or eating habits. Be mindful about comments about food, body, and the messages they send.
Even the most well-intentioned conversations can have unintended consequences. Patients often share that they started restricting eating after feedback that their PCP was worried about their weight or shape. We encourage you to follow up with kids and teens shortly after such conversations to see if they are preoccupied by it.
Examples of what not to say:
- “Oh, I wish I had that, I have no self control around food.”
- “Wow, you look great, what have you been doing?”
- “Oh, I have to take a long run after work to make up for those cookies I ate at lunch.”
Examples of what to say instead:
- “I’m noticing that your weight has changed since you were last here. Tell me what has been going on.”
- “I had the most delicious cookie at lunch today. Do you have a favorite flavor?”
Criteria for Medical Stabilization
When your patient might need to be admitted
We recommend the Society for Adolescent Health and Medicine guidelines for determining if your patient may need admission for medical stabilization. If your patient meets any of the below criteria, please call your local children’s hospital or eating disorder medical unit for consultation:
- Bradycardia: heart rate < 50 beats per minute (daytime) or < 45 beats per minute (with sleep)
- Hypotension: blood pressure < 90/45
- Orthostatic increase in pulse (>20 beats per minute) or decrease in blood pressure (>20 mm Hg systolic or > 10 mm Hg diastolic) upon standing
- Severely low body weight (less than 75 percent of the median BMI for age), losing a large percentage of body weight rapidly, or precipitous fall off their growth chart line
- Potassium < 3.5, Phosphorus < 3.0, Magnesium < 1.8
- Prolonged QTc on EKG
How Does Equip Treatment Work
Equip’s care model was built on the foundation of Family-Based Treatment (FBT), the radical idea that families are best suited to help their loved ones through recovery; and then amplified with our 5-person care team.
Family-Based Treatment (FBT), built from the Maudsley Method, is the primary evidence-based model for lasting recovery in children and adolescents.6 In FBT, parents and guardians work with their care team to renourish their children and help eliminate eating disorder behaviors.
Phases of FBT
Phase I: Parents are tasked with renourishing their child: Focused on parent empowerment and alignment. Parents plan, prepare, and plate all meals and snacks with close monitoring by medical provider and planning with Registered Dietitian
Phase 2: Child begins to slowly and gradually regain independence under observation and supervision.
Phase 3: Child is eating independently, focus shifts to normal adolescent concerns.
Coordinated circle of care: FBT works, but it’s not easy. The provider team is there to support families through all of it. Each family has a dedicated five-person care team, including a peer mentor, family mentor, medical provider, therapist, and dietitian.
Virtual by Design: Treatment is 100% virtual so families (of all configurations) can help loved ones from the comfort of home.
The power of lived experience: Peer and family mentors know what it’s like to go through treatment. They’ll be there with emotional and practical support.
Empowering Families: FBT empowers families to be at the heart of their loved one’s treatment to make lasting recovery possible.
Patients Are Getting Better
After eight weeks of treatment, Equip families are well on their way to healing:
In the first 8 weeks
Average weekly weight gain for the 75% of Equip patients on weight restoration, meeting the gold standard
of patients report an increase in hope and recovery
of patients report a reduction in eating disorder symptoms
report improvements in mood
of patients with depression are no longer depressed
of parents report feeling more confident in caring for their child
- Asch DA, Buresh J, Allison KC, et al. (2021). Trends in US Patients Receiving Care for Eating Disorders…Before and During the COVID-19 Pandemic JAMA Netw Open, 4(11).
- Otto, A. K., Jary, J. M., Sturza, J., et al. (2021). Medical Admissions Among Adolescents With Eating Disorders During the COVID-19 Pandemic. Pediatrics, 148(4).
- Chesney E, Goodwin GM, Fazel S.(2014). Risks of all-cause and suicide mortality in mental disorders. World Psychiatry, 13(2).
- Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007).The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3).
- Hart, L., Granillo, M., Jorm, A. and Paxton, S. (201 Unmet need for treatment in the eating disorders. Clinical Psychology Review, 31(5).
- Loeb, K. L., LeGrange, D. (2009). Family-Based Treatment for Adolescent Eating Disorders. International Journal of Child Adolescent Health, 1–13.