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Adult Eating Disorders, Primary Care, and the MedFT

Posted By Lisa Zak-Hunter, Tuesday, February 21, 2012

During my faculty/resident lunch lecture on diagnosing and treating eating disorders (EDs) in primary care, I was asked the following question "I was wondering how well an appetite stimulant would work with someone who is restricting?” Heads around the room nod and there are a few approving looks toward the inquiring physician.

I affirm the suggestion: "Well, that seems to make sense. When I’m hungry, I look for something to eat. So, if someone’s appetite was stimulated, wouldn’t that increase eating behaviors? Not necessarily with someone who has an ED. EDs aren’t generally about food. They involve complicated feelings about control, self-worth, body image, stress, anxiety, attachment concerns, and many others. Food restriction, purging, and binging all become vehicles of self expression. People who restrict are familiar with hunger pains. However, the hunger has come to represent different things. For some, it is a sign of success, for others it is an annoying side effect they have gotten used to or put up with, and to others it may indicate they are losing control. Increasing appetite would likely only serve to increase these feelings and could actually spiral someone further into the ED.”

I’m met with looks of surprise, confusion, and understanding. At this point there are 15 minutes left, and I’m beginning to wish I’d signed up to do the whole week’s worth of lunch seminars. I’m struck by how little education there is on EDs in primary care and the importance of increasing physician awareness.

Eating Disorders in Adulthood

The Canadian and United States’ Eating Disorder Awareness weeks both occur in February, making this an appropriate time to address adult EDs and the role of medical family therapists in helping to raise awareness within the healthcare community. Eating disorders include anorexia nervosa, bulimia nervosa, and binge eating disorder (currently being considered as a separate diagnosis for the DSM-V).

Although EDs are often considered adolescent concerns, within the past decade there has been a significant increase in the number of early to middle aged women presenting for treatment.* Many of them are coupled and/or have children. Some have developed their first ED as adults, and others have struggled for years and never sought help or have relapsed.

Eating Diorders aren’t generally about food. They involve complicated feelings about control, self-worth, body image, stress, anxiety, attachment concerns, and many others. Food restriction, purging, and binging all become vehicles of self expression.
The reasons for developing or exacerbating ED behaviors in midlife are varied: job stress/loss, increased social pressure to maintain youthful body image ideals, pregnancy and a desire to regain pre-partum figure, couple conflict, menopause, sexual intimacy issues, distancing from or loss of parents, conflict with children, etc.  Symptoms in adults can be more severe than in adolescents, increasing the need for immediate action. Without treatment, approximately 10% of women with anorexia will die within 10 years, making it one of the most lethal psychological disorders. The systemic impact of adult EDs uniquely affects partners, children, parents, employers, and healthcare systems- all of which are underprepared and undereducated to appropriately respond.

Eating Disorders and Primary Care

As with most psychosocial concerns, ED or body image concerns are often first presented to a primary care provider. Many do not have sufficient knowledge or resources to ask the right questions, run the right labs, or make the right referrals. During my lecture, the well-intentioned physicians were also surprised to learn that EDs can develop at any age and that there has been an increase in adult diagnoses. With the increased focus on obesity, primary care providers often do not suspect or understand pathogenic weight control-especially in adults. Lack of understanding EDs in general complicates obtaining appropriate and immediate care for suffering adults. Based on the statistics I mentioned above, if a woman has already suffered for 10+ years without treatment prior to presenting to her primary care provider, time is of the essence. Enter the MedFT.

Working With and Educating The Physician

Many MedFTs are integrated to some degree within a larger healthcare practice such as a residency training program, medical center, or hospital. They are in a prime position to educate others, treat adult EDs from a systemic perspective, and offer collaborative care. The MedFT can improve patient care by facilitating communication between patient and provider, inform the provider if a patient has an ED and discuss how to address this in treatment, suggest what types of labs to run to monitor physical well-being, offer to run a lecture/discussion or grand rounds about diagnosing EDs in primary care, warning signs, and the importance of/how to discuss positive body image with patients- even adults.

They can encourage providers (and themselves) to inquire about current and past body image and dieting practices in their patients of all ages and discuss eating behaviors as a reaction to or coping mechanism for the presenting problem (if it is not an ED). A former colleague of mine (physician) contacted me after discussing weight management strategies with a new obese patient in her mid 40s. He wanted my opinion and further suggestions for how to handle the case. He had first explored the patient’s past dieting behaviors and exercise. He was surprised to learn the patient had a history of anorexia and became concerned about how to help the patient lose weight without triggering an ED. He decided the patient would need to attend counseling while on weight loss medication in case any ED behaviors resurfaced. The patient was unhappy with his decision, but I agreed with the physician. Proceeding in this manner could prevent a relapse and provided more responsive care.

Providing Treatment

Because of the systemic focus of their training, MedFTs can bring that perspective to consults with the provider and therapy sessions. Often, patients with EDs will deny or minimize the severity of the ED. Circular questioning is an excellent way to gather more relational information and assess severity (e.g., how would your partner say your eating practices affect your couple relationship? What would your children say you’ve taught them about food and body image?).

Lastly, the MedFT can increase collaborative care. The most effective ED treatment attends to the biopsychosocial-spiritual nature of the individual by combining individual, group, and family therapies, psychiatric care, nutrition counseling, weight and health management, and expressive therapies such as art, equine, or yoga therapy. MedFTs are well-trained in this theoretical perspective, so they can help coordinate communication among care providers and provide couple or family work (both of which are less commonly addressed in adult ED treatment). Not every family therapist may feel prepared to work with an ED and the patient may need more intense care such as a day program or in-patient therapy. Knowing local resources- especially those that are able to treat adult EDs- is key.

These ideas are meant to inspire, not serve as an exhaustive list of ways to increase consciousness or attend to adult EDs as a MedFT. Some are appropriate for working with adolescents as well. Overall, if you’ve walked away from this with a newfound awareness of adult EDs and a few ideas of how to address them with care providers in your practice, I’ve done my job.

ED resources for mental health professionals, physicians:

ED resources for patients, families/friends, others:

ED treatment referral sites:

*Eating disorders are thought to affect approximately 1 million men and 10 million women in the US alone. Because of this disparity, there is less research on male eating disorders, especially in adulthood. Please note that my blog focuses on findings for adult women, simply due to lack of research on adult men.

Lisa Zak-Hunter, MS is a doctoral candidate specializing in family therapy at the University of Georgia. She is currently completing a behavioral medicine internship with the Department of Family Medicine and Community Health at the University of Minnesota. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

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