You are a health care provider — an emergency room doctor, a pediatric nurse practitioner, a physician assistant. You meet a young woman whose partner found her unresponsive after vomiting, an adolescent boy training for his school’s track team and not meeting growth targets, or a man prescribed a weight loss medication who now isolates himself due to strict food rules.
When we hear these scenarios, one of our first thoughts is “potential eating disorder.” But if you’re like most medical professionals globally, you have little to no training in eating disorders. You might not consider an eating disorder diagnosis, suspect one but be unsure what to ask, or worry about asking something the “wrong” way.
These situations are too common. Medical providers, not mental health professionals, are often the first — and sometimes only — stop for patients with eating disorders.
As eating disorders specialists, we wholeheartedly believe that all medical providers can deliver the fundamentals of good care for these patients. We also understand that non-specialists may not feel up to the task, and for good reason. Most residency programs and medical schools lack clinical training or classroom learning on eating disorders. Across medicine, nursing, and even nutrition, students and professionals say they are not as prepared as they would like.
More training has long been essential. However, the Covid-19 pandemic’s toll on mental health corresponded to a worldwide uptick in eating disorders. The impact was greater than on other mental health conditions, such as anxiety or depression, and highest among teenagers, a generation already experiencing a mental health crisis. More people are showing up across treatment settings than ever before, but misconceptions about who gets eating disorders remain widespread and lead to delays in diagnosis and care.
Fixing the problem requires creativity, humility, and fortitude.
To overcome barriers that traditionally siloed experience and expertise, let’s meet learners where they tend to seek out information: online. Several research groups, including ours, are at work on this. A brief video training created by the Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED) at the Harvard T.H. Chan School of Public Health improved screening and referral in pediatricians. Our freely available curriculum, PreparED (available in both English and Spanish), offers short, standalone modules, and it improved knowledge and attitudes in nurse practitioners and nutrition trainees. Australia’s InsideOut Institute developed The Essentials, a virtual program reaching rural providers that improved users’ skills and willingness to work with eating disorders.
But this material means nothing if people don’t access it, and we know there are many competing demands on the medical workforce. When developing educational material, we must collaborate with health care providers early and throughout the process. Prioritizing brevity will increase buy-in and, perhaps, downstream impact.
In addition to creating new educational opportunities, let’s seize the existing ones.
For example, starting in July, the Accreditation Council for Graduate Medical Education will require pediatric trainees to spend four weeks learning about mental health. Eating disorders, uniquely positioned at the intersection of physical and psychological health, need to be included in this initiative alongside psychiatric illnesses that typically receive more attention.
Across disciplines, health care education uses case material. Weaving in eating disorder examples can show that the most common eating problems do not involve being underweight; that males and people of color are affected; sexual and gender minorities are at increased risk; and those who are not wealthy are not spared. Through clinical simulations, learners can muddle through discomfort and find language that feels most natural to identify and assist those in need.
Education also needs to target current providers who are already encountering these patients while supervising trainees. The knowledge gap is gradually being acknowledged by Congress and state legislatures. A 2016 federal law was the first to include provisions aimed at strengthening eating disorders training. In 2020, Kentucky established an Eating Disorder Council within its Cabinet for Health and Family Services charged, in part, with overseeing the development and implementation of eating disorders education. Colorado, Texas, and Vermont followed suit, each trying to fill needs to improve prevention and referral for services in their respective states. More recently, the SERVE Act, part of the 2022 National Defense Authorization Act, stipulated requirements in eating disorders continuing education for medical providers to the military, a subgroup at increased eating disorder risk.
Training for seasoned providers must acknowledge and address concerns they have about discussing eating behavior and unusual attempts at weight control, such as inducing vomiting, drinking teas promoting a laxative effect, or exercising specifically to “undo” eating. In a culture rife with diet talk and the idealization of being thin, clinicians need guidance in talking about trends like intermittent fasting and eliminating gluten or dairy without medical rational. We can reduce uncertainty about the lines between normal eating, disordered eating, and eating disorders by sharing what is known about how people along the spectrum decide what to eat and how much guilt or shame they feel afterward.
Conversations about weight can feel emotionally charged for both patient and provider, yet weight monitoring is a well-recognized component of eating disorder care. Enhanced training should include guidance on discussing weight patterns, rather than any one measurement, and doing so sensitively, without shaming or praising based on a number on the scale.
The common ingredient across effective treatments for eating disorders is behavior change, an essential step before psychological improvements can follow. Behavior change is hard, but it’s easier if providers are trained in strategies that make it possible. That includes asking patients about eating and exercise patterns.
We can also use what we know about behavior change to shape progress among clinicians. Adjustments to the electronic medical record may help. It is now commonplace for providers across medical settings to ask questions about mood and anxiety. Minor modifications to routine visit forms can remind clinicians to assess everyone for eating disturbances as well. A few judiciously placed alerts — for example, about notable weight change or bloodwork results potentially indicative of purging or malnourishment — and prompts for nonjudgmental follow-up questions might keep eating disorder symptoms top of mind.
Eating disorders can be deadly, second among psychiatric illnesses only to opioid use disorder, but they are also treatable.
The young woman found unresponsive after vomiting ought to be asked about purging and learn the risks and ineffectiveness of this behavior. The adolescent boy and his parents need to hear that he should still be growing and be closely monitored for progress. The man losing his social life alongside pounds requires help evaluating his weight loss medication, and treatment recommendations that account for the risks he is experiencing. Every clinical encounter is an opportunity. Let’s ensure that medical providers are ready, willing, and able to meet the moment.
Deborah R. Glasofer, Ph.D., is an associate professor of clinical medical psychology at Columbia University Medical Center and a practicing clinical psychologist in New York City focused on eating disorders education for both professional and public audiences. Evelyn Attia, M.D., is a professor of psychiatry at the Columbia University and Weill Cornell Medical Centers who has spent over 30 years dedicated to furthering the understanding and treatment of eating disorders.