Eating Disorders 101:
How to Screen, Assess,
and Diagnose Students
with Eating Disorders
The Alliance for Eating Disorders Awareness
Joann Hendelman, Ph.D., R.N., FAED, CEDS-S
Clinical Director
Johanna S. Kandel
Founder/CEO
Eating Disorders Stats…
More than
30 Million Americans
are currently battling
eating disorders
College Students and Eating Disorders

25% of college-aged students have eating disorders
(NIMH 2012).

College administrators report a 24.3% rise in eating
disorder behavior among college students (2010 National
Survey of Counseling Center Directors).

91% of women on college campuses have attempted to
control their weight through excessive dieting (ANAD)

At least three quarters (75%) of college students are
dissatisfied with their weight (Soet, J. and T. Sevig, 2006)

Less than 20% who screened positive for EDs report
receiving treatment on college campuses (Stanford 2013)
College Students and Eating Disorders
ACHA’s 2010 National College Health Assessment

44% of college women are dieting to lose weight

27% of college men are dieting to lose weight

61% of college women are exercising to lose weight

45% of college men are exercising to lose weight
“The mortality rate for those with anorexia
nervosa is estimated at 5% per decade…
making it one of the leading contributors to
excess mortality of any of the psychiatric
disorders. Research tells us that anorexia is a
brain disease with severe metabolic effects on
the entire body. While the symptoms are
behavioral, this illness has a biological core,
with genetic components, changes in brain
activity and neural pathways
currently under study.”
Thomas Insel, M.D., Director, National Institute of Mental Health, Bethesda, MD, April 2007
Heritability in
Anorexia and Bulimia
Genetics
“We think genes load the gun by creating behavioral
susceptibility such as perfectionism or the drive for
thinness. Environment then pulls the trigger.”
– Walter H. Kaye, M.D.
50 to 80% of cause is genetic
 AN & BN share common genes
 AN & BN run in families

Contributing Factors
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Genetics
Traumatic experiences
Family difficulties
Onset of mental illness
History of substance abuse
History of dieting
Sports/activities where weight regulation is
demanded
Physical illness that causes weight loss
Perfectionism
Vegetarianism

Eating disorders display substantial comorbidity with other mental health
disorders.

While eating disorders often coexist with
other mental health disorders, eating
disorders often go undiagnosed and
untreated.

A low number of sufferers obtain
treatment for their eating disorder hence
inaccurate measures of incidence
(Only 1 in 10).

Eating disorders frequently impair the
sufferer's home, work, personal, and social
life.

Binge Eating Disorder is more common than
anorexia or bulimia and is commonly
associated with severe obesity.

Researchers found a surprisingly high rate of
anorexia and bulimia among men,
representing approximately one fourth of all
the cases of each disorder.
Eating disorders DO
NOT discriminate
between age, gender,
race and class –
NO ONE IS IMMUNE
New Trends…
Men
Women
in Midlife
Young Children
“Which of these trends has the
highest percent increase?”
Women in Midlife
 Triggers
 Desire to remain young in a society
that does not let you grow old
gracefully.
 Divorce Rate in the U.S. (50%)
 Menopause
 Empty Nest Syndrome
 Loss (i.e. spouse, parent, child)
 Eating Disorders that were not
treated years prior
Males and Eating Disorders
• Recent research indicates that 1 in 4
•
•
•
•
people with eating disorders is male
Rate of men with BED is similar to
women
Greater tendency to use compulsive
exercise rather than purging for weight
control.
Preferred body image is muscular.
Increasing evidence as concerned about
body image as women.
Eating Disorders in Children

10% of eating disorders clients are < 10 years of age.

119% increase in hospitalizations in children < 12 yrs.

Nearly HALF of 3- to 6-year-old girls reported they
worry about being fat (Tantleff-Dunn, 2009)

Children maturing earlier and earlier

Being teased by peers

Society’s obsession with thinness

OBESITY EDUCATION
.
EATING
DISORDERS
EDNOS
Anorexia
Nervosa
Bulimia
Nervosa
Restricting
Type
Purging Type
Binge/Purge
Type
Exercise
Binge Eating
Disorder
Eating Disorders
Not Otherwise
Specified
Avoidant/
Restrictive Food
Intake Disorder
Other Eating
Disorders
Orthorexia
Subsyndromal/
Atypical Symptoms
Muscle Dsymorphia
Chewing and Spitting
Drunkorexia
Night Eating
Syndrome
Diabulimia
PICA
Anorexia Nervosa:
(Self-Starvation)
A self-imposed starvation resulting from
a distorted body image and an intense
fear of gaining weight.
Demographics of Anorexia
1% of suburban female teens
 Bimodal peak of onset:

 12-13 years old
 17 years old
50% restrictors (limit food and exercise)
 50% bulimic subtype:

 also purge
Anorexia Nervosa:
(Self-Starvation)
Restricting type - dieting, fasting
and/or excessive exercise
Binge-eating/purging type - vomiting,
misuse of laxatives, enemas and/or
diuretics; carries greater medical risk.
Review of Symptoms:
Anorexia

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Sizeable weight change
Disturbed body image
Cold
intolerance/hypothermia
Constipation
Loss of muscle mass
Depressive symptoms
Anxiety
Cognitive impairment

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Dizziness/fainting
Loss/delay menses
(Amenorrhea)
Orthostatic hypotension
Self mutilation
Sleep disturbance
Brittle nails
Thinning/dull hair
Physical Findings:
Anorexia
 Emaciation
 Hyperkeratosis
 Bradycardia
 Edema
 Hypothermia
 Anemia
 Lanugo
 Cyanotic
hair
 Dry skin
 Carotenemia
extremities
 Hypotension
 Gastroparesis
Anorexia:
The Dangerous Reality
 Mortality
 Anorexia Nervosa has the highest
mortality rate among all psychiatric
disorders.
 10 – 20 % will die
○ Death from cardiac arrest, suicide,
starvation, other medical complications
Bulimia Nervosa
(Binge-Purge)
“A disorder in which an individual
engages in episodes of bingeing
and purging.”
Demographics:
Bulimia
 21%
of college-aged women
 Peak onset: college age
 Duration before presentation: 5 years
 Normal weight range
 30% hx of obesity
 20% hx anorexia
Bulimia Nervosa
(Binge-Purge)
75% - 85% of individuals
with Bulimia are normal
weight to overweight
Review of Symptoms:
Bulimia

Average weight w/
weight fluctuation

Abdominal pain

Self mutilation

Feelings of shame
and guilt

Disturbed body image

Depressive symptoms

Anxiety

Sleep disturbance

Dizziness and fainting

Bloating/heartburn

Fatigue

Bowel paralysis

Chipmunk facies
Physical Findings:
Bulimia

Normal or
Overweight

Edema

Extremity
weakness

Hypertensive

Parotid enlargement

Esophagitis

Dental erosions


Russell's sign - scars
on knuckles
Electrolyte
imbalance

Sore throat
Boerhaave Syndrome

Dehydration

Binge Eating Disorder
(Bingeing)
“Recurrent episodes of
binge eating without the
purging behavior of
Bulimia Nervosa.”
Binge Eating Disorder

Recurrent episodes of binge eating with:
 Eating in discrete period of time an amount of food larger than most people
would eat
 A sense of lack of control over eating during the episode (a feeling that one
cannot stop eating or control what or how much one is eating)


The binge eating occurs at least once a week for three (3)
months.
The binge eating episodes are associated with:
 eating much more rapidly than normal
 eating until feeling uncomfortably full
 eating large amounts of food when not feeling physically hungry
 eating alone because of feeling embarrassed by how much one is eating
 feeling disgusted with oneself, depressed, or very guilty afterwards
Binge Eating Disorder :
Physical Findings

Overweight or
obesity

Heart disease

Type II diabetes

Gallbladder
disease

Lipid
abnormalities

Increased BP

Osteoarthritis

Increased
cholesterol

Sleep apnea
Obesity
30-50% of hospital based obese population
have BED
 20-30% of patients seeking medical weight
loss treatment have BED
 Treatment issues of obesity with
consideration of eating disorders (obesity
prevention)

 Following involvement in an obesity prevention
program, 30% of children aged 6-14 displayed one or
more behaviors that could be associated with the
development of an eating disorder (Science Daily, 2012)
Eating Disorders
Not Otherwise Specified
Significant eating disorder that
does not exactly meet criteria for
AN or BN
Avoidance/Restrictive
Food Intake Disorder

Persistent disturbance in eating leading to
 Weight loss/inadequate growth
 Significant nutritional deficiency
 Dependence on tube feeding/nutritional supplements
 Impaired psycho-social functioning/inability to eat
with others

Exclusions
 Lack of food, cultural practice
 Other medical/psychological issues
 Irrational fear of weight & shape = eating disorder
Other Types of
Eating Disorders
Orthorexia
Muscle
Dysmorphia
Drunkorexia
PICA
Diabulimia
Orthorexia
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Coined in 1997 by Steven Bratman, MD
Defined as an obsession with "healthy or
righteous eating.”
It often begins with someone's simple and
genuine desire to live a healthy lifestyle.
The severe restrictive nature of orthorexia
could easily morph into anorexia.
Can result after major illness
Muscle Dysmorphia

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

Obsess/worry about being small,
underdeveloped, and/or
underweight.
Many are obsessed with having
the perfect physique and are
addicted to lifting weights.
Muscle-bound, but believe their
muscles are inadequate.
Steroid abuse, unnecessary
plastic surgery, and even suicide.
Drunkorexia
A non medical term, for the practice
of swapping food calories for those in
alcohol.
 Statistics suggest that 30% of 18-24
year olds skip food in order to drink
more.
 Also known as a mixture of
alcoholism, bulimia and anorexia
 Prominent among young college
women who skip meals so they can
get drunk at night and not worry
about the calories

PICA (as an Eating Disorder)


Pica is disorder in which a person has a
strong desire to eat, lick, or chew non-food
items in lieu of eating caloric foods.
Persistent eating of nonnutritive substances
for a period of at least 1 month. The eating of
nonnutritive substances is inappropriate to
the developmental level.
Diabulimia:
Type 1 Diabetes

"Diabulimia" is used to describe people with
diabetes that manipulate their intake of insulin
in order to temporarily alter their weight.

"Diabulimia" is extremely serious
 Doubled rate of physical toll taken on the body than
diabetes or an eating disorder alone.
 Manipulation of ketone levels may result in
dehydration, kidney dysfunction, and blindness.

40% mortality rate.
Warning!!!
Do NOT ask your patient if
they are manipulating
their insulin in order to
lose weight. You do not
want to teach them a
‘trick!’
Screening Questions

Do you feel big/small in your body?

When/what did you last eat? What did you eat yesterday? Do
you have forbidden foods?

What is your ideal body weight? How often do you weigh
yourself? Have you lost/gained weight within the last 3
months? What has your weight range been?

Do you make yourself sick (i.e. purge) when you feel
uncomfortably full?

Do you binge? What constitutes a binge for you?

Do you eat when you’re hungry and stop when you are full?
Do you worry you have lost control over how much you eat?

Would you say that food/ food thoughts dominate your life?

What is your exercise regimen?

Be mindful when screening not to ignore males!!
Evaluation of patients
with eating disorders
History:
 Weight/diet history
 Exercise regimen
 Menstrual history
 Compensatory behaviors:
& pattern
 Body image
disturbance
 Eating habits
laxative, diuretic, diet
pills/stimulants, ipecac use
 Suicidal ideations
 Psychiatric history
 Binge eating &
○ including - family history of
purging behaviors
 Current & past
medications
 Substance abuse
disordered eating, addictive
disorders, depression,
anxiety, etc.
 Sexual history
Evaluation
Continued
Physical exam:
Systems:
Heent:
 Vitals
○ Body temperature
○ Heart rate
○ Blood pressure
○ Height & weight
 Perimyolysis
Heart:
 Cardiac arrhythmias
 Heart palpitations
 Chest pain
 Dental caries
 Chipped teeth
 Mouth sores
 Sialadenosis
Evaluation
Continued
Physical exam:
Endocrine
 Amenorrhea/irregular





menses
Loss of libido
Decreased bone density
Osteoporosis
Infertility
Poor glucose control &
diabetic ketoacidosis (in
diabetics)
Skin
 Dry skin
 Brittle nails
 Carotenemia
 Pigmentation
 Hair loss/thinning
 Lanugo hair
 Russell’s sign
 Poor wound healing
Evaluation
Continued
Labs/Studies
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EKG
CBC w/ diff
Full thyroid panel (T², T³, T , TSH)
Urinalysis; specific gravity, sodium
Bone density scan
Complete metabolic profile
Full chemistry amylase
Serum magnesium/glucose/electrolytes
Amenorrhea evaluation
Evaluation
Continued

Special Circumstances (e.g. clients <15% IBW)

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Chest x-ray
Complement 3
24 hour creatinine clearance
Uric acid
Brain scan
Echocardiogram
Skin testing for immune functioning
DXA scan (amenorrhea 6+ months)
Estradiol level (or testosterone in males)
ANA, amylase, lipase, LH, FSH, prolactin
UGI+/-SBFT
Laboratory Clues

Low Glucose = Poor nutrition

High Glucose = Insulin omission

Low Potassium = Vomiting, laxatives, etc

Low Chloride = Vomiting

High Chloride = Laxatives

High Blood Bicarbonate = Vomiting

Low Blood Bicarbonate = Laxatives

High Blood Urea Nitrogen = Dehydration
Laboratory Clues

High Creatinine = Dehydration

Low Calcium = Poor nutrition at expense of bone

Low Phosphate = Poor nutrition or refeeding

Low Magnesium = Poor nutrition or laxatives

High Amaylase = Vomiting, pancreatitis

High Lipase = Pancreatitis

High Total Bilirubin = Liver dysfunction

High Total Protein/Albumin = Malnutrition
Occasional
Lab Findings

Hormones
 Low Estradiol (Females)
 Low Testosterone (Males)

Lipids: anything goes
 High Cholesterol = Short term starvation
 Low Cholesterol = Long term starvation

“Sick euthyroid”
 Low T4, normal TSH
Electrocardiogram
Usually normal
 Bradycardia or other arrhythmias
 Signs of hypokalemia
 Low voltage changes
 Prolonged QTc – Greater than 440
 Occasional ST-segment depression

Criteria for
Hospitalization

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Weight more than 25% below IBW
Bradycardia < 50 BPM
Temperature < 96 degrees F (< 35.6 C)
Hypotension < 80/50 mm Hg
Orthostasis > 20 BMP
Hypokalemia < 3
Renal failure
ECG abnormalities
Failure in outpatient intervention
Suicidality
Role of the Practitioner
Selling patients treatment they
don’t want for a problem they
don’t think they have
Do’s
Motivational Interviewing:
Offer empathy
 Roll with the
resistance
 Avoid
accusations/arguing/
pressuring

Ask open ended
questions
 Listen reflectively
 Affirm/validate
 Summarize

Don’ts

Do not believe all patient reports are
accurate

Do not tell an underweight person with ED’s
to “just eat” or they are “lucky” to be thin

Do not tell an overweight person to just stop
eating

Do not expect this will go away with time

DON’T DELAY with early onset ED
symptoms
Clinic Culture
 Weighing
 Office staff must be trained to use standardized
protocols to record consistent, reliable measurements
 Scale should be located in a private area
 Client should be weighed backwards to avoid
revealing their true weight to them (Blind weights)
 Be aware that clients may drink extra fluids (water-
loading), put weight in pockets/rocks in underwear,
and/or wear layers of extra clothing before being
weighed
Clinic Culture
 Weighing
 Never leave chart unattended – and
do not vocalize number or share
whether it’s up/down
 Comments about weight should be
minimized and made discretely
Clinic Culture

When words have unintentional meanings
 “Healthy”
 Fat
 Gained weight
 Out of Control
 “Look Better”
 Fat
 Gained weight
 Out of Control
 “You look very nice today”
 Fat
 Gained weight
 Out of Control
Clinic Culture

They Said What???
 “If you have an eating disorder, then why aren’t you
skinnier?”
 “So what? An eating disorder? I’ve had one of those…This is
all your choice. Some people have real problems.”
 “You’re a guy, and guys don’t get eating disorders.”
 “No you don’t have an eating disorder…you’re not that
skinny and your teeth are not yellow.”
 “I had an eating disorder when I was younger, but I weighed
much less than you do now.”
 “You can starve yourself, and binge and purge as much as
you want as long as you take vitamins, and don’t hit your
head when you pass out. You’ll grow out of this stage
eventually.”
Hostile Recovery
Environment
We are In A Hostile
Recovery Environment

Pervasive on college campuses

Glamorization/encouragement of the illness

Thinness = control, popularity, success,
relational connection

Fat = out of control, shunned, failure, relational
rejection

Readily available and legal drug of choice

War on Obesity
Questions?
For more information, please call:
The Alliance for
Eating Disorders Awareness
(866) 662-1235
www.allianceforeatingdisorders.com