Volume 52, Issue 12, December 2023

December 2023 correspondence

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Thank you to Donker and Hadinata1 for their article, which highlights the general practitioners’ (GPs) role in early identification and management of Binge Eating Disorder (BED), the most common of the eating disorders. Eating disorders are a prime example of the complex whole-person care at which GPs excel in managing when supported by multidisciplinary collaborators, and we wish to draw attention to some resources that aim to support GPs to do this.

The InsideOut Institute at The University of Sydney has developed a new screening tool that addresses significant concerns clinicians have with the Sick, Control, One stone, Fat, and Food (SCOFF) questionnaire and the Eating Disorder Screen for Primary Care (ESP) screeners recommended in the article. The InsideOut Institute Screener (IOI-S)2 is a six-item digital tool that has been validated and co-designed with lived experience experts and clinicians. It uses stigma-reducing language and can be administered online, increasing accessibility and empowering consumers.3 It has also been successfully validated for face-to-face delivery in primary care settings (Bryant, Spielman, Burton, et al, unpubl. data).

We would also like to bring colleagues’ attention to recent research that demonstrates effectiveness of an online brief therapy intervention for Binge Eating Disorder (BEeT), which addresses several barriers to treatment access.4 As is stated in the article, treatment for BED is largely psychological and dietetic, but only 23.2% of individuals with EDs access evidence-based treatment;5 this percentage is likely even lower in patients with BED where intra-personal barriers such as shame and secrecy create further difficulties in accessing care.6 Screening, assessment and diagnosis are well described in the article and the earlier this occurs, the better the prognosis. The BEeT intervention has recently received Australian Government funding for further dissemination,7 and aims to be accessible, cost-effective and rapidly available.

GPs will soon have access to both of these innovative tools for eating disorder management via the InsideOut GP Hub, which will address many system gap issues demonstrated by needs analysis of consumers and clinicians.8


Karen Spielman MBBS, FRACGP, CEDC, FASPM, Senior Research Officer and GP consultant, InsideOut Institute for Eating Disorders, Faculty of Medicine and Health, University of Sydney and Sydney Local Health District, Sydney, NSW

Emma Bryant BPsychSci/BMedSci (Hons), Research Officer, InsideOut Institute for Eating Disorders, Faculty of Medicine and Health, University of Sydney and Sydney Local Health District, Sydney, NSW

Sally Corry Grad Cert Medical Management and Leadership, General Manager/Primary Health Lead, InsideOut Institute for Eating Disorders, Faculty of Medicine and Health, University of Sydney and Sydney Local Health District, Sydney, NSW

Peta Marks RN, BN, MPH, MCFT, National Programs Manager, InsideOut Institute for Eating Disorders, Faculty of Medicine and Health, University of Sydney and Sydney Local Health District, Sydney, NSW

Sarah Barakat BPsych (Hons I), M Clin Psych, PhD, Clinical Psychologist and Postdoctoral Research Associate, InsideOut Institute for Eating Disorders, Faculty of Medicine and Health, University of Sydney and Sydney Local Health District, Sydney, NSW

Sarah Maguire BPsych (Hons), MA, DCP, PhD, Clinical Psychologist and Director, InsideOut Institute for Eating Disorders, Faculty of Medicine and Health, University of Sydney and Sydney Local Health District, Sydney, NSW

Competing interests: KS is the Advocacy Chair for the Australian Society for Psychological Medicine. All other authors have no conflicts of interests to declare.

  1. Donker T, Hadinata IE. Update on binge eating disorder: What general practitioners should know. Aust J Gen Pract 2023;52(6):386–90. doi: 10.31128/AJGP-12-22-6649.
  2. InsideOut. Do you want to screen for yourself or someone you care about? InsideOut, 2023. Available at [Accessed 18 June 2023].
  3. Bryant E, Miskovic-Wheatley J, Touyz SW, Crosby RD, Koreshe E, Maguire S. Identification of high risk and early stage eating disorders: First validation of a digital screening tool. J Eat Disord 2021;9(1):109. doi: 10.1186/s40337-021-00464-y.
  4. Barakat S, Touyz S, Maloney D, et al. Supported online cognitive behavioural therapy for bulimia nervosa: A study protocol of a randomised controlled trial. J Eat Disord 2021;9:126. doi: 10.1186/s40337-021-00482-w.
  5. Hart LM, Granillo MT, Jorm AF, Paxton SJ. Unmet need for treatment in the eating disorders: A systematic review of eating disorder specific treatment seeking among community cases. Clin Psychol Rev 2011;31(5):727–35. doi: 10.1016/j.cpr.2011.03.004.
  6. Kornstein SG, Kunovac JL, Herman BK, Culpepper L. Recognizing binge-eating disorder in the clinical setting: A review of the literature. Prim Care Companion CNS Disord 2016;18(3):10.4088/PCC.15r01905. doi: 10.4088/PCC.15r01905.
  7. InsideOut’s GP Hub and eClinic receives investment to improve outcomes for those living with an eating disorder. InsideOut, 2023. Available at’s-gp-hub-and-eclinic-receives-investment-to-improve-outcomes-for-those-living-with-an-eating-disorder [Accessed 18 June 2023].
  8. Merrell P, Hendry R, Meld Studios Peta Marks & Sean Rom. Supporting early intervention for people with eating disorders at the point of primary care. InsideOut, 2020.


Thank you, Karen Spielman, Emma Bryant, Sally Corry, Peta Marks, Sarah Barakat and Sarah Maguire for your response and contribution to the topic of Binge Eating Disorder (BED). Thank you for drawing our attention to the ‘IOI-S’1 tool as a method of screening.

We acknowledge the very real limitations and barriers that patients face in accessing treatment in the community. We agree that the online brief therapy intervention for BED (BEeT)2,3 can help to address this in select patients.

Furthermore, we would like to encourage general practitioners who are interested to become an accredited provider for ‘Focused Psychological Strategies’ through the General Practice Mental Health Standards Collaboration (GPMHSC).3


Tayla Donker BSc, School of Biomedical Sciences, The University of Melbourne, Melbourne, Vic

Ignatius Eric Hadinata MBBS, BMedSci, FRACGP, General Practitioner, Barwon Health Geelong, Vic; Addiction Medicine Registrar, Western Health, Melbourne, Vic

Competing interests: IEH is a Victorian Council Member at the RACGP (unpaid). TD has no conflicts of interest to declare.

  1. InsideOut. Do you want to screen for yourself or someone you care about? InsideOut, 2023. Available at [Accessed 2 August 2023].
  2. Barakat S, Touyz S, Maloney D, et al. Supported online cognitive behavioural therapy for bulimia nervosa: A study protocol of a randomised controlled trial. J Eat Disord 2021;9:126. doi: 10.1186/s40337-021-00482-w.
  3. General Practice Mental Health Standards Collaboration. Mental health training standards 2023–25: A guide for general practitioners. East Melbourne, Vic: The Royal Australian College of General Practitioners, 2022.

Regarding psychological distress due to climate change, Seth et al say it is ‘rational given the evidence’ and that ‘climate change is a significant existential threat.’1 There is no evidence for such pessimism.

Our furless species evolved on the warmest continent during a warm interglacial2,3 and survived a much warmer one than now.4,5 Cold weather increases respiratory,6,7 cardiovascular8,9 and cerebrovascular disease,10–12 and kills nearly 20-fold more people than hot weather globally,13 over 40-fold more in northern Europe,14 and is projected to remain more lethal than heat here this century,15 even using models running hot on implausibly high emissions.16

By slowing surface cooling, greenhouse gases elevate minimum temperatures,17 reducing the diurnal temperature range18 linked to respiratory infections,19 cardiovascular and respiratory mortality,20,21 childhood asthma22 and even diarrhoea.23 By making long winters milder and daily temperatures more even, climate change has contributed to humanity’s unprecedented longevity.

Over the past century, the global population quadrupled whereas deaths from extreme weather events declined by nearly 98%.24 Heatwave mortality is impacted much more by urban heat than by global warming.25 Bushfires burnt 7% of NSW in 2019–20, but one-quarter of Victoria in 1851.26 Megadroughts preceded White settlement.27 Gympie’s worst recorded flood was in 1893.28 Cyclones in North Queensland have declined since the preindustrial era.29 Greenhouse gases reduce temperature gradients and hence the pressure gradients that produce storms.

Carbon dioxide is an essential plant food, greening the planet,30 producing more food per hectare31 with less water,32 mitigating heat-stress33 and drought,34 and reducing the net global population at high risk of water stress.35 Genotype selection and nitrogen fertilisation can maintain protein content.36,37 Horticulturalists increase it in greenhouses to 2.5-fold the present atmospheric level. Reducing it by one-third to the preindustrial level would result in mass starvation.

Apocalyptic hyperbole can rob youth of a career, family, health, and happiness and has no place in scientific journals.


David Weston Allen MBBS, FRACGP, Grad Dip Phys Med, Director, Kingscliff Health Pty Ltd, Kingscliff, NSW

Competing interests: DWA is a member of the CO2 Coalition.

  1. Seth A, Maxwell J, Dey C, Le Feuvre C, Patrick R. Understanding and managing psychological distress due to climate change. Aust J Gen Pract 2023;52(5):263–68.
  2. Callaway E. Oldest Homo sapiens fossil claim rewrites our species’ history. Nature 2017.
  3. Candy I, Coope GR, Lee JR, et al. Pronounced warmth during early Middle Pleistocene interglacials: Investigating the Mid-Brunhes Event in the British terrestrial sequence. Earth Sci Rev 2010;103(3–4):183–96.
  4. Wikipedia. Eemian. Available at [Accessed 27 July 2023].
  5. Lozhkin AV, Anderson PM. The last interglaciation in Northeast Siberia. Quat Res 1995;43(2):47–158.
  6. Keatinge WR, Donaldson GC. Mortality related to cold and air pollution in London after allowance for effects of associated weather patterns. Environ Res 2001;86(3):209–16.
  7. Gouveia N, Hajat S, Armstrong B. Socioeconomic differentials in the temperature-mortality relationship in São Paulo, Brazil. Int J Epidemiol 2003;32(3):390–97.
  8. Hajat S, Haines A. Associations of cold temperatures with GP consultations for respiratory and cardiovascular disease amongst the elderly in London. Int J Epidemiol 2002;31(4):825–30.
  9. Enquselassie F, Dobson AJ, Alexander HM, Steele PL. Seasons, temperature and coronary disease. Int J Epidemiol 1993;22(4):632–36.
  10. Nakaji S, Parodi S, Fontana V, et al. Seasonal changes in mortality rates from main causes of death in Japan (1970–1999). Eur J Epidemiol 2004;19(10):905–13.
  11. Chang CL, Shipley M, Marmot M, Poulter N. Lower ambient temperature was associated with an increased risk of hospitalization for stroke and acute myocardial infarction in young women. J Clin Epidemiol 2004;57(7):749–57.
  12. Gill RS, Hambridge HL, Schneider EB, Hanff T, Tamargo RJ, Nyquist P. Falling temperature and colder weather are associated with an increased risk of aneurysmal subarachnoid hemorrhage. World Neurosurg 2013;79(1):136–42.
  13. Gasparrini A, Guo Y, Hashizume M, et al. Mortality risk attributable to high and low ambient temperature: A multicountry observational study. Lancet 2015;386(9991):369–75. doi: 10.1016/S0140-6736(14)62114-0.
  14. Masselot P, Mistry M, Vanoli J, et al.; MCC Collaborative Research Network; EXHAUSTION project. Excess mortality attributed to heat and cold: A health impact assessment study in 854 cities in Europe. Lancet Planet Health 2023;7(4):e271–81.
  15. Gasparrini A, Guo Y, Sera F, et al. Projections of temperature-related excess mortality under climate change scenarios. Lancet Planet Health 2017;1(9):e360–67.
  16. Hausfather Z, Peters GP. Emissions – the ‘business as usual’ story is misleading. Nature 2020;577(7792):618–20.
  17. Knappenberger PC, Michaels PE, Davis RE. The nature of observed climate changes across the United States during the 20th century. Clim Res 2001;17:45–53.
  18. Braganza K, Karoly DJ, Arblaster JM. Diurnal temperature range as an index of global climate change during the twentieth century. Geophys Res Lett 2004;31(13):217–21.
  19. Ge WZ, Xu F, Zhao ZH, Zhao JZ, Kan HD. Association between diurnal temperature range and respiratory tract infections. Biomed Environ Sci 2013;26(3):222–25.
  20. Braga ALF, Zanobetti A, Schwartz J. The effect of weather on respiratory and cardiovascular deaths in 12 U.S. cities. Environ Health Perspect 2002;110(9):859–63.
  21. Song G, Chen G, Jiang L, et al. Diurnal temperature range as a novel risk factor for COPD death. Respirology 2008;13(7):1066–69.
  22. Xu Z, Huang C, Su H, Turner LR, Qiao Z, Tong S. Diurnal temperature range and childhood asthma: A time-series study. Environ Health 2013;12(1):12.
  23. Xu Z, Huang C, Turner LR, Su H, Qiao Z, Tong S. Is diurnal temperature range a risk factor for childhood diarrhea? PLoS One 2013;8(5):e64713.
  24. Goklany IM, Morris J. Wealth and safety: The amazing decline in deaths from extreme weather in an era of global warming, 1900–2010. Reason 2011;393:1–24. Available at [Accessed 27 July 2023].
  25. Wong KV, Paddon A, Jiminez A. review of World Urban Heat Islands: Many linked to increased mortality. J Energy Resour Technol 2013;135(2):1217–28.
  26. Strutt W. Black Thursday bushfires. National Museum Australia, 2022. Available at [Accessed 28 July 2023].
  27. Meko DM, Woodhouse CA, Baisan CA, et al. Medieval drought in the upper Colorado River basin. Geophys Res Lett 2007;34(10):705–10.
  28. Gympic Regional Libraries. Floods of Gympie. Gympie Regional Memories, 2023. Available at [Accessed 27 July 2023].
  29. Nott J, Haig J, Neil H, Gillieson D. Greater frequency variability of landfalling tropical cyclones at centennial compared to seasonal and decadal scales. Earth Planet Sci Lett 2007;255(3–4):367–72.
  30. Zhu Z, Piao S, Myneni RB, et al. Greening of the earth and its drivers. Nature Clim Change 2016;6:791–95.
  31. Ainsworth EA, Long SP. What have we learned from 15 years of free-air CO2 enrichment (FACE)? A meta-analytic review of the responses of photosynthesis, canopy properties and plant production to rising CO2. New Phytol 2005;165(2):351–71.
  32. Konzmann M, Gerten D, Heinke J. Climate impacts on global irrigation requirements under 19 GCMs, simulated with a vegetation and hydrology model. Hydrol Sci J 2013;58(1):88–105.
  33. Gutiérrez D, Gutiérrez E, Pérez P, Morcuende R, Verdejo AL, Martinez-Carrasco R. Acclimation to future atmospheric CO2 levels increases photochemical efficiency and mitigates photochemistry inhibition by warm temperatures in wheat under field chambers. Physiol Plant 2009;137(1):86–100.
  34. Fleisher DH, Timlin DJ, Reddy VR. Elevated carbon dioxide and water stress effects on potato canopy gas exchange, water use and productivity. Agric For Meteorol 2008;148(6-7):1109–22.
  35. Wiltshire A, Gornall J, Booth B, et al. The importance of population, climate change and carbon dioxide plant physiological forcing in determining future global water stress. Glob Environ Change 2013;23(5):1083–97.
  36. De Costa J, Weerakoon WMW, Chinthaka KGR, Herath HMLK, Abeywardena RMI. Genotypic variation in the response of rice (Oryza sativa) to increased atmospheric carbon dioxide and its physiological basis. J Agron Crop Sci 2007;193(2):117–30.
  37. Sultana H, Armstrong R, Suter H, Chen D, Nicolas ME. A short-term study of wheat grain protein response to post-anthesis foliar nitrogen application under elevated CO2 and supplementary irrigation. J Cereal Sci 2017;75:135–37.


Thank you for the opportunity to respond to this letter. We note that the reader disagrees that anthropogenic climate change exists, and therefore asserts that the approach we describe in our article is misinformed and harmful. This view is simply not credible based on the evidence.1

There is no equivalence between the consensus of the global scientific community and the biased presentation of outlier opinion and research. Efforts to provoke debate about already well-established evidence are an unhelpful distraction from focusing on the urgent work that needs to be done to protect the health of our communities as our climate continues to change.2

The view expressed by the reader is of interest as an illustration of the type of dismissive response that those who express concerns about climate change might encounter. In our experience, views such as these are far more likely to be harmful to the wellbeing of a person with climate distress than the person-centred, validating and empowering approach we describe.

We are grateful to belong to a college of our peers that is rigorously evidence-based and dedicated to ensuring the health of our community. The RACGP, along with the majority of medical colleges, has a clear position statement about climate change, includes the topic in its curriculum, and has a range of education resources for members.3

We thank the AJGP for its commitment to advancing professional knowledge on this topic through the publication of the climate change focus issue in which our article was included.


Anna Seth MBBS, FRACGP, DRANZCOG, DCH, General Practitioner, Private Practice, Kingston, Tas

Cybele Dey MBBS (Hons 1), M.Psychiatry, FRANZCP (Cert. Child & Adolescent), FRACP (Paeds), Child and Adolescent Psychiatrist, Staff Specialist, Department of Psychological Medicine, The Sydney Children’s Hospital Network (SCHN), Sydney, NSW; Conjoint Lecturer, School of Clinical Medicine, Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, NSW

Competing interests: AS is Co-Chair of Doctors for the Environment Specific Interest Group in Mental Health (unpaid). CD is Co-Chair of Doctors for the Environment Mental Health Special Interest Group, Sustainability and Net Zero Clinical Lead at the Sydney Children’s Hospital Network, Co-Chair of the NSW RANZCP Climate Psychiatry Group and Chair of the SCHN Psychological Medicine Climate and Mental Health Working Group.

  1. Intergovernmental Panel on Climate Change (IPCC). AR6 synthesis report: Climate change 2023. IPCC, 2023. Available at [Accessed 21 September 2023].
  2. Beggs PJ, Zhang Y, McGushin A, et al. The 2022 report of the MJA-Lancet Countdown on health and climate change: Australia unprepared and paying the price. Med J Aust 2022;217(9):439–58. doi: 10.5694/mja2.51742.
  3. The Royal Australian College of General Practitioners. Climate change and health. RACGP, 2023. Available at [Accessed 21 September 2023].
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