Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Hiding in Plain Sight: Just Ask, or You’ll Miss Most Eating Disorders


Although five percent of the population has a clinically significant eating disorder, most aren't detected because clinicians don’t ask. Simply asking,“What is the MOST you would be comfortable weighing?” can help identify a restrictive eating disorder.

The pandemic has disrupted daily routines, causing stress and isolation and increasing our exposure to social media. All of these have been implicated in a drastic rise in children and adolescents presenting for care with an eating disorder over the past 18 months. Although adolescents are usually brought to care by parents concerned about changes in their child’s eating or exercise behaviors, for adults with an eating disorder, often no one is watching, and detection can be less straightforward.


My patient Elizabeth was no stranger to mental healthcare. She’d been in therapy for years, had overcome alcohol use disorder, had talked through her childhood and struggles in therapy, had married and divorced—yet her moods were still unstable, she still felt unhappy, self-critical, and often worthless. When I asked why she was here she replied, “My nurse practitioner is concerned that I might have an eating disorder and that it’s gotten worse since COVID.”


“Great!” I thought. “Finally, someone asked!” No prior therapist or clinician had asked Elizabeth about her eating or exercise behaviors, or whether she felt overly preoccupied with weight and shape. She’d never told anyone that she spent most days preoccupied with what to eat, feeling fat, worrying about how to avoid eating at work gatherings, secretly fasting then binge eating and scheduling taking laxatives around access to a private bathroom. Although five percent of the population has a clinically significant eating disorder—that’s one in 20 of our patients—most aren’t detected because clinicians don’t ask. And when doctors don’t ask, most patients don’t tell.


Why patients may ask for help but not tell you they have an eating disorder

Stigma, shame, and ambivalence about seeking care or denial of illness hang like a shroud around an eating disorder. When patients seek help, it’s often not for the eating disorder but for secondary consequences of disordered eating and weight control behaviors. They present with mood and anxiety symptoms, sexual and reproductive disorders, gastrointestinal complaints, neurological symptoms including dizziness, headaches or syncope, fatigue, or poor concentration and attention. Often, they undergo exhaustive unrevealing medical workups, take multiple meds to try to treat complications of chronic restricting, binge eating, purging, or excessive exercise behaviors, and yet the underlying behavioral cause of their symptoms remains unidentified and unaddressed.


Just ask

Screening for an eating disorder isn’t difficult. The SCOFF is a simple screener with five questions. A score of two positive responses has good sensitivity and specificity for anorexia nervosa or bulimia nervosa.


S: Do you make yourself SICK (vomit) because you feel uncomfortably full?

C: Do you worry you have lost CONTROL over how much you eat?

O: Have you recently lost more than ONE stone (14 lbs) in a three-month period?

F: Do you believe yourself to be FAT when others say you are too thin?

F: Would you say FOOD dominates your life?


Additional questions that can help clarify a diagnosis include:


“Do you feel excessively preoccupied with food, weight, or shape, or do others think you are?”


A dietary recall from the prior 24 hours can help identify restrictive eating patterns or binge eating behavior. Look for skipped meals, avoidance of fat and calorically dense foods, and a limited food repertoire with little day to day variety. Ask about binge eating on calorically dense foods, and/or a sense of loss of control over eating.


“What is the most you would be comfortable weighing?


Inquiring about desired weight by saying something like, “What is the most you would be comfortable weighing?” can help identify a restrictive eating disorder. A desired BMI ≤18.5 in someone who is underweight suggests an anorectic ideal consistent with fear of fatness.


Asking, “If exercise didn’t burn calories how much would you exercise?” may help to distinguish obligate exercise driven by body image concerns.


Follow-up positive responses with questions regarding the extent and frequency of fasting, binge eating, purging (vomiting or laxatives), or excessive exercise behaviors and recent changes in weight.


Finally, ask family members or social supports if they’ve noticed changes in the patient’s eating habits or preoccupation with food, weight, or shape. Collateral information from significant others can often clarify the extent and degree of eating or weight control behaviors.


Instill hope and the desire for change

Most people with an eating disorder have tried to change but failed. Many believe they cannot get better. Yet the vast majority will improve or recover with appropriate treatment. The strongest evidence supports behavioral approaches that help patients normalize their eating and weight control behaviors, counter negative thoughts, and manage uncomfortable feelings or mood states. Most secondary complications will resolve with treatment of the eating disorder. Be compassionate, but also coach your patient, encouraging them to embark on the journey to recovery and to seek the care they need to achieve positive change.






This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.