Eating Disorders
The following information for health professionals has been supplied by the National Eating Disorders Collaboration.
Primary care providers have a crucial role in the prevention, identification, diagnosis and medical management of eating disorders.
Depending on your role, you can:
prevent eating disorders through the use of ‘Eating Disorder Safe’ approaches to all patient care, early intervention and patient education in cases of disordered eating/body image concerns.
identify eating disorders by recognising and following up on warning signs, and proactively screening at-risk groups
assess, diagnose and medically manage eating disorder presentations
refer to eating disorder-specific mental health treatment OR provide eating disorder-specific treatment if accredited to do so
refer to dietitian and other health professionals and medical specialists, as required
manage the care team across the course of treatment
General Practitioners: Click here to access the RACGP CPD Approved activity “ A practical guide to prevention, identification and response to eating disorders for GPs”
Assessment
An assessment for an eating disorder involves two stages:
Assessment of medical and psychiatric risk
Comprehensive assessment
Medical assessment
Assessment of eating disorder symptoms and severity
Mental health assessment
1. Assessment of medical and psychiatric risk
The initial assessment of medical and psychiatric risk should include physical assessment and diagnostic tests, as well as a mental health risk assessment. The mortality rate for people with eating disorders is up to six times higher than that for people without eating disorders, so ensuring assessing for suicide risk is crucial.
Admission to hospital is indicated if a patient is at imminent risk of serious medical or psychiatric complications. Indicators for hospital admission for adults, adolescents and children are outlined in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the treatment of eating disorders.
2.a. Medical assessment
A physical assessment can be a confronting and distressing experience for some people. All physical examinations should be conducted in a sensitive, trauma informed manner. In particular, weighing someone with a suspected eating disorder can be a deeply shameful and anxiety provoking experience.
Measurement of height, weight, and determination of body mass index; record weight, height and BMI on growth charts for children and adolescents
Sitting and orthostatic heart rate and blood pressure
Body temperature
Hydration status (e.g., poor skin turgor, slow capillary return)
Assessment of skin, hair and nails (e.g., brittle nails, carotenaemia (orange discolouration), dry skin, lanugo hair, callused knuckles)
Oral examination (e.g., dental erosions, gingivitis, pharyngeal redness and parotid enlargement)
Assessment of breathing and breath (e.g., ketosis)
Examination of periphery for circulation and oedema
Gastrointestinal function (e.g., bloating, pain, constipation, diarrhoea)
Menstrual history (e.g., menarche, last menstrual period, regularity, oral contraceptive use, oral contraceptive use that may be masking the impact of eating disorder on menstrual status)
Laboratory Assessments for Clients with Eating Disorders
2.b. Assessment of eating disorder symptoms and severity
The EDE-Q is a self-report questionnaire providing a measure of the range and severity of eating disorder behaviours. It is not a diagnostic tool, however, information from the EDE-Q can assist in forming an opinion on diagnosis, and the patient’s answers can form useful prompts for further investigation. The EDE-Q is a compulsory component of the Medicare Benefits Schedule (MBS) Eating Disorders Plan (EDP) for all eating disorders except anorexia nervosa. A patient must have an EDE-Q global score of greater than 3 to be eligible for an EDP.
Eating Disorder Examination Questionnaire and Scoring
2.c. Mental health assessment
The mental health assessment should include:
psychiatric history including previous treatments, comorbidities and substance use
family history of mental illness and/or eating disorders
social and support context (e.g., living situation, support network including relationship with family, friends or spouse, school or work)
a mental-state examination.
Screening
Several screening tools can be used in the primary care setting to assist in the detection of eating disorders. Screening tools are not diagnostic eating disorder tools, but rather, are used to detect the possibility of an eating disorder and identify when a comprehensive assessment is warranted.
The Eating Disorder Screen for Primary Care (ESP) below can be used as a screening tool in primary care settings.
Eating Disorder Screen for Primary Care (ESP) (7)
Are you satisfied with your eating patterns?
Do you ever eat in secret?
Does your weight affect the way you feel about yourself?
Have any members of your family suffered with an eating disorder?
Do you currently suffer with, or have you ever suffered in the past, with an eating disorder?
A ‘no’ to question 1. is classified as an abnormal response.
A ‘yes’ to questions 2-5 is classified as an abnormal response.
Any abnormal response indicates that the patient needs further assessment
Another screening tool is the InsideOut Screener.
Please note that the neither the IOI-S or the ESP screen for ARFID, Pica or Rumination Disorder and may not be suitable for screening First Nations people, neurodivergent people and the culturally linguistically diverse community.
For screening ARFID, Pica and Rumination Disorder please use the PARDI-AR-Q.
NEDC’s Screening, identification and referral guidelines can be found here.
Diagnosis
The following document outlines the diagnostic criteria for eating disorders according to the DSM-5 and can be used to guide your diagnosis.
DSM- 5 Diagnostic criteria for Eating Disorders
Further information on each eating disorder diagnosis:
Medicare Benefits Schedule
Rapid access to effective treatment prevents the eating disorder from becoming established and improves the course and prognosis. ‘Watchful waiting’ should never be used in the management of eating disorders.
When referring under the MBS, GPs should complete the appropriate plan and refer to a mental health professional and, when indicated, a dietitian. A referral to a psychiatrist or paediatrician will also be required to provide a review after 20 sessions, it is helpful to complete this referral when completing the EDP to accommodate in case of extended wait times to see a psychiatrist or paediatrician. A medical and a mental health professional working collaboratively constitute the minimum team for community eating disorder treatment. A referral to a dietitian should be completed when a patient experiencing an eating disorder requires nutrition education and support for effective treatment and recovery.
Referral using MBS can occur through an Eating Disorders Plan (EDP) or a Mental Health Care Plan (MHCP) and/or a Chronic Condition Management Plan (CCMP). GPs should consider the best match for the patients within the local service system.
Eating Disorder Plan (EDP)
Patients eligible for the EDP will be able to access comprehensive treatment and management services for a 12-month period, including:
up to 40 eating disorder psychological treatment (EDPT) services
up to 20 dietetic services
review and ongoing management services to ensure that the patient accesses the appropriate level of intervention.
Eligibility for EDP
Two cohorts of eligible patients can access EDPs:
Patients with a clinical diagnosis of anorexia nervosa; or
Patients who meet the eligibility criteria (below) and have a clinical diagnosis of bulimia nervosa, binge eating disorder or other specified feeding and eating disorder.
* Please note that patients with ARFID are not currently eligible for an EDMP.
Patients with anorexia nervosa are eligible without any further criteria needing to be met. The eligibility criteria that need to be met for a patient with a clinical diagnosis of bulimia nervosa, BED and OSFED, are:
EDE-Q scores ≥ 3 and
The condition is characterised by rapid weight loss, or frequent binge eating, or inappropriate compensatory behaviour as manifested by 3 or more occurrences per week and
Two of the following indicators are present:
clinically underweight with a body weight less than 85% of expected weight where weight loss is directly attributable to the eating disorder
current or high risk of medical complications due to eating disorder behaviours and symptoms
significant functional impairment resulting from serious comorbid medical or psychological conditions
admission to a hospital for an eating disorder in the previous 12 months
inadequate treatment response to evidence-based eating disorder treatment over the past 6 months despite active and consistent participation.
To create an EDP for an eligible person, the medical practitioner can use the InsideOut Institute Eating Disorders Care Plan template.
Further resources:
Mental Health Care Plan (MHCP)
A person who does not meet the criteria for an EDP can still receive up to 10 sessions of psychological treatment from a mental health professional over a 12-month period under a Mental Health Treatment Plan (MHTP, also known as the Better Access Initiative). Support is available through eligible psychologists, social workers, occupational therapists, general practitioners (GP), and other medical practitioners.
The rebate is available to people with a diagnosed mental disorder, such as an eating disorder, or comorbid conditions such as depression and anxiety. Someone experiencing disordered eating alongside a diagnosed mental disorder can also access treatment under the Better Access Initiative.
A MHTP can be created by a GP, psychiatrist or paediatrician and a referral made to an eligible treatment provider. After six sessions, the mental health professional must report back to the referring medical practitioner on the progress of treatment. The referring practitioner determines the need for further services and can re-refer for the remainder of the available psychological sessions.
For more information on MHCP’s see MBS notes.
Chronic Disease Management (CDM) Plan
CCM Plans are available for people living with chronic medical conditions and who require multidisciplinary, team-based care from a GP and at least two other health or care providers. This includes complex needs which may or may not be associated with an eating disorder. In some cases, it may be appropriate for management of a medical condition to be provided under a CDM and treatment for an eating disorder provided under an EDP. In this case, both plans and items can be used.
A CCM is developed and managed by a GP and this type of plan enables a GP to plan and coordinate the multidisciplinary care team and treatments.
For more information on CCM Plans see Services Australia.
Treatment
Therapeutic treatment providers, such as psychologists, will need to consider a variety of things when deciding on a treatment approach. Treatment type and the setting in which the treatment is provided should be matched according to the age of the person, type of eating disorder, the severity of the problem and the person’s goals, values and readiness for change.
Treatment for an eating disorder can take place within a variety of settings across outpatient, inpatient, residential or day programs, and involves a multidisciplinary team of providers. The treatment team at a minimum would comprise a mental health professional and a medical practitioner. Dietitians, other health professionals, and recovery support professionals may also be involved.
Treatment options for people experiencing an eating disorder within Australia include both private and public options.
You can read more about treatment options available within both inpatient and outpatient settings on the Stepped System of Care and Treatment Approaches pages of the NEDC website.
Psychosocial and recovery supports
Psychosocial support refers to services and programs which support the broader psychological and social needs of the person experiencing or at risk of an eating disorder and their family/supports and community. Recovery support refers to services and programs which support a person experiencing an eating disorder to engage with or sustain recovery or improved quality of life and assist family/supports and community in their caring role. It is important to consider the whole person when deciding what supports might be most suitable for someone. Each person will benefit from different approaches, types of supports and settings. A collaborative approach to engaging in support helps to ensure the patients preferences are included in the process.
Psychosocial and recovery supports can also include peer support and support groups.
Family, supporters and community
Families and support people play a crucial role in the care, support and recovery of people experiencing an eating disorder. A carer or support can be a parent, partner, friend, sibling, grandparent, child, grandchild, relative, neighbour, colleague or any other person caring for or supporting someone living with an eating disorder.
Carers and supports can contribute to an effective collaborative care approach in three key areas:
Supporting engagement with treatment: Some people experiencing an eating disorder may be reluctant to seek help due to the nature of the eating disorder. Families and supports play a vital role in influencing help seeking, raising awareness of eating disorder behaviours, and supporting recognition of stages in recovery.
Supporting implementation of treatment strategies and approaches: The family and/or support network are integral members of the care team. They may support the person to implement behavioural changes throughout treatment, such as sitting with the person at mealtimes and helping them cope with distress.
Supporting recovery: Recovery takes time and families and supports have a key role to play in supporting a person throughout their recovery journey.
Supporting someone with an eating disorder can be an exceptionally difficult experience, so consideration around whether a supported may benefit from a mental health care plan can be helpful.
NEDC have collated a list of resources for families and supports of people with lived experience of an eating disorder. These resources include online materials, tools, and programs. Click here to access the full list of resources.
Local Service Providers
NEDC’s Service Locator includes information about eating disorder-specific clinical services. It does not include information about individual practitioners. For information about individual practitioners, you can search the Butterfly Foundation’s Referral Database. For information about non-clinical supports, visit NEDC’s peer support and support groups page.
Eating Disorder Credentialed Clinicians
The Australia and New Zealand Academy for Eating Disorders (ANZAED) and the National Eating Disorder Collaboration (NEDC) partnered to develop a credentialing system for mental health and dietetic eating disorder treatment providers and general practitioners. The credentialing system aims to help people experiencing eating disorders to identify and access the right treatment at the right time, increasing the chance of timely intervention and positive treatment outcome.
if you are a referrer looking for a Credentialed Eating Disorder Clinician, please see the searchable database.
If you are looking to become a credentialling clinician, please see here. Credentialed clinicians receive a post-nominal (CEDC), digital badge, listing on the searchable database and access to professional development and networking with other CEDCs.
Eating Disorder Safe principles and practice
The Eating Disorder Safe principles aim to prevent eating disorders, reduce risk factors, bolster protective factors and minimise harm for anyone experiencing an eating disorder. They provide a framework for whole-of-community action to support everyone to enjoy a safe and supported relationship with their health, food, mind and body.
The ways that health professionals speak about bodies, teach about nutrition, develop health and related policies and accommodate difference can help to minimise unintended risks and harms in relation to eating disorders, disordered eating and body image distress. Eating Disorder Safe practice is suitable for all patients and does not need to be limited to use with patients with a diagnosed or suspected eating disorder.
The following documents provide in-depth information about the ED safe principles.