This month the NCIBH spoke with Angela Guarda, MD, Director of the Eating Disorders Program at Johns Hopkins Hospital.
Angela Guarda, MD is the Stephen and Jean Robinson Associate Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins School of Medicine and Director of the Eating Disorders Program at Johns Hopkins Hospital. She is an active clinician, educator, and researcher. Her clinical research interests include improving intensive treatment outcomes and rates of meal-based weight restoration for anorexia nervosa and for avoidant restrictive food intake disorder. She is the recipient of research grant funding from both the NIH and the Klarman Family Foundation and is involved in neuroimaging research examining neural mechanisms of appetite dysregulation that may contribute to the driven nature of eating disorders. Dr. Guarda is an inducted member of the Miller Coulson Academy of Clinical Excellence and has been named every year since 2009 in Castle Connolly’s “America’s Top Doctors” for eating disorders.
In this month's featured interview, we discussed Dr. Guarda’s recommendations for eating disorder care in primary care settings.
What are some key recommendations for primary care providers in terms of recognizing and responding to eating disorders?
Identify and learn what questions to ask to elicit a diagnosis
Be familiar with front line medical interventions
Know when to refer to a higher level of care or specialist treatment. Early recognition and intervention in the primary care setting can help a significant proportion of patients.
If a primary care provider suspects an eating disorder they should ask direct questions such as “Have you ever worried you may have an eating disorder or disordered eating?”, “Do you feel excessively preoccupied with thoughts of food, weight or shape?”, “Have you ever made yourself vomit or taken laxatives or exercised excessively to control your weight or shape?”, “Do you ever binge eat – by that I mean consume a large amount of food, more than others would eat under similar circumstances and experience a sense of loss of control over your eating.”
Weight is a vital sign. Always weigh your patient and pay attention to sudden changes in weight. Low potassium due to vomiting or laxative use, as well as syncope or presyncopal symptoms related to dehydration can also be a warning sign of an eating disorder. Additionally, a low weight or a BMI of <18.5 should raise concern for anorexia nervosa. Weight restoration to a BMI of 19 or 20 is essential to recovery from anorexia nervosa and requires nutritional rehabilitation. Sudden gains in weight may reflect binge eating behavior.
Why is screening for eating disorders so important in primary care?
Although many patients with eating disorders will seek care for the consequences of their eating disorder, most avoid specialty treatment. The primary care provider plays a crucial role in diagnosis, helping patients to seek specialty care, and monitoring their progress. Screening matters because eating disorders are serious conditions associated with elevated morbidity and mortality, functional impairment, and both medical and psychiatric comorbidity. Anorexia nervosa has one of the highest mortality rates of any psychiatric diagnosis.
What do you believe are the top issues providers should be aware of when screening for eating disorders in primary care settings?
Primary care providers should be aware that one in every twenty individuals is likely to have an eating disorder. Most patients however are unlikely to volunteer this diagnosis to their primary care provider due to a combination of embarrassment, shame, guilt or denial of illness. Despite this, patients often seek medical help for secondary consequences of eating disordered behaviors including headache, dizziness, fatigue, gastrointestinal complaints, food intolerances, anxiety, and depressive symptoms. Functional gastrointestinal complaints are especially common, and can include constipation, abdominal pain, heartburn, reflux and bloating. These are often exacerbated by weight loss, binge eating, vomiting or laxative overuse and respond poorly to treatment unless the underlying eating behavior improves.
What do you think are some successful strategies for overcoming stigma of treating mental health conditions in primary care settings?
Eating disorders are treatable conditions and the vast majority of patients get better with treatment. I would start by talking about eating disorders with incoming patients. Make sure to ask family members if they are concerned or have noticed preoccupation with food, weight, abnormal eating, or weight control behaviors in loved ones. Providers should be prepared to be met with some degree of denial or resistance, but never ignore the topic.
It's common for patients to seek treatment only after trusted health care providers or close family members encourage them to do so. Eating disorders are driven by behavioral problems and patients are often resistant to behavior change. While patients recognize the consequence of the eating disorder on one level, they may not feel able to change their behaviors. The treatments with the best evidence are behaviourally focused and help patients to normalize their eating, reverse the starved state if underweight, and identify triggers including feelings and thoughts that sustain the behavior.
Do you know of any eating disorder prevention, education, curricula or training resources for primary care providers that you would like to share?
There are extensive free online resources available for providers, patients and families. The Medical Standards Task Force of the Academy of Eating Disorders (AED) “purple brochure” was developed for medical providers to promote the recognition, risk management, and care of individuals with eating disorders and can be accessed online here. This brochure provides information on signs, symptoms, laboratory tests, and recommendations for when a higher level of care or hospitalization may be required. Resources for patients and family members include the National Eating Disorders Association website as well as F.E.A.S.T. Additional resources and worksheets for clinicians, as well as online trainings in cognitive behavioral therapy for eating disorders are available at the Center for Clinical Interventions and on the enhanced cognitive behavioral therapy or CBT-E website.
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