Early Detection and

Intervention in the
Treatment of Eating
Disorders

Haley Lauren Hamschin

Pennsylvania State University | College of the Liberal Arts

Introduction
Eating disorders are complex biopsychosocial illnesses that emerge in response to a variety of
genetic and environmental influences. In any given year, an estimated five to eight million
Americans suffer from a clinically significant eating disorder and research has found that
approximately 13.2% of females will meet the criteria for a DSM-5 eating disorder by age 20.1
The National Eating Disorders Association (NEDA) cites “[a]norexia [as] the third most common
chronic disease among young people, after asthma and type 1 diabetes.”2 Unfortunately, many
individuals, including family members, educators, and medical professionals fail to recognize
that eating disorders can affect individuals of any age, race, gender, ethnicity, or body type. 3
Former Penn State football player, Joey Julius, One Direction band member, Zayn Malik, and
actress, Zoë Kravitz, are examples of people who do not reflect the eating disorder stereotype.
While it is helpful for people to see that eating disorders can affect anyone, that is only one
piece of the puzzle – there is still much to be done in the pursuit to identify, understand, and
manage these conditions.

Common Misconceptions
Despite an increase in public conversation, eating disorders remain widely misunderstood.
When discussing the different types of eating disorders, people often think the manifestations
are classified into two diagnoses: anorexia and bulimia nervosa. However, OSFED, or Otherwise
Specified or Feeding or Eating Disorders makes up 70% of all eating disorder diagnoses. 4
Despite having the highest mortality rate of all types of eating disorders, the severity of OSFED
is often overlooked because sufferers may not “look” sick.5 People as a whole struggle to
understand that OSFED “catch-all” diagnosis serves to classify eating disorders that may not fit
into one clear-cut category, such as atypical anorexia or purging disorder.6

At times, the behaviors that lend themselves to an OSFED diagnosis are described as
“subclinical,” which is misleading to the general public and medical professionals alike –
“subclinical” is not to be confused for less significant. The American Academy of Pediatrics
cautions providers to treat OSFED just as seriously as anorexia or bulimia nervosa – if a person
is experiencing rapid weight loss but is at or above a normal weight, that does not negate the
severity of the condition nor does it eliminate the risk for serious medical consequences. 7
Eating disorders can be deadly regardless of size.

Problematic Oversight
Since many patients with eating disorders are suffering from OSFED, binge eating disorder, or
another condition that does not fit the clear-cut criteria for one of the better understood

1
diagnoses of anorexia or bulimia, their symptoms are often overlooked or dismissed by medical
professionals. Eating disorder survivor, Grace Moloney, is one of many individuals who feel that
they have been failed by the medical community. In a written account of her experiences, she
expresses her frustrations: “[y]ou are misdiagnosed, unheard, told [the eating disorder is] a
phase… You are told time and time again that you’re not sick enough, not thin enough, not
ready, not brave, not worthy, not yet. That you have to wait. Then it’s eight months later and
you’re worse than ever.”8 She argues that this oversight is not an act of intentional ignorance,
but rather a product of inadequate professional training.9 With eating disorders, medical
complications may not appear in the initial stages of the illness.10 Patients need to be
monitored, both medically and psychologically, throughout the entire treatment process.11
Without intervention, the health consequences of eating disorders can be fatal. 12

When treating patients with eating disorders, it is important to be aware that a myriad of
medical complications may arise. Restriction can cause muscle breakdown, and consequently
heart damage, as well as number of gastrointestinal issues, neurological problems, and
endocrine changes.13 Self-induced vomiting can cause electrolyte imbalances that, if not
checked at regular intervals, can be fatal.14 Individuals who suffer from eating disorders for an
extended period of time may suffer from dehydration, amenorrhea, decreased bone density,
hair loss, and ultimately, organ failure.15 While there is not yet a way to eradicate the eating
disorder epidemic, prevention and intervention efforts could decrease the prevalence of the
condition and improve outcomes for those with eating disorder symptomology. With early
detection and appropriate intervention, full recovery is possible.16

Challenges Associated with Preventative Measures

The National Eating Disorders Association defines ‘prevention’ as “any systematic attempt to
change the circumstances that promote, initiate, sustain, or intensify problems like eating
disorders.”17 Prevention efforts can help shape people’s knowledge of eating disorders as well
as their attitudes about food, body image, exercise, and factors that influence their perception
of the world around them.18 It is broken down into three types: universal, selective, and
targeted prevention.19 Universal prevention is designed to reach as many people as possible in a
population with the goal of gaining attention about an important issue and initiating change. 20
While there is a lack of research surrounding the effectiveness of this approach, advocates for
eating disorder awareness would argue that eating disorders do not receive adequate attention
given their prevalence, making universal prevention efforts a suitable avenue to begin reaching
people. Selective prevention has been proven to be slightly more effective than universal
efforts as it encompasses efforts focused on at-risk populations, such as those with family
histories of disordered eating and female athletes participating in aesthetic sports, such as
dance, gymnastics, diving, and figure skating who do not yet display eating disorder

2
symptomology.21 However, targeted prevention, which aims to stop existing eating disorder
behaviors or body image distress from intensifying in severity, has been found to be the most
effective ways to manage eating disorders.22 This type of approach focuses on working with one
individual, identifying the problem early, and guiding them through the traditional recovery
process.23 While it is classified as a type of prevention, a targeted approach encompasses the
traditional steps of intervention, thus contributing to its effectiveness.

Despite some evidence of success with a variety of prevention efforts, the National Eating
Disorders Association explains that “[m]uch more research is needed concerning prevention.” 24
There is, however, a greater likelihood of a person fully recovering with early intervention. 25
Joanna Kay, an eating disorder survivor, advocates for early detection and intervention
procedures in primary medical care, “[w]e know that early medical interventions save lives.
Cancer that is caught at stage 1 has a better prognosis than a cancer that isn’t discovered until
stage 4. Treating a localized infection is much simpler than chasing it through the body after it
has spread to the bloodstream.”26 The same goes for eating disorders – professionals in the
field have seen that early intervention decreases the length of time a person suffers the
severity of the condition, and the likelihood of long-term or irreversible health consequences.27
For example, a study discussed by the National Eating Disorders association shows that “when
adolescents with anorexia nervosa are given [treatment] within the first three years of the
illness onset they have a much greater likelihood of recovery.”28

Need for Physician Education

Because eating disorders commonly affect adolescents and young adults, primary care
pediatricians are often the first to encounter individuals presenting with eating disorders and
should be able to conduct clinical assessments if they feel capable.29 However, “[a] 2015 study
of Family medicine, Internal medicine, Psychiatry (general, child, and adolescent) and Pediatrics
residency programs revealed that less than 10% included specific training on eating
disorders.”30 This lack of training is a disservice to physicians and patients alike – physicians may
be in a position where they feel ill-equipped to handle patients with eating disorders which in
turn inhibits patients from receiving proper care. Outside referrals are always an option,
however, with inadequate training, medical professionals may struggle to identify eating
disorders such as OSFED, binge eating disorder, and diabulimia, all of which differ from the
stereotypical presentation of the condition.

Physicians, especially primary care pediatricians who are often faced with adolescents and
young people in the early stages of their eating disorders, need adequate training to be
effective health care providers.31 The Australian Department of Health and Human Services has
seen success with efforts to train physicians based on approaches proposed by ‘Operation EAT,’

3
an early intervention and treatment program through the Victorian Centre of Excellence in
Eating Disorders.32 Operation EAT proposes that physicians complete continuing eating disorder
education through active learning modules, in-person or remote seminars, practice visits, and
conferences.33 Much like the Australian Department of Health and Human Services, the
American Academy of Pediatrics would benefit from requiring practicing physicians to
participate in continuing education at regular intervals throughout the year. Additionally, the
International Association of Eating Disorders Professionals offers a specialized training program
that physicians can complete to become Certified Eating Disorders Specialists (CEDS).34 Though
it would be unrealistic to expect every pediatric primary care physician to have specialized
training in the treatment of eating disorders, the importance of having at least one CEDS in
every private practice and several within a hospital or larger healthcare system is significant.
When educated appropriately, pediatricians can serve a vital role in the medical stabilization
and continued monitoring of patients with eating disorders.

Methods of Assessment
When faced with a potential eating disorder, pediatricians must complete a comprehensive
examination, screening patients both physically and psychologically for eating disorder
symptomology.
Recording a
patient’s vitals,
height and weight
in a gown,
orthostatic blood
pressures,
menstrual history,
and 24-hour food
history would be an
effective way to
begin the physical
examination,
however, physicians
need to be aware that Figure 135

a lack of medical evidence does not necessarily correlate to the absence of an eating disorder. 36
It is known that “[a]lthough weight may be associated with certain eating disorders, clinically
significant disordered eating behaviors may be present across the weight spectrum” and “[t]he
outside rarely tells the full story.”37 Because of the often invisible nature of these conditions,
the psychological component of the assessment needs to include insight into a patient’s

4
exercise habits, attitudes about body and food, eating disorder behaviors, and overall mental
stability.38 Ideally, this conversation should allow the pediatrician to conduct a psychosocial
assessment, which “should include an evaluation of the patient’s degree of obsession with food
and weight, understanding of the diagnosis, and willingness to receive help; an assessment of
the patient’s functioning at home, in school, and with friends; and a determination of other
psychiatric diagnoses (such as depression, anxiety, and obsessive-compulsive disorder), which
may be comorbid with or may be a cause or consequence of the eating disorder.” 39 In
conducting the psychological component of the eating disorder screening, experts encourage
physicians to screen the patient both with and without parents in the room because it could be
helpful to speak with parents in the event that the child is not being truthful, however, there
are instances where parents may be in denial as well.40 When interviewing parents as part of
the screening process, it is important to observe reactions to the subject because in the event
that an eating disorder is present, parent attitudes towards the situation will influence
subsequent steps of intervention.41

Research has shown

that, when treating
adolescents and young
adults, self-report
screenings are an
effective way to obtain
information about
potential eating
disorders prior to or in
conjunction with a
comprehensive
assessment.42
Adolescent
psychiatrist, Dr. Rachel
Figure 243
Zuckerbrot, explains
that “[t]eenagers are often more honest [about their mental health] when they're not looking
somebody in the face who's asking questions.”44 These types of diagnostic measures, which can
be administered both on paper and electronically, give adolescents the opportunity to answer
questions about themselves in a private, low-pressure environment where they can be truthful
about their internal experiences.45 As for the detection of eating disorders, there are currently
two commonly used self-report screenings: the SCOFF questionnaire and the Eating Attitudes
Test.46 The SCOFF Questionnaire is a brief survey that allows providers to get a general idea of a
patient’s attitudes about food and body image while the Eating Attitudes Test is a 26 question
screening that goes in-depth about specific eating-disordered behaviors.47 If looking to utilize

5
self-reports during yearly physicals, pediatricians would benefit from employing the SCOFF
Questionnaire when assessing at-risk populations and the Eating Attitudes Test with patients
who have a clinically significant SCOFF score or exhibit warning signs of a potential eating
disorder.48

Summary
Eating disorders are complex biopsychosocial illnesses that affect a significant proportion of the
adolescent and young adult population.49 These conditions have the highest mortality rate of
any type of mental illness as young people with eating disorders are ten times more likely to die
than their same-age peers.50 It is important to understand that all types of eating disorders can
be fatal, regardless of weight or physical appearance, and need to be treated with a
combination of medical, nutritional, and psychological intervention meausres.51 Research has
shown that early detection and intervention are crucial to minimizing medical consequences
and shortening the recovery process.52 Pediatricians, when appropriately educated, can serve
an important role in the identification and treatment of eating disorders in young people – with
early detection and proper treatment, full recovery is possible.53

6
Endnotes
1 17
Anorexia Nervosa & Related Eating Disorders, National Eating Disorders Association,
“Statistics: How Many People Have Eating “Prevention,” available at
Disorders?” available at https://www.nationaleatingdisorders.org/learn/gen
https://www.anred.com/stats.html (last accessed eral-information/prevention (last accessed April
April 2018); National Eating Disorders Association, 2018).
18
“Statistics & Research on Eating Disorders,” available Ibid.
19
at Ibid.
20
https://www.nationaleatingdisorders.org/statistics- Ibid.
21
research-eating-disorders (last accessed April 2018). Ibid.
2 22
National Eating Disorders Association, “Statistics & Ibid.
23
Research on Eating Disorders.” Ibid.
3 24
National Eating Disorders Association, “Nine Truths Ibid.
25
about Eating Disorders,” available at Joanna Kay, “Early Intervention Could Have
https://www.nationaleatingdisorders.org/blog/nine- Rewritten My Eating Disorder Story,” Proud 2B Me,
truths-about-eating-disorders (last accessed April National Eating Disorders Association, available at
2018). http://proud2bme.org/content/early-intervention-
4
Walden Eating Disorders Treatment, “What is could-have-rewritten-my-eating-disorder-story (last
OSFED?” available at accessed April 2018).
26
https://www.waldeneatingdisorders.com/what-is- Ibid.
27
osfed/ (last accessed April 2018). Ibid.
5 28
National Eating Disorders Association, “Statistics & Megan Jones and Tess Brown, “Why Early
Research on Eating Disorders.” Intervention for Eating Disorders Is Essential,”
6
Walden Eating Disorders Treatment, “What is National Eating Disorders Association Blog, National
OSFED?”; American Academy of Pediatrics, Eating Disorders Association, available at
“Identifying and Treating Eating Disorders,” https://www.nationaleatingdisorders.org/blog/why-
American Academy of Pediatrics 111 (1) (2003): 204- early-intervention-eating-disorders-essential (last
211, available at accessed April 2018).
29
http://pediatrics.aappublications.org/content/111/1 American Academy of Pediatrics, “Identifying and
/204 (last accessed April 2018). Treating Eating Disorders,” 204-211.
7 30
American Academy of Pediatrics, “Identifying and Erin Horan, “10 things every pediatrician should
Treating Eating Disorders,” 204-211. know about eating disorders,” Boston Children’s
8
Grace Moloney, “How The System is Failing Eating Hospital’s Clinical Health Blog, Boston Children’s
Disorder Patients,” Beating Eating Disorders, Hospital, available at
available at https://notes.childrenshospital.org/10-things-every-
http://beatingeatingdisorders.com/2018/03/05/syst pediatrician-should-know-about-eating-disorders/
em-failing-eating-disorder-patients/ (last modified (last modified October 12, 2016).
31
March 5, 2018). Jones and Brown, “Why Early Intervention for
9
Ibid. Eating Disorders Is Essential.”
10 32
American Academy of Pediatrics, “Identifying and The Victorian Centre of Excellence in Eating
Treating Eating Disorders,” 204-211. Disorders, “Model for Early Intervention and
11
Ibid. Integrated Solutions in Eating Disorders,” available
12
National Eating Disorders Association, “Health at
Consequences,” available at http://www.ceed.org.au/sites/default/files/resource
https://www.nationaleatingdisorders.org/health- s/documents/Approach%20to%20Early%20Intervent
consequences (last accessed April 2018). ion%20in%20Eating%20Disorders%20for%20PHNs.p
13
Ibid. df (last accessed April 2018).
14 33
Ibid. Ibid.
15 34
Ibid. International Association of Eating Disorders
16
National Eating Disorders Association, “Nine Professionals Foundation, “CEDS Checklist for
Truths about Eating Disorders.” Traditional Certification,” available at
http://www.iaedp.com/upload/Certification/Overvie

7
w/Traditional/02_Traditional_CEDS_Checklist_12.pd Golden, “Eating disorders in children, adolescents,
f (last accessed April 2018). and young adults.”
35 42
Susanne P Martin, MD and Neville H Golden, MD, Allison Aubrey, “Pediatricians Call For Universal
“Eating disorders in children, adolescents, and young Depression Screening For Teens,” National Public
adults,” Contemporary Pediatrics, Modern Medicine Radio, available at
Network, available at https://www.npr.org/sections/health-
http://contemporarypediatrics.modernmedicine.co shots/2018/02/26/588334959/pediatrians-call-for-
m/contemporary-pediatrics/content/tags/anorexia- universal-depression-screening-for-teens (last
nervosa/eating-disorders-children-adolescents-and- updated February 26, 2018).
43
youn?page=full (last updated June 1, 2014); Martin and Golden, “Eating disorders in children,
Moloney, “How The System is Failing Eating Disorder adolescents, and young adults.”
44
Patients.” Aubrey, “Pediatricians Call For Universal
36
Ibid. Depression Screening For Teens.”
37 45
Dawn M. Eichen, PhD and Denise E. Wilfley, PhD, Ibid.
46
“Diagnosis and Assessment Issues in Eating Martin and Golden, “Eating disorders in children,
Disorders,” Psychiatric Times 33 (5), Modern adolescents, and young adults.”
47
Medicine Network, available at Ibid.
48
http://www.psychiatrictimes.com/special- Ibid.
49
reports/diagnosis-and-assessment-issues-eating- National Eating Disorders Association, “Nine
disorders (last updated May 26, 2016); Kay, “Early Truths about Eating Disorders.”
50
Intervention Could Have Rewritten My Eating National Eating Disorders Association, “Statistics &
Disorder Story.” Research on Eating Disorders.”
38 51
Martin and Golden, “Eating disorders in children, National Eating Disorders Association, “Nine
adolescents, and young adults.” Truths about Eating Disorders.”
39 52
American Academy of Pediatrics, “Identifying and Megan Jones and Tess Brown, “Why Early
Treating Eating Disorders,” 204-211. Intervention for Eating Disorders Is Essential.”
40 53
Ibid. National Eating Disorders Association, “Nine
41
American Academy of Pediatrics, “Identifying and Truths about Eating Disorders.”
Treating Eating Disorders,” 204-211; Martin and