Identifying Eating Disorders - Signs and Symptoms

EARLY INTERVENTION SAVES LIVES

For people with eating disorders, early intervention can be life-saving. Unfortunately, studies indicate four to six-year delays, on average, between the onset of symptoms and when an individual finally seeks treatment - with stigma cited as the most impactful treatment barrier. 1

When an individual is entrenched in their eating disorder, they are likely to experience difficulty in making objective decisions about treatment. It may be helpful to discuss the benefits associated with not delaying care with your clients. Early intervention can mean less time spent in treatment, a reduced likelihood of relapse, and fewer physical and mental health risks.

Your ability to recognize early eating disorder signs (including those unrelated to weight) and encourage clients to seek help before symptoms escalate can have a life-saving impact.

EATING DISORDER STATISTICS

• Eating disorders are among the deadliest mental illnesses; Anorexia Nervosa has one of the highest mortality rates of any mental health condition, second only to opioid overdose.

• The lifetime prevalence of bulimia nervosa for adult women ranges from 1.7%-2.0% and for men ranges from 0.5-0.7%.2

• People with anorexia are up to 56 times more likely to die by suicide than the general population.

• BIPOC are significantly less likely than white people to have been asked by a doctor about eating disorder symptoms.3

• Less than 6% of people with eating disorders are medically diagnosed as underweight.4

• 60% of adults with BED are not sure whether they need to receive help.5

1Hamilton A, Mitchison D, Basten C, Byrne S, Goldstein M, Hay P, Heruc G, Thornton C, Touyz S. Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders. Aust N Z J Psychiatry. 2022 Mar;56(3):248-259. doi: 10.1177/00048674211020102. Epub 2021 Jul 12. PMID: 34250844.

2Keski-Rahkonen A, Raevuori A, Hoek HW. Epidemiology of eating disorders: an update. Annual Review of Eating Disorders: CRC Press 2018:66-76.

3Becker, A. E., Franko, D. L., Speck, A., & Herzog, D. B. (2003). Ethnicity and differential access to care for eating disorder symptoms. International Journal of Eating Disorders, 33(2), 205-212. doi:10.1002/eat.1012.

4Flament, M., Henderson, K., Buchholz, A., Obeid, N., Nguyen, H., Birmingham, M., Goldfield, G. (2015). Weight Status and DSM-5 Diagnoses of Eating Disorders in Adolescents From the Community. Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 54, Issue 5, 403-411.

5Linardon, J., Rosato, J., & Messer, M. (2020). Break Binge Eating: Reach, engagement, and user profile of an Internet-based psychoeducational and self-help platform for eating disorders. International Journal of Eating Disorders, 53, 1719-1728.

If your clients are exhibiting medical or behavioral signs of disordered eating, contact our admissions team today to discuss care options. 866.651.7129

EATING DISORDER DIAGNOSES

ANOREXIA NERVOSA

Severe restriction of food intake or calories, an intense fear of gaining weight, and excessive weight loss. Atypical anorexia: An eating disorder in which a person meets all of the criteria for anorexia but is not at a low body weight.

A V OIDANT /R EST R ICTIVE FOO D IN TAKE DISO R DE R (A R FID )

More than just picky eating, individuals with ARFID often don’t eat enough to meet their energy and nutritional needs. Unlike individuals with anorexia, people with ARFID tend not to worry about their weight or body shape. ARFID has a growing prevalence among adolescents.

BIN G E E ATING DISO R DE R (BED)

The consumption of food in a discrete period of time (e.g., within any two-hour period) that is larger than most people would eat during a similar amount of time and under similar circumstances. During this episode, an individual experiences a lack of control over eating.

BULIMIA NERVOSA

Periods of binge-eating (eating large portions of food uncontrollably) or excessive overeating, followed by purging or getting rid of calories usually through fasting, laxative use, or self-induced vomiting.

DIABULIMIA (ED-DMT1)

“Diabulimia” is the colloquial name for the dual diagnosis of a person with eating disorders and type 1 diabetes who manipulates their insulin doses in an effort to control their weight. More formally, these behaviors are referred to as the dual diagnosis of “eating disorder-diabetes Mellitus type 1,” or “ED-DMT1.”

OTHE R SPE C IFIED FEEDIN G O R E ATIN G DISORDE R ( OSFED )

Symptoms that don’t meet the strict diagnostic criteria of a specific eating disorder, but that significantly interfere with a person’s functioning. Symptoms include obsession with food cleanliness or exercise, feeling overweight despite weight loss, loss of control when eating including impulsive or irregular eating habits, etc.

EATING DISORDER SCREENING QUESTIONS

The SCOFF questionnaire is a simple, five-question screening measure to assess the possible presence of an eating disorder.

1. Do you make yourself Sick because you feel uncomfortably full?

2. Do you worry that you have lost Control over how much you eat?

3. Have you recently lost more than One stone [approximately fifteen lbs] in a three-month period?

4. Do you believe yourself to be Fat, even when others say you are too thin?

5. Would you say that Food dominates your life?

Two "yes" responses indicate a possible presence of an eating disorder. Contact our team or visit alsana.com/admissions to schedule an assessment.

SIGNS, SYMPTOMS, AND HEALTH RISKS

Less than half of Americans with eating disorders ever receive treatment.1 As providers, it is important to know there are significant disparities in terms of early detection and eating disorder diagnoses; symptoms are often missed in males, communities of color, and people in larger bodies.2 Early eating disorder detection and treatment intervention can have a meaningful impact on clients' symptom severity, quality of life, treatment effectiveness, and mortality rates.

• Noticeable changes in weight

• Bradycardia and/or orthostatic vital sign changes

• Delayed onset of menses or secondary amenorrhea

• Fatigue, cold intolerance, dizziness

• Hair loss or thinning

• Cardiac failure

• Gastrointestinal dysfunction, including gastroesophageal reflux, disease, gastroparesis, constipation, and diarrhea

• Early satiety, bloating, and nausea

• Parotid gland enlargement

• Abnor mal electrolytes

• Unexplained swelling

• Dental enamel erosion (with or without decay)

• Osteopenia or osteoporosis in premenopausal women

• Loss of libido

1(Hudson JI, Hiripi E, Pope HG, Jr., Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007;61:348-58.)

2 (Becker AE, Franko DL, Speck A, Herzog DB. Ethnicity and differential access to care for eating disorder symptoms. Int J Eat Disord 2003;33:205-12. | Austin SB, Penfold RB, Johnson RL, Haines J, Forman S. Clinician identification of youth abusing over-the-counter products for weight control in a large U.S. integrated health system. Journal of Eating Disorders 2013;1:40. | Austin SB, Ziyadeh NJ, Forman S, Prokop LA, Keliher A, Jacobs D. Screening high school students for eating disorders: Results of a national initiative Preventing Chronic Disease 2008;5:1-10. | Marques L, Alegria M, Becker AE, et al. Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. Int J Eat Disord 2010;44:412-20.)

BEHAVIORAL SIGNS

• Sudden interest in weight loss diets (e.g., keto diet) or specialized diets (e.g., no sugar)

• Excessive/compulsive exercise

• Binge eating

• Self-induced vomiting

• Laxative, diuretic, and/or diet pill abuse

• Food chewing and spitting

• Insulin misuse (in diabetics)

• Marked distress and feelings of disgust, depression, or guilt

HEALTH RISKS

• Vital sign changes, including hypother mia, resting bradycardia, exertional tachycardia, hypotension, and hypertension

• Cardiac arrhythmias

• Cardiac atrophy

• Heart failure

• Pericardial effusion

• Hypoglycemia

• Refeeding syndrome

• PseudoBartter’s syndrome

• Electrolyte abnor malities

• Sialadenosis

• Edema

• Gastroparesis

• Gastroesophageal reflux disease

• Superior mesenteric artery syndrome

• Liver dysfunction

• Constipation

• Diarrhea

• Muscular weakness, including swallowing difficulties

• Amenorrhea in females

• Osteoporosis

• Diabetes mellitus type I or II

• Obstructive sleep apnea

• Polycystic ovarian syndrome

MANIFES TATIONS O F

E ATING DISORDER S

Psychological: depression, anxiety, OCD, insomnia, fear of gaining weight, shame, low self-esteem, substance misuse

Neurological: memory

dizziness, fatigue

Hair/Skin: lanugo hair, hair loss, brittle nails, easy bruising, xerosis, acrocyanosis (bluish/purplish discoloration of tips of skin), abrasions on knuckles

Heart: palpitations, chest pain, arrhythmias, low or high blood pressure, slow heart rate, fast heart rate on exertion, shortness of breath, heart failure

Lungs: cough, shortness of breath, obstructive sleep apnea

Liver: starvation hepatitis, non-alcoholic fatty liver, coagulopathy

Face: temporal wasting, parotid swelling, nose bleeding

Face: temporal wasting, parotid swelling, nose bleeding

Mouth: caries, cavities, dental erosions, perimylolysis, temperature intolerance

Mouth: caries, cavities, dental erosions, perimylolysis, temperature intolerance

Stomach: nausea, vomiting, bloating, early satiety, disease, gastroparesis

Stomach: nausea, vomiting, bloating, early satiety, disease, gastroparesis

Electrolytes: dehydration, low sodium, low potassium, high bicarbonate, low phosphorus, low magnesium Endocrine: poorly controlled diabetes (I and II), metabolic syndrome, primary or secondary amenorrhea, irregular menses, osteopenia, osteoporosis, high cholesterol, abnor mal thyroid function,

Electrolytes: dehydration, low sodium, low potassium, high bicarbonate, low phosphorus, low magnesium Endocrine: poorly controlled diabetes (I and II), metabolic syndrome, primary or secondary amenorrhea, irregular menses, osteopenia, osteoporosis, high cholesterol, abnor mal thyroid function,

miscarriages, decreased libido, hot/cold intolerance

miscarriages, decreased libido, hot/cold intolerance

Kidney: kidney failure, kidney stones

Kidney: kidney failure, kidney stones

Intestine: constipation, diarrhea, superior mesenteric artery syndrome, villous blunting, cramping, rectal prolapse

Intestine: constipation, diarrhea, superior mesenteric artery syndrome, villous blunting, cramping, rectal prolapse

Blood: low white blood cells, low red blood cells (anemia), low platelets

Blood: low white blood cells, low red blood cells (anemia), low platelets

Musculoskeletal: muscle weakness, fractures

Musculoskeletal: muscle weakness, fractures

Eating disorders do not discriminate. These disorders affect individuals of all ages, genders, and sexual orientations.

Eating disorders do not discriminate. These disorders affect individuals of all ages, genders, and sexual orientations.

Medical status

Medical status

LEVEL 1 : Outpatient

LEVEL 1 : Outpatient

LEVEL 2 : Intensive Outpatient

Suicidality

Suicidality

Weight as percentage of healthy body weight

Motivation to recover including cooperativenss, insight, and ability to control obsessive thoughts

LEVEL 2 : Intensive Outpatient LEVEL

LEVEL 3 : Partial Hospitalization (Full-Day Outpatient Care)

Partial Hospitaliza (Full-Day Outpatient

Medically stable to the extent that more extensive medical monitoring, as

Medically stable to the extent that more extensive medical monitoring,

If suicidality is present, inpatient monitoring and treatment may be needed depending

Weight as percentage of healthy body weight

Generally >85%

Motivation to recover including cooperativenss, insight, and ability to control obsessive thoughts

Fair-to-good motivation

Co-occuring disorders such as sustance use, depression or anxiety

Co-occuring disorders such as sustance use, depression or anxiety

Structure needed for eating/gaining weight

Structure needed for eating/gaining weight

If suicidality is present, inpatient monitoring and treatment may be

Generally >85% Fair-to-good motivation

Generally >80% Fair motivation

Generally >80% Fair motivation

Generally >80%

Generally

Partial motivation; cooperative; patient preoccupied with intrusive, repetitive thoughts >3 hours/day

Partial motivation; cooperative; preoccupied intrusive, repetitive thoughts >3

Needs some structure to gain weight

Needs some to gain weight

Ability to control complusive exercising

Ability to control complusive exercising

Can manage compulsive exercising through self-control.

Can manage compulsive exercising through self-control.

Purging behavior, i.e. using laxatives and diuretics

Purging behavior, i.e. using laxatives and diuretics

Can greatly reduce the incidents of purging in an unstructured setting; no abnormalities, suggesting the need for hospitalization.

Environmental stress

Environmental stress

and practical support and structure.

Can greatly reduce the incidents of purging in an unstructured setting; abnormalities, suggesting the need for hospitalization. and practical support and structure.

Others able to provide at least limited support and structure.

Others able to provide at least support and structu

Geographic availability of treatment program

Geographic availability of treatment program

Patient lives near treatment setting.

Patient lives near treatment setting.

IDELINES FOR P A TIENTS WITH E A TING DISORDE R S

LEVEL 4 : Residential Treatment Center

LEVEL 4 : Residential Treatment Center

LEVEL 5 : Inpatient Hospitalization

LEVEL 5 : Inpatient Hospitalization

Adults: Heart Rate <40 bpm

stable to the extent

nasogastric tube feedings, or daily laboratory tests needed.

Medicaly stable to the extent nasogastric tube feedings, or multiple daily laboratory tests are not needed.

estimated level of risk.

Generally >85%

Generally >85%

-to-fair motivation; patient eoccupied with intrusive thoughts 4-6 hours a patient cooperative with structured treatment.

• BP <90/60 mmHg

• Electrolyte imbalance

• Glucose <60mg/dl •

• Temp <97.0 F

•ment: • Poorly controled diabetes

Adults: Heart Rate <40 bpm • BP <90/60 mmHg • Glucose <60mg/dl • • Electrolyte imbalance • Temp <97.0 F • Dehydration •ment: • Poorly controled diabetes

• Dehydration

Children and Adolescents: Heart rate near 40 bpm • Orthostatic blood pressure changes (>20 bpm increase in heart rate or > 10 mmHg to 20 mmHg drop) • Blood pressure <80/50 mmHg • Hypokalemia, hypophosphatemia, or hypomagnesaemia

Children and Adolescents: Heart rate near 40 bpm • Orthostatic blood pressure changes (>20 bpm increase in heart rate or > 10 mmHg to 20 mmHg drop) • Blood pressure <80/50 mmHg • Hypokalemia, hypophosphatemia, or hypomagnesaemia

depending on the estimated level of risk.

indicated in patient with sucidal ideas or after a suicide attempt or aborted attempt, depending on the presence or absence of other factors modulating suicide risk.

indicated in patient with sucidal ideas or after a suicide attempt or aborted attempt, depending on the presence or absence of other factors modulating suicide risk.

Generally <85% • acute weight decline with food refusal even if not <85% of healthy body weight.

Generally <85% • acute weight decline with food refusal even if not <85% of healthy body weight.

Poor-to-fair motivation; patient preoccupied with intrusive repetitive thoughts 4-6 hours a day; patient cooperative with highly structured treatment.

Very poor to poor motivation; patient preoccupied with instrusive repetitive thoughts and patient uncooperative with treatment or cooperative only in highly structured environment.

Very poor to poor motivation; patient preoccupied with instrusive repetitive thoughts and patient uncooperative with treatment or cooperative only in highly structured environment.

supervision at all meals estrict eating.

Needs supervision at all meals or will restrict eating.

Needs supervision during and after all meals or nasogastric/special feeding modality

Needs supervision during and after all meals or nasogastric/special feeding modality

for and use support others or use cognitive behavioral skills to rging.

Can ask for and use support from others or use cognitive and behavioral skills to inhibit purging.

Needs supervision during and after all meals and in bathrooms; unable to control multiple daily episodes of purging that are severe, persistent, and disabling, despite appropriate trials of outpatient care, even if routine laboratory test results no obvious metabolic abnormalities.

Needs supervision during and after all meals and in bathrooms; unable to control multiple daily episodes of purging that are severe, persistent, and disabling, despite appropriate trials of outpatient care, even if routine laboratory test results no obvious metabolic abnormalities.

program is too distant for patient to participate from home.

Treatment program is too distant for patient to participate from home.

ADAPTIVE CARE MODEL ®

The Adaptive Care Model is the foundation upon which all Alsana’s in-person and virtual treatment programs are built. This evidence-based, compassion-focused approach facilitates healing for the whole person; it consists of five interconnected dimensions of wellness: medical, nutrition, therapeutic, movement, and relational. Each of these dimensions plays a significant role in reducing eating disorder symptoms from admission to discharge.

MEDICAL

We heal bodies and minds.

Our medical program is infused with compassion and designed to meet the unique recovery needs of each individual. Its purpose is to provide a physical foundation for lasting recovery and to educate clients about the physiologic changes they experience during the healing process. Care is provided by our multidisciplinary teams of attentive treatment professionals within an affirming, respectful environment.

NUTRITION

We believe in and practice all-inclusive nutrition. Nutritional care is designed in alignment with our “all-inclusive nutrition” philosophy, which embraces flexibility and the enjoyment of foods without shame or self-judgment. Our goal is to create food neutrality by taking the moral judgment out of food and focusing on nourishment, flexibility, and pleasure in the nutritional healing process. Clients gain valuable culinary skills and nutrition education, and are encouraged to explore their personal and cultural connections with food. We believe in healing that reflects each client's unique life story and adapting their meal plan to embrace their journey to recovery.

THERAPEUTIC

We cultivate compassion.

Alsana provides a soft landing for clients by meeting them with care and understanding rather than rigidity. We take a de-shame and de-blame stance that empowers clients and honors their intrinsic wisdom. We offer empathetic understanding and thoughtful interventions to support clients in leaning into difficult emotions so they can be learned from, tolerated, and disentangled from harmful behavior. By providing evidence-based and compassionate care, we help clients to reduce self-criticism while building the foundation for a meaningful and fulfilling life.

RELATIONAL

We are accepting of all lived experiences. Alsana is committed to embracing and respecting client and staff diversity. This commitment includes diversity based on ethnicity, race, nationality, neurodiversity, gender identity, sexual orientation, age, spirituality, ability, economic class, social class, and body shape and size. Our approach is to create an affirming environment where clients show up as their whole self, including the context of their culture, identities, and lived experiences. Alsana affirms the scientific evidence that oppression, including stigma and discrimination, has a significant negative impact on staff and clients’ mental health, physical health, and overall wellbeing. We provide affirming care and incorporate the client's community into their treatment process.

MOVEMENT

We support movement for every body. The movement program employs a variety of engaging techniques that invite clients to explore their motivations and relationships with exercise. We rely on evidence-based, eating disorder-specific movement therapy interventions, with movement experientials that include a mix of sports, games, recreational outings, dance, art, expressive activities, walks, and stretching. We incorporate relaxation, yoga, meditation training, and psychoeducation about movement into the treatment experience.