What does an eating disorder look like?

When Alex Rodriguez was 11 years old, he almost lost his life to the snowball effects of an eating disorder.
 
What began as low self-esteem following his parents’ divorce and being bullied at primary school, developed into obsessive behaviour around body image and disordered eating.
 
But Alex was fortunate to have a GP who was ‘instrumental’ in helping him access the treatment he needed and guiding him towards recovery.
 
‘Earlier on [as an 11-year-old] there were lots of different sociocultural and psychological risk factors present,’ Alex told newsGP.
 
‘I started restricting my eating and over-exercising pretty frequently on a daily basis, and I lost lots of weight very rapidly. My mum took me to a dietitian who got me back on track fairly quickly, and they taught me how to eat a little bit more healthily.’
 
But when Alex was a 14-year-old in high school, many of these risk factors started showing up again, such as anxiety, depression and low self-esteem.
 
‘I didn’t really know who I was and where I fit in in the world,’ he said.
 
‘I clung back on to this obsession with fitness, and again my exercise became very excessive and rigid, particularly in the form of running. And my eating progressively became more and more restrictive.’
 
At first people were very praising of Alex – his family, friends, teachers – for how rigid he was with exercise and nutrition. They thought it was healthy and disciplined.
 
Then progressively over six months, things ‘psychologically and physically spiralled’ and Alex ended up in hospital. It was only at the insistence of his mum, who was the most worried and recognised the signs from when he was younger, that he went to see a GP.
 
Early intervention and the GP’s role
After conducting blood tests, checking vitals, weight monitoring and working alongside a dietitian, Alex’s GP became increasingly concerned and was the one who eventually recommended he attend emergency because of how dangerous his vital signs were looking.
 
‘[Even] before those things started looking very bad, my GP was mindful of some of the risk factors present – the behavioural and psychological risk factors, how my eating and exercise was so rigid and obsessive,’ Alex said.
 
‘He started flagging these things for very early on, rather than towards the end when my vitals were starting to deteriorate.’
 
Dr Libby Crouch is a GP with a special interest in eating disorders (not Alex’s GP). She told newsGP the role of a GP within a multidisciplinary team is critical.
 
‘The GP’s role can include monitoring signs and symptoms – a role that we are very familiar with in several chronic disease states such as cardiovascular, diabetes, asthma,’ she said.
 
‘Equally important is supporting the patient, acknowledging the treatment can be very challenging and distressing and reassuring them that you will help to support them through it. People need realistic expectations, that treatment is not a quick fix and sometimes can be slower than others.
 
‘GPs are also important to instil hope and allow patients to express their feelings about their situation.’
 
Recovery and becoming a healthcare provider
After being discharged from hospital as a teenager, Alex was managed in the outpatient setting then a private setting by both dietitians and mental health professionals for the rest of his adolescence.
 
But even though he maintained his weight and didn’t physically deteriorate, psychologically Alex still needed ‘lots of help’ for all the different contributing factors which come with an eating disorder.
 
Then in early-to-mid university, he again started to become rigid and obsessive with food and exercise, but in a different way.
 
‘It was less about being a good runner and being leaner, more about being excessive, muscular and obsessed with being strong,’ Alex said.
 
‘And that started to take over my life there as well. I didn’t need to see a GP at that time, because medically I was okay, but I did access a psychologist to help me work further through my mental health journey side of things.’
 
Today Alex is an accredited eating disorder dietitian at Queensland’s River Oak Health and a lived experience advocate through his role as a Butterfly Foundation ambassador.
 
Initially, ‘and perhaps not for the best reasons’, Alex entered his studies in dietetics because of his ‘rigid obsessions’ with food. But towards the end of his studies, he became more interested in the mental health angle and helping people through empathising with their experiences.
 
He also now works working alongside GPs from a different angle to when he was a patient – helping them screen for eating disorders.
 
‘I get to see the full spectrum of things,’ Alex said.
 
‘[When I was experiencing my eating disorder] I was incredibly fortunate to have a GP who was well informed and who was able to screen not only medically for risk, but also for lots of the other psychological behavioural science that I was experiencing early on.
 
‘We are very fortunate [at River Oak Health] to now collaborate with GPs like that and ask them medical questions. They help us recommend hospital admission to people who need it and inform us on certain nutritional requirements based on vitals and blood tests.’
 When patients open up about eating and body image issues, this can give GPs an opportunity to further explore in a safe and non-judgemental way, says expert Dr Libby Crouch.

Further educating GPs
However, Alex believes more can be done to help GPs treat and manage eating disorders, and understand the broad range of things that accompany the condition.
 
‘It’s not only the ones that are typical presentations by people in slim bodies that have lost lots of weight and who identify as female, but to help GPs understand the broad spectrum of disordered eating and eating disorders in lots of different diverse population groups, body sizes, ethnicities, socio-cultural and economic status,’ he said.
 
‘Also to help GPs break down weight stigma and certain assumptions around nutrition and health that unfortunately, most of society anyway, believes about eating and exercise.’
 
According to Dr Crouch, a GP’s demeanour during a consultation can affect whether people will open up about eating and body image issues. And when they do, picking up cues from the patient can give an opportunity to explore their worries.
 
‘Developing the skill of looking relaxed with plenty of time for the patient definitely encourages people to talk about these deeply personal issues,’ she said.
 
‘If someone presents with a trivial concern there is usually a more significant problem which they want to address but are testing the waters first. Giving attention to the minor problem and providing advice in a non-judgmental way can give permission to speak about the bigger problems.
 
‘Making self-deprecating comments can be a clue to self-esteem issues and it is appropriate to pick this up and ask about this … and signals that you are interested in the person rather than their medical conditions.’
 
If patients are reluctant to discuss issues but are giving signals that they are struggling, Dr Crouch advises asking general questions about energy levels, sleep and whether they are eating well can often lead to a deeper discussion.
 
‘GPs are often worried about opening up the conversation with patients because the problems of eating disorders are so complex,’ she said.
 
‘But being part of a multidisciplinary team and supporting our patients is a very rewarding experience.’
 
Beneath the surface
Rapid weight loss and a thin or undernourished physical appearance can be hallmark signs of an eating disorder, but that may not always be the case.
 
While Alex acknowledges significant and potentially dangerous weight loss does happen and is important to monitor, he wants to raise more awareness outside the one-size-fits-all box and encourages GPs to monitor patients more frequently because of existing stereotypes.
 
‘Sometimes people with certain eating disorders … are in a larger body and have rapidly lost weight and are medically at risk,’ he said.
 
‘But on the surface, they may not appear to be very thin or very undernourished, and unfortunately, there can be lots of assumption with that, with some GPs but in society in general.
 
‘There’s lots of different people who may experience eating disorders, regardless of their diversity and their presentation – even if they don’t fit the white, thin female stereotype, which does exist, but it’s only one of endless amounts of presentations that can occur with eating disorders.
 
‘And they all deserve screening and to be listened to.’
 
Alex believes that the focus needs to be less about weight and appearance and more about potential impacts on physical, mental and social health that can present as warning signs for an eating disorder. This approach may help to fill some knowledge gaps for GPs, he said, as eating disorders can present on the surface, but not always.
 
‘That’s only the tip of the iceberg, the actual eating disorder is a very big piece of ice underneath the water,’ he said.
 
‘It goes much more beyond a look.’

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body image disordered eating eating disorders lived experience mental health