Woman using a knife and fork to eat a single pea on a plate.

Underserved Populations: Eating Disorder Patients and Patients in Larger Bodies

Digital Exclusive - March 2022
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The first thing we ask most patients to do when they come into a physician’s office is step on the scale. For patients with eating disorders, stepping on the scale can be detrimental to their recovery and treatment. Some common symptoms of eating disorders that people typically struggle with include:

 

  • An obsession, or preoccupation with the numbers tied to their weight

  • Manipulating their food intake in the name of the eating disorder

  • Variable symptoms like self-induced vomiting, laxative abuse, slowed heart rate, fainting, hair falling out, difficulty sleeping, depression, and anxiety amongst others that breakdown both mental and physical health

 

Physicians who fail to recognize and help treat their patients, exhibiting eating disorder behavior, are advertently or inadvertently failing to ensure they receive proper care.

 

Today, eating disorders are prevalent in up to 9% of the population and rates have risen (with estimates stating that eating disorders are 400% more prevalent than we were even aware of) since the start of the pandemic.(1) In the greater-Phoenix Metropolitan area, there are not any physicians who specialize in eating disorders. Additionally, there is only one registered nurse practitioner in this area who practices in this specialty.  Considering there are almost 300,000 individuals

 

Whether you think you treat patients with eating disorders or not, you do. Eating disorders come in all shapes and sizes.  We do not have enough support or training to deal with the demand of patients that need specialized help and doctors to recognize and treat them effectively.

Dictionary showing the definition of eating disorder.

 

What can we do to help patients exhibiting an eating disorder?

As a registered dietitian treating patients with eating disorders since 2017, I have seen, firsthand, the detriment of providers treating patients who are unfamiliar with identifying eating disorder symptoms. 

 

Over these years, I’ve had many patients share disheartening anecdotes about the care they received from their providers that include:

 

  • Missing the eating disorder diagnosis entirely;

  • Clear and present weight bias in treatment, including ignoring the patient’s complaints by telling them to just, “change your diet, exercise more and you’ll feel better.” This is dangerous as it can delay treatment to the actual underlying issue that’s ailing them; and

  • An overall lack of understanding in the various eating disorder phenotypes and how to properly treat the patient.

Thankfully, there are some small changes we can make to show our patients that we care and hear them. And that starts with making our offices a safe place, not only for eating disorder patients, but all our patients.

 

Real-life Examples of Creating a Better Patient Experience

At the end of January, a story went viral on Twitter about a young woman who used “Don’t Weigh Me Cards” at her doctor’s office.(2,3) These cards are given to medical providers to help their patients decline to be weighed for their appointment, unless [absolutely] medically necessary.

 

For this doctor’s office, they observed the real value and positive change in the patient’s experience once they began accepting practice of them. Since then, they’ve implemented a few new processes into their practice which include:

 

  • Providing these cards to all patients before each appointment

  • Asking patients directly [depending on appointment type] if they want to be weighed or not for their appointment, instead of it having to be a “medical ritual,” or expectation

 

Our healthcare system is incredibly weight centric. This is not good.

 

For many patients with eating disorders, their appointment becomes focused on weight, rather than the primary issues and concerns that they went in for. When you focus specifically on the weight, and not the underlying issues that the patient is seeing you for, you could potentially be missing out on the true symptoms and diseases that are ailing your patient. The delayed time in true diagnosis of symptoms can be detrimental in many variable ways to your patient.

 

Whether or not patients have an eating disorder, the anxiety around having continued conversations around weight may lead to heightened anxiety for them. People in larger bodies tend to avoid doctor’s offices altogether, which delays disease diagnosis, increases risk for depression, anxiety and binge eating disorders.(4)

Studies have shown that patients who experience this weight stigma are likely to exhibit:(5)

  • Unhealthy eating and exercise behaviors such as binge eating disorder and decreased motivation to make healthy behavior change

  • Increased blood pressure, blood sugar, and cortisol (stress hormone)

  • Increased risk for substance abuse, depression, anxiety and suicidal ideation

  • Increased likelihood of poorly managed chronic illnesses and low quality of life

 

As medical providers, you can make subtle changes that make a big difference in your patient’s lives. A good place to start would be asking patients if they want to be weighed at the doctor’s office like what is described above.

The expectation is to include patient’s consent, and to take a deeper look at a medical routine that continues to cause harm. If and when weights are necessary, have that conversation then.

It’s imperative that you are looking at the whole picture of your patient, not just a person’s weight when providing treatment and care.

Man measuring chest circumference.

Ideas to Add to Your Practice

 

Do your waiting and exam rooms have seating to accommodate patients in larger bodies?

If not, make the change. Consider getting chairs without arm rests and blood pressure cuffs in different sizes. Patients deserve to be comfortable and welcomed at the doctor’s office. We work for our patients.

 

Ask your patients about their eating habits rather than assume.

Commonly, if a patient feels fatigued, or has joint pain, etc. we may say “lose some weight, you’ll feel better”. There have been far too many instances where disease diagnosis has been delayed for a year(s), due to this misjudgment. Before making dietary recommendations such as losing weight, we should first know what our patients typical eating patterns look like.

 

Do you have therapists, dietitians and psychiatrists that you refer to you?

National Eating Disorders Association has a map of national providers.(6) Pointing patients in this direction endorses your understanding and that we are taking their disease seriously, as well as connecting your patient to trusted providers.

Citations:

(1) Zipfel, Stephan. Schmidt, Ulrike Giel, Katrin E. The hidden burden of eating disorders. The Lancet. 9(1), p9-11, 2022 January 1.  https://doi.org/10.1016/S2215-0366(21)00435-1

(2) Donovan, D. [@danidonovan] (2021, Dec 15). They have cards at my doctor’s office now to tell them if you’d prefer not to be weighed [Tweet]. https://twitter.com/danidonovan/status/1471136450989199361

(3) More-Love.Org. Don’t Weigh Me Cards. https://more-love.org/free-dont-weigh-me-cards/

(4) Wu YK, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018 May;74(5):1030-1042. doi: 10.1111/jan.13511. Epub 2017 Dec 8. PMID: 29171076.

(5) Rubino, F., Puhl, R.M., Cummings, D.E. et al. Joint international consensus statement for ending stigma of obesity. Nat Med 26, 485–497 (2020). https://doi.org/10.1038/s41591-020-0803-x

(6) NEDA Resources. Map of Providers. National Eating Disorders Association. Accessed January 2022. Available online at https://map.nationaleatingdisorders.org/