Eating Disorders in Primary Care: What’s Recommended?
When it comes to treating eating disorders, one of the most important steps is receiving a diagnosis. That diagnosis informs what type of treatment and what level of care (e.g., outpatient, day treatment, hospitalization) are needed to treat the current symptoms. One challenge, however, is that eating disorders often go undetected and people may struggle for years before receiving a diagnosis and specialty treatment. Part of this is due to longstanding stereotypes about what someone with an eating disorder “looks like,” and part of this is also due to the fact that many people with an eating disorder might not have obvious signs or symptoms that indicate there is a problem. For example, not everyone will have tooth decay from self-induced vomiting and not everyone will have marked changes in their weight. For these (and many other reasons), people with eating disorders can appear well or healthy and their conditions may therefore be easily overlooked.
One way to improve overall detection of eating disorders is to have screening conducted in the primary care setting (e.g., family medicine, internal medicine) on a regular basis. Primary care providers already conduct screenings of all sorts: screenings for breast cancer, for high blood pressure, and even for other mental health conditions like depression and anxiety. Thus, the clinicians in primary care are well-versed in doing this type of work and have the ability to then refer patients to specialty clinicians who can conduct more thorough assessments and provide specialty treatment. This role could be particularly useful for eating disorders where patients routinely need to be connected with specialty treatment in order to receive a formal diagnosis and treatment.
In recent months, the US Preventive Services Task Force (USPSTF) recognized the potential role of primary care in detecting and managing eating disorders by including it as a topic in their portfolio. For those who are unfamiliar, the USPSTF is a panel of national experts who make evidence-based recommendations about services that are provided in primary care (e.g., screening, counseling, and some medications). For example, the USPSTF has issued recommendations on when and how often to screen for breast cancer, for substance use disorders, and even intimate partner violence. The recommendations from the USPSTF are letter grades ranging from A to D. When the USPSTF issues a recommendation, it signals to primary care providers the types of services that they are encouraged to use in their clinical practice. In light of that, it was particularly exciting that this group identified eating disorders as an area of focus for the first time in its history!
In March 2022, the USPSTF released their recommendations on screening for eating disorders in adolescents and adults in the primary care setting. Their recommendations were based on a rigorous systematic review of the existing literature—a process that took place over more than a year and involved several teams of experts who scanned the existing studies, reviewed and analyzed all of the relevant data, and then wrote it in a report presented to the USPSTF. After reviewing the report, members of the USPSTF issued an I Statement indicating that the current evidence is insufficient to recommend for or against routinely screening for eating disorders among individuals who do not have obvious signs or symptoms. Essentially, this meant that the existing literature did not provide a clear enough signal to either encourage or discourage this practice in primary care. Despite that fact, there are a number of important take-home messages for clinicians and researchers alike.
For clinicians, the USPSTF I Statement does not mean that eating disorders are unimportant in primary care—it simply means that there is insufficient evidence to recommend for or against the preventive service of screening. There are many other ways in which clinicians in this setting can help manage eating disorders outside of the practice of screening. For example, in their recommendation, the USPSTF encourages clinicians to ensure that patients who express concerns about their eating and/or those who have more obvious signs or symptoms of an eating disorder be referred to specialty care. They also encourage clinicians to be aware of risk factors, signs and symptoms of eating disorders, and to consider monitoring high-risk groups (e.g., adolescents, transgender individuals, and those exposed to childhood trauma). In this way, primary care providers can play a pivotal role in ensuring their patients with eating disorders receive care in an efficient manner.
For researchers, the USPSTF I Statement is a clear indication that future research is needed to improve the evidence base around screening for eating disorders in primary care. In particular, the systematic review (referenced above) highlighted the need for studies that examine the benefits and potential harms of routine eating disorder screening versus treatment as usual (e.g., no screening). The systematic review also revealed a lack of studies involving populations typically seen in primary care, namely individuals who are racially, ethnically, and socioeconomically diverse. Undertaking such studies would dramatically improve the current understanding of how a preventive service like screening for eating disorders might improve health outcomes for patients who do not have obvious signs or symptoms. Additionally, the opportunity to add to the existing literature base is timely since the USPSTF regularly updates their recommendations based on new or emerging literature. Thus, there is the potential for the current I Statement to be modified to reflect new findings.
In the interim, it is encouraging to know that a well-respected and influential group like the USPSTF understand that eating disorders are a priority issue in primary care. Despite the issuance of an I Statement, clinicians and researchers alike have various ways in which they can help move the needle toward ensuring that all individuals with eating disorders receive the care they need to achieve recovery.
