Primary Care: Taking the History
Please note: Eating disorders develop in men, women, girls, and boys. For ease in reading, we have used "she" and "her" in the text below.
Through a comprehensive evaluation, the primary care physician determines whether or to what degree an individual meets the diagnostic criteria for an eating disorder. The patient’s history—information collected through an interview or written questionnaire—is a crucial part of the assessment. Questions vary based on developmental stage since some aspects are more applicable to adults than to young patients and vice versa. In addition, eating disorder evaluations take the patient’s cultural and ethnic identities into account.
When an individual presents with unexpected weight loss, the primary care physician determines whether it is related to an eating disorder and/or to another illness, such as diabetes mellitus, inflammatory bowel disease, celiac disease, a malignancy, thyroid dysfunction, or Addison's disease. Having an eating disorder does not preclude these other diagnoses.
Infectious mononucleosis, a virus that occurs most often in adolescents and young adults, can result in unintentional weight loss. When an individual recuperates from “mono,” her body—in its efforts to maintain homeostasis—will presumably return to its pre-illness weight range. Some post-mononucleosis patients, however, are particularly pleased with their weight loss—especially if they receive compliments for it—and aspire to get thinner, subsequently falling prey to an eating disorder.
The doctor will be interested in whether the individual has a history of depression, anxiety disorder, obsessive compulsive disorder or substance abuse. These conditions often coexist with eating disorders.
The primary care physician will want to know about the health of the individual’s family. Does she have relatives with a medical illness such as diabetes mellitus, colitis, cancer or thyroid disease? Are there family members with eating disorders, weight concerns, substance abuse, depression or other mental illness?
Another set of questions involves weight. What is the most and the least the patient has weighed and when did each of these occur? During this part of the interview, the physician not only collects facts but also explores the individual’s attitudes about her body size and shape. What would she like to weigh and how would achieving this goal improve her life? How frequently does she step
on the scale? Is she trying to lose weight?
It is very important for an individual to be honest with her physician about her eating habits. One reason for this is that a
person with an eating disorder may have a normal physical exam and normal laboratory tests, especially if she is in the early stage of the illness. And the severity of a patient’s eating behaviors is often key in determining whether treatment is indicated. What weight control practices has she engaged in? Has she cut back on the kinds and amounts of food she takes in? Does she eat large amounts within a short period of time? Does she take diet pills, diuretics, or laxatives? Does she induce vomiting? How long ago did she start these behaviors and how frequently has she engaged in them? When a patient has a particularly hard time telling her physician about her eating, information provided by the family can often help her get the care she needs.
Many individuals with eating disorders exercise to an extreme, often for the purpose of controlling their weight. The primary care physician is likely to ask the patient what sports or other physical activities (such as dance) she participates in. How frequent are her workouts and how long do they last? Does she train in solitude, feel compelled to exercise or find it difficult to stop? Has she had any sports injuries? Has she been tested for bone density?
Absent or irregular menstrual periods are a major feature of eating disorders. The doctor will want to know how old the patient was when her periods started. Have her cycles been regular or has she skipped some? Does she use birth control pills or other form of contraception? Has she been pregnant?
When asked about specific symptoms, some individuals say they feel fine while others report one or more of the following:
If a patient is over 18 years of age, her medical evaluation is held in strict confidentiality; if she is younger, however, information is usually given to her parents.
- Feeling cold
- Low in energy
- Low in mood
- Trouble concentrating or making decisions
- Frequent, persistent worries about food, body size or weight
- Swollen cheeks
Practice guideline for the treatment of patients with eating disorders
American Psychiatric Association (APA). Practice guideline for the treatment of patients with eating disorders. 3rd ed. Washington (DC): American Psychiatric Association ; 2006 Jun. 128 p. [765 references].
Behavioral management for anorexia nervosa
Attia, E., Walsh, B.T. Behavioral management for anorexia nervosa. New England Journal of Medicine. 2009; 360: 500-6.
Becker, A.E., Grinspoon, S.K., Klibanski, A., Herzog, D.B. Eating disorders. New England Journal of Medicine. 1999; 340: 1092-8.
Stigmatization of anorexia nervosa: Characteristics and response to intervention
Crisafulli, M.A., Thompson-Brenner, H., Franko, D.L., Eddy, K.T., Herzog, D.B.
Stigmatization of anorexia nervosa: Characteristics and response to intervention.
Journal of Social and Clinical Psychology. 2010; 29: 756-770.
Goldstein, M.A., Dechant, E.J., Beresin, E.V. Eating disorders
Pediatrics in Review. 2011; 32: 508-21.
Case records of the Massachusetts General Hospital. Case 29-2008. A 19-year-old man with weight loss and abdominal pain
Goldstein, M.A., Herzog, D.B., Misra, M., Sagar, P. Case records of the Massachusetts General Hospital. Case 29-2008. A 19-year-old man with weight loss and abdominal pain. New England Journal of Medicine. 2008; 359: 1272-83.
Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa
Grinspoon, S., Thomas, E., Pitts, S., Gross, E., Mickley, D., Miller, K., Herzog, D., Klibanski, A.
Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Annals of Internal Medicine. 2000. 133: 790-4.
SCOFF, the development of an eating disorder screening questionnaire
Hill, L.S., Reid, F., Morgan, J.F., Lacey, J.H. SCOFF, the development of an eating disorder screening questionnaire. International Journal of Eating Disorders. 2010; 43: 344-51.
The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa
Klibanski, A., Biller, B.M., Schoenfeld, D.A., Herzog, D.B., Saxe, V.C. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa Journal of Clinical Endocrinology and Metabolism . 1995; 80: 898-904.
Early identification and treatment of eating disorders: prodrome to syndrome
Le Grange, D., Loeb, K.L. Early identification and treatment of eating disorders: prodrome to syndrome. Early Intervention in Psychiatry. 2007; 1: 27-39.
Medical complications of bulimia nervosa and their treatments
Mehler, P.S. Medical complications of bulimia nervosa and their treatments. International Journal of Eating Disorders. 2011; 44: 95-104.
Medical findings in outpatients with anorexia nervosa
Miller, K.K. Grinspoon, S.K., Ciampa, J., Hier, J., Herzog, D., Klibanski, A. Medical findings in outpatients with anorexia nervosa. Archives of Internal Medicine. 2005; 165: 561-6.
Physiologic estrogen replacement increases bone density in adolescent girls with
Misra, M., Katzman, D., Miller, K.K., Mendes, N., Snelgrove, D., Russell, M., Goldstein, M.A.,
Ebrahimi, S., Clauss, L., Weigel, T., Mickley, D., Schoenfeld, D.A., Herzog, D.B., Klibanski, A.
Physiologic estrogen replacement increases bone density in adolescent girls with
anorexia nervosa. Journal of Bone and Mineral Research. 2011; 26: 2430-8.
Excessive exercise in eating disorder patients and in healthy women
Mond, J.M., Calogero, R.M. Excessive exercise in eating disorder patients and in healthy women. Australian and New Zealand Journal of Psychiatry. 2009; 43: 277-34.
Managing anorexia nervosa
Nicholls, D., Hudson, L., Mahomed, F. Managing anorexia nervosa. Archives of Disease in Childhood. 2011; 96: 977-82.
Course and outcome of eating disorders in a primary care-based cohort
van Son, G.E., van Hoeken, D., van Furth, E.F., Donker, G.A., Hoek, H.W. Course and outcome of eating disorders in a primary care-based cohort. International Journal of Eating Disorders. 2010; 43: 130-8.
Nursing Magnet Application Send-Off
Standardized Patient Program: male student-female patients
Track & Field Practice
This page was updated on November 17, 2010 in collaboration with Mark A. Goldstein, M.D.,
Chief, Division of Adolescent and Young Adult Medicine, Massachusetts General Hospital.