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My Masters Project Paper

Kowledge of the Screening for Eating Disorders in the Education of Primary Care Providers

Knowledge of the Screening for Eating Disorders in the Education of Primary Care Providers

Emily K Marr

Grand Valley State University Masters of Clinical Dietetic

Masters Project

December 13, 2017

  Abstract

Background

National surveys estimate that 20 million women and 10 million men in America will have an eating disorder at some point in their lives.3 Eating disorders have become one of the nation’s deadliest psychological conditions; one out of every five people with anorexia eventually die of causes related to the disorder.3,7

Purpose

Increased prevalence of eating disorders in children and adolescents have made it progressively more important that primary care providers, especially pediatricians and physician assistants, be familiar with the early detection and appropriate management of this disease.18,19 However, research shows that PCPs feel unprepared to identify and manage complex chronic disorders, especially in the area of mental health like eating disorders.

Methods

First year and last year Grand Valley State University physician assistant students took an online survey to gain a better understanding of the current knowledge/training of eating disorders in the education of primary care providers.

Results

We can see a statistically significant increase in confidence level with last year students compared to first year students in recognizing ED symptoms and prescribing treatment. However, most results prove that education in this area is lacking.

Discussion/Conclusion

Studies show that more research in eating disorders is needed. It has been found that not enough primary care providers have the knowledge and confidence it takes to screen, assess, and treat patients with eating disorders.23 Physicians do not have adequate knowledge in nutrition, especially in complex situations that also include mental health and nutrition deficiences.1 Basic training sessions, routine screening assessments, and increased awareness about eating disorders have been shown to produce great improvement towards the treatment of eating disorders in primary care settings.23,35 Further studies need to be done to find out more on how to improve treatment and awareness in the primary care settings.

 

Introduction

Eating disorders are conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual’s physical and mental health. They are serious mental illnesses that can affect people of every age, sex, gender, race, ethnicity, and socioeconomic group, but are treatable. No one knows exactly what causes eating disorders, but it is thought to be an assortment of biological, psychological, and sociocultural factors.1 Epidemiologic studies show a steady increase in the number of children and adolescence with eating disorders since the 1950s.2 National surveys estimate that 20 million women and 10 million men in America will have an eating disorder at some point in their lives.3  During the past decade, obesity prevalence in children and adolescence has increased significantly causing an unhealthy emphasis on dieting and weight loss along with an increased concern with weight related issues in children at progressively younger ages.2 Micali et al.4 in a case-register study assessing the prevalence of ED in the general population, found that the peak age of anorexia nervosa diagnosis was between the ages of 10–14 years whereas diagnoses of bulimia nervosa peaked between 15 and 19 years old.5 When the age of onset falls between 10-15 years old, it can result in a 25-year reduction of life span.6

Eating disorders have become one of the nation’s deadliest psychological conditions; one out of every five people with anorexia eventually die of causes related to the disorder.3,7 In fact, the annual death rate associated with anorexia nervosa is more than twelve times higher than any other causes combined for females between 15 and 24 years old.8 Also, anorexia nervosa claims the spot as one of the highest suicide rates of any psychiatric condition; a study found that those with eating disorders are 56 times more likely to take their own life then their healthy peers.2 Even though most patients with anorexia attain partial recovery at some point during their illness, the rate of sustained full recover is just 33%.5 Once the disorder has taken over, most people become mentally and physically incapable of controlling their eating and/or weight and require professional help.1

Early diagnosis

Eating disorders are debilitating and can be fatal, but recognition of the seriousness and burden of this illnesses is lacking. Only half of those with anorexia and bulimia nervosa fully recover, and even among those who have, many continue to maintain low body weights and experience depression.3 Detection and intervention correlating with early age at diagnosis are shown to have improved outcomes and better chance of full recovery with eating disorder patients.4 The most commonly adopted definition of early stage illness is an illness duration of less than three years.5 A delay in treatment can increase the risk of serious medical complication such as osteoporosis, brain atrophy, vital organ damage, and sudden cardiac death; when left untreated, mortality rates for eating disorders reach close to 20%.6 Because family physicians and physician assistants serve as primary care providers for adolescents from birth to 18 years old, they have an important role in being aware of and diagnosing these disorders.8,9

There is a paradox of increasing utilization of health services on one side and an underutilization of appropriate health services on the other.3 Only a minority of people with an eating disorder receive treatment specifically for the disorder. Primary care providers do not consistently or universally assess for eating disorders even for patient groups where universal screening is recommended, such as adolescent females.10 In one study of health service utilization, only one-third of eating disorder sufferers were asked about problems with eating by a primary care provider during any medical visit.10 In a national US survey of primary care providers, including nurses, nurse practitioners, and physicians, 68% of respondents indicated they did not think to screen for eating disorders due to it not being the presenting concern.10 Treatment for eating disorders is not only time consuming and potentially costly, but specialty providers are limited and only a small portion of individuals with eating disorders are treated in a specialty setting. Research notes that most people are resistant when it comes to specialty care and are more likely to “open up” in their usual primary care setting.10

Risk Factors

For years it was believed that eating disorders originated from environmental influences such as peer pressure, societal expectations, and/or the media. Uneducated people set a stereotype that eating disorders were choices by vain girls who just wanted to be skinny.11 Recent work is now showing the genetics and biological risk factors might play a large role in disease manifestation. The Minnesota Twin Family Study found that the heritability of eating disorder symptoms increased from zero before puberty to 50 percent after puberty. With this, it has been suggested that the greatest heritability in disordered eating occurs when estrogen levels are at their highest.11

Following this further, new Functional Magnetic Resonance Imaging (fMRI), brain imaging work by Oregon Research Institute psychologist Eric Stice,11 showed that bulimia may be hard-wired in some females. Thirty-three adolescent females and 43 young women were involved in Stices’ study where he observed their brain activation after tasting a chocolate milkshake. It was found that the women who showed greater activation in the key reward areas of the brain, such as gustatory cortex, somatosensory cortex and striatum, reported an increase in bulimic behaviors over a one-year follow-up period.11 In other words, exposure to high-fat, high-sugar diets in children can lead to a grown craving for these types of foods later in life, which may be what sets these young women up for bulimia. However, it has also been shown that genetic predispositions to many trait disturbances such as behavioral rigidity, perfectionism, or harm avoidance may play an even larger role then genetic influence on eating, hunger, or satiety.12 These traits lead back to the feeling of “control,” and as stated before, an eating disorder is something the person can have “control” over when other aspects of their life seem out of control.

Neuroendocrine abnormalities can increase the risk for eating disorders. Leptin, a hormone produced in adipose tissue, is mainly involved in the long-term regulation of body weight and energy balance by acting as a hunger suppressant signal to the brain.12 Leptin is also involved with reproduction, immune function, physical activity, and some endogenous endocrine axes. Leptin is not directly involved in the etiology of anorexia or bulimia. However, changes due to poor nutrition and unnecessary weight loss in its physiology may contribute to the origin and/or the maintenance of some clinical signs of eating disorders, which in turn can have an impact on the prognosis of anorexia.12

Diagnostic Criteria for common eating disorders

Eating disorders are psychiatric conditions with severe physical consequences. It is not just about going on a diet or exercising every day to lose weight, but extreme behaviors that are never ending and will become more excessive/restrictive over time unless help is found. There is a point where the person will no longer socialize with friends because in a social situation, they will not be able to control when or where they eat, or when they can go exercise.13 A person with an eating disorder may have started out eating smaller or larger portions, but eventually the urges to eat became uncontrollable.11 The two most common eating disorders are anorexia nervosa and bulimia nervosa (DSM criteria found in appendix). However, other food-related disorders are now becoming more common. First there is binge eating disorder, categorized by recurrent-persistent incidents of uncontrolled binge eating without the purging behaviors of Bulimia nervosa.14 Lifetime rates of BED have been estimated at about 2.8% with the prevalence being higher among obese adults ranging from 8-28%.15 In weight control clinics, it has even been reported in as many as 48% of patients.15 Then there is body dysmorphia, the obsession with perfection and defined as the impaired preoccupation with a nonexistent or minimal flaw in appearance. This affects 0.7-2.4% of the general population and a much larger percentage of those trying to receive aesthetic treatments.16 Finally we have orthorexia, a pathological obsession with proper nutrition that is characterized by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods believed to be unhealthy or impure. Even with it being a distinct behavioral pattern frequently seen by clinicians, orthorexia has gotten little empirical attention. Existing estimates of orthorexia range from 6.9% to 57.6% in the general population,17 social media being a huge contributor.  

Most of the medical and physical complications associated with these disorders can resolve with re-feeding and/or the cessation of purging. However, there are certain complications, if not stopped, starving, stuffing, and purging can lead to irreversible physical damage and even death. These include, but are not limited to, growth retardation, structural brain charges, and low bone mineral density which can lead to osteoporosis, even in adolescents.12 But the most life-threatening damage is usually the havoc wreaked on the heart. As the body loses muscle mass, it loses heart muscle at a preferential rate, so the heart gets smaller and weaker. The cardiac tolls are acute and significant, and set in quickly. Heart damage is the most common reason for hospitalization in most people with anorexia.12

PCPs role in screening for EDs

Increased prevalence of eating disorders in children and adolescents have made it progressively more important that primary care providers, especially pediatricians and physician assistants, be familiar with the early detection and appropriate management of this disease.18,19 When eating disorders start between 10 and 15 years of age, it can result in a 25-year reduction in lifespan.20 Also, with the estimated financial cost associated with disability-adjusted life years due to eating disorders being greater than that for anxiety and depression combined, it is considered a significant public health concern.20

Early detection can prevent the physical and psychological consequences of malnutrition that cause the progression to later stages.18 However, research shows that PCPs feel unprepared to identify and manage complex chronic disorders, especially in the area of mental health like eating disorders. This is due to the multiple psychiatric and medical comorbidities, making management challenging.18 Patients, families, and professionals alike are concerned about the gaps in eating disorder care with PCPs being dissatisfied in their training with eating disorders.5

Primary care providers are dissatisfied with the level of training they receive regarding assessment, diagnosis, and treatment of eating disorder with many rating their undergraduate and even postgraduate training as poor. A 2013 study in Canada showed that more than 90% of the PCPs participating said they encountered patients who presented with an ED, but were unable to treat due to lack of skill, case complexity, and/or a lack of recourses as their primary obstacles.5 The training gaps and needs suggested by PCPs included outpatient services, diagnostic methods, management planning, and screening tools.5

PCPs current education and training

Many pleas have been made over the past few decades to improve nutrition knowledge and skills of primary care professionals. However, many students continually rate their nutrition knowledge and preparation to be inadequate.1,21 Medical instructors also want additional nutrition instruction at their institutions, and it has been proven that current nutrition education is indeed inadequate. This determination is based off two well-known group reports. First is the National Academy of Science report of 1985 that suggests 25 hours of nutrition instruction as a minimum. The other is the 1989 American Society of Clinical Nutrition recommendation that 37 to 44 hours be dedicated to nutrition instruction during medical school.22 By either standard, even two decades later, medical schools are falling far short of providing adequate training.

Moreover, a study by Adems1 et al., following up from their study in 2004, found that of the 103/109 schools they surveyed that required some nutrition education, only 25 (25%) required a dedicated nutrition course; in 2004, 32 (30%) of 106 schools did. Overall, medical students received 19.6 contact hours of nutrition instruction during their medical school careers (29% reported requiring 12 or fewer hours); the average in 2004 was 22.3 hours. Only 28 (27%) of the schools met the minimum requirement of 25 hours; in 2004, 40 (38%) of schools did.22 It is important to note that 80% of nutrition education in medical schools is not specifically identified as such in the curriculum with the bulk being taught in the basic science courses, weakening its importance and not giving it the emphasis it deserves.1 Also, it still appears that most nutrition education that does occur, takes place in the first two years (preclinical), and would be more beneficial later when the students can see the direct relationship between nutrition principles and medical treatment.22

Some barriers that have been found as to why nutrition is not getting the recognition it deserves is the fact that nutrition is not considered a science to academic physicians.1 Studies have found that physicians perceive nutrition as a soft topic and are not comfortable when the intervention requires behavioral change.23 It has also been found that the absence of curricula is due to lack of expert nutrition faculty to advocate for these classes and show how nutrition can be applied to modern medical practices.22 Another more recent barrier is a lack of time for newer courses or additional lectures. Lastly, students do not need to have much nutrition knowledge for their licensing exams.1

Following this further, eating disorders are seen as a public health concern. This is due to the co-occurrence of physical and psychological problems, the likelihood of going untreated, its high mortality rate, and lack of treatment sites/centers or referral opportunities. Mortality rates are up to 4.5%, most often due to medical complications.2 Therefore, the most effective treatment is a collaborative approach between medical and mental health professionals.24 The problem is, medical providers see eating disorders as primarily mental health problems, whereas mental health providers see them as mainly medical concerns.2

In the year prior to an eating disorder diagnosis, the use of healthcare rises drastically, more than five visits versus the usual one to two, to treat medical concerns.18 However, eating disorder sufferers often go untreated due to many factors such as a fear of telling their physicians, defensive response when questioned about eating behaviors, shame, and even self-denial.2 Women who have recovered from eating disorders stress the importance of screening by primary care providers as an important step towards intervention.2 One study found that only one-third of eating disorder sufferers were asked about problems with eating by their primary care provider, and only one in ten bulimia nervosa patients were recognized and diagnosed.2

Despite these barriers, routine screening for eating disorders can increase patient disclosure and treatment outcomes. Findings from a brief eating disorder training for medical social workers found that eating disorder knowledge in the participants increased and was maintained over a six-month period.2 So, even a minimal eating disorder training can be effective for increasing providers’ knowledge and skills in addressing eating disorders in their practice and can increase knowledge and likelihood of routine eating disorder assessment.2

However, some studies have shown that, when it comes to eating disorders, some clinicians can do more harm than good. Without the proper experience or knowledge of this disorder, some clinicians can stand in the way of early detection.3 When patients visit their doctor knowing or thinking they have “disordered eating” or an eating problem, but are not at a “severe” low weight or have serious medical problems, some clinicians will not think they actually need medical help.3

Thomas-Brenner3 looked at 20 studies and found that clinicians’ negative reactions to patients with eating disorders stemmed from clinicians’ frustration, hopelessness, lack of competence, and worry. Inexperienced clinicians showed even more negative views towards eating disorder patients especially when compared to their other patients.3,23 These reactions seemed to be associated with patients’ lack of improvement and personal pathology, along with clinicians’ stigmatizing beliefs, inexperience, and gender. It was even found that medical and nursing students considered patients with eating disorders to be significantly more responsible for their illness then schizophrenic patients.3 Stigma is one of the main components when it comes to clinicians’ attitudes towards eating disorder patients. When this is the root of the clinicians’ reactions, patients are reluctant to seek more treatment. Decreasing these stigmatized beliefs and behaviors can lead to better care, more referrals, and better outcomes.4 Therefore, all healthcare professionals would benefit from improved training on issues in mental health, especially with eating disorders.

The need for screening

Disordered eating, along with depression and anxiety, is one of the most common mental health difficulties. Early diagnosis is linked to improved outcome, however, detection of eating disorders in primary care is poor. The National Institute for Clinical Excellence (NICE) guidelines on the management of eating disorders show the need for improved identification and screening of eating disorders in primary care settings.10,25 A survey by the National Eating Disorder Association showed that 42% of primary care providers did not make an early diagnosis (meaning before severe medical complication took place), indicating that services are failing to meet the NICE recommendations that eating disordered patients seeking help be assessed and receive treatment as early as possible.10 The treatment for eating disorders is not only a long and costly process, but specialists are limited and only a small portion of eating disorders are treated in specialty care settings. Research suggests that individuals with eating disorders show resistance to specialty care settings and are more likely to seek help with their primary care doctor.12 Therefore, primary care settings are most often the main treatment setting for eating disorders and should be the main place for screening, diagnosis, and treatment.26

Since primary care providers, especially pediatricians and their physician assistants, usually follow a child from birth to at least 18 years of age, they are in a unique position to detect the onset of eating disorders and stop their progression at an earlier stage of the illness.27 This is especially important because the assessment protocols for children and adolescence have evolved greatly in the last 10 years.28 They are different then general practice in the sense that eating disorders in children and adolescence present differently than adults. Rather than weight loss, there may be a failure to achieve expected weight gain. So, they may not present as underweight, but their height and weight trajectories will move away from their expected path.28

Screening questions about eating patterns and approval of body appearance should be asked of all preteens and adolescence as part of routine pediatric health care.  Continual measures of weight and height, as well as BMI, need to be plotted on pediatric growth charts for evaluation. Any sign of inappropriate dieting, excessive concerns with weight, or weight loss patterns, as well as failure to achieve appropriate increase in weight or height in growing children require further attention.27 However, let it be known that patients with eating disorders may try to hide their illness. Failure to notice an eating disorder at an early stage can result in an increase in severity of the illness, be it further weight loss or increased binge/purge behaviors, which can cause it to be more difficult to treat.27 Also, if an adolescent is referred to a primary care provider due to concerns from parents, friends, or school staff that he/she is displaying signs of an eating disorder, it is most likely to be true. Therefore, PCPs need to be cautious by following weight and nutrition patterns very closely or referring to specialty experts in the treatment of eating disorders when suspected.27

What PCP should look out for

Table 1: Risk factors for development of an eating disorder
Female sexMiddle-class or upper-class socioeconomic statusFamily history of an eating disorderParticipation in activities valuing thinness (eg, sports, dance, modeling)Unsuccessful attempts at dieting and weight lossHistory of sexual abuseFamily issues (eg, separation difficulties, overinvolvement, abandonment) Psychiatric co-morbidities (eg, depression, anxiety, substance abuse)Type 1 diabetes
aAdapted from Kondo DG, Sokol MS, 2006

Eating Disorders are complex diseases with multifaceted etiological factors such as psychological, familial, cultural, and genetic pieces with the rate of co-morbidities with other psychiatric illnesses as high as 89.5%.29 People who suffer from eating disorders have a higher likelihood of suffering from anxiety and depression than those who do not suffer from eating disorders. In fact, up to 80 percent of those with anorexia have suffered major depression at some point in their lives, and as many as 80 percent of bulimics have suffered from an anxiety disorder.29

Body image and dieting culture have also affected our youth. Findings of moderate dieting is leading to six times the chance of developing an eating disorder and severe dieters showing an 18-fold risk.30  Patients with eating disorders visit their PCPs more often than other patients in the five years before diagnosis in which they present and are “treated” for the many medical signs, symptoms, and complications associated with their ED.31 Because most patients do not typically present with the chief complaint of an eating disorder, primary care providers need to be attentive to the possibility, especially with young Caucasian females.32

Presenting symptoms can include fatigue, dizziness, low energy, amenorrhea, weight loss or gain, constipation, bloating, abdominal discomfort, heart burn, sore throat, palpitations, polyuria, polydipsia, and insomnia.32,33 Primary care providers need to monitor patient histories and take note of low weight for age, progressive weight loss, cold intolerance, and/or concerns from family or friends. On physical exams, the patient may be hypotensive or bradycardic with substantial orthostatic signs, as well as irregular cardiac rhythms and peripheral edema; the skin may be yellow and lanugo hair may be present.34,33 If an eating disorder is suspected, it is best to try and get a detailed history from both the patient and the family. Clues of an eating disorders can include preoccupation with weight loss, food, calories, fat grams (or any certain food categories), food refusal, rituals around food/mealtimes (such as picking at food, small excessive bites, eating in a certain order, etc.), excessive and inflexible exercise schedules, and withdrawal from friends and activities. When asked by primary care providers, it has been shown that most

patients are willing to talk about these kinds of issues.29

Table 2: Medical Signs, Symptoms, and Complications of Eating disorders
Cardiovascular        Arrhythmia        Bradycardia       Cardiomyopathy        Congestive heart failure        Electrocardiographic abnormalities        OrthostasisGynecologic and reproductive        Amenorrhea        Dysmenorrhea        Infertility
Dermatologic        Alopecia        Callus formation on knuckles        Cheilosis        Dry Skin        Hypercarotenemia        LanugoHematologic        Anemia        Iron/Folate deficiency        Leukopenia        Neutropenia        Thrombocytopenia        Acanthocyotsis
Endocrine and metabolic         Refeeding syndrome         Pubertal delay         Metabolic acidosis         Hypothermia         Hypo (natremia, magnesemia,                                                                                                                                                                                                                                                                                                                                  phosphatemia, kalemia)         Hyper (phosphatemia, cortisolemia)Musculoskeletal        Osteopenia        Osteoporosis
Gastrointestinal        Constipation        Decreased intestinal motility        Delayed gastric emptying        Dental carries        Diarrhea (from laxative abuse)        Erosion of tooth enamel        Esophagitis        Gastric rupture (after binging)        Parotid glad enlargementNeurologic        Peripheral neuropathy        Reversible brain atrophy        Seizures        Ventricular enlargement
a adapted from Kondo DG, Sokol MS, 2006


It is a sad paradox that the person who develops an eating disorder often begins with a diet, believing that weight loss will lead to improved self-confidence, self-respect, and self-esteem. The cruel reality is that persistent undereating, binge eating, and purging have the opposite effect.3 Eating disorders bring pain and suffering not only to the people who have them but also to their families, friends, and romantic partners. They cause disruption of family — blame, fights over food, weight, treatment, etc. Family members often struggle with guilt, worry, anxiety, and frustration. Nothing they do seems to make things better.14 Therefore, treatment is the only option.

Materials and Methods

The purpose of this research was to gain a better understanding of the current knowledge/training of eating disorders in the education of primary care providers. The population examined are first year and last year Grand Valley State University physician assistant program students. GVSU IRB approval of exempt research was obtained before research began. For this study, approval was granted by two professors in the PA program (whithin the physician assistant studies department) and given permission to conduct an online survey through eSurv.org with PA Students. A link to the survey (see appendix) and a script of consent (shown below) was provided to the professors to share with PA students via blackboard. Students had two weeks to complete the online survey.

After results were obtained, the survey showed more first year students than last year student participated. In order to increase the sample size, the survey was sent out again via a professor a few weeks later to last year students who did not participate the first time. Because this was still the beginning of the first semester, answers would not be significantly different then if the students participated in the first survey. They were given four days to complete the survey. This provided a more even distribution of first and last year students giving a larger sample size. The completed surveys were then put into SPSS24 to analyze the data collected; SPSS9.4 was also used when assumptions for chi squared were not met.

Grand Valley State University’s Physician Assistant studies is part of the University’s College of Health Professions and is designed for practitioners seeking a career as a Physician Assistant. The Master of Physician Assistant Studies (M.P.A.S.) program is accredited by The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA.). Because of this, we can assume results and student demographic to be comparable to all PA programs across the country.

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Results

There was a total of 42 last year and 48 first year PA students at GVSU. The sample that participated in the study included 16 first year students and 16 last year students with a total of 20 female and 13 male responses. This is the first career path for 21 of the students and the second career path for 11 students, who are mostly coming from health/science backgrounds.

Table 3: Student Characteristics:
First Years:Last Years:
n= 16n=16
Age      (20-25): n=10         (> 26): n=6Age       (20-25): n=9         (> 26): n=7
Second career: n=8aSecond career: n=4a
Know(n) someone     with ED: n=15Know(n) someone with ED: n=11
Learned about EDs outside of school: n=14bLearned about EDs outside of school: n= 8b

aOther careers noted: Business, education, biology/chemistry, allied health care, nuclear medicine, nursing, cardiac rehabilitation

b Other means: Social, personal studies, social media/movies, patients, undergrad, personal experience, previous work, conference, pod casts

Table 4: First year vs Last year student results
ObsYearQuestion (measure)responseRow Percent (%)Test Statistic, dfp-value
1First YearNutrition Class >100Yes47.05880.863, 10.353
No52.9412
Last YearNutrition Class >100Yes31.2500
No68.7500
2First YearFirst careerYes52.94121.7333, 10.188
No47.0588
Last YearFirst careerYes75.0000
No25.0000
3First YearPsy Class >100Yes94.11760.3353
No5.8824
Last YearPsy Class >100Yes81.2500
No18.7500
4First YearWill work with Children?Yes58.82350.047, 10.829
unsure41.1765
Last YearWill work with Children?Yes62.5000
Unsure37.5000
5First YearLearned EDs through other meansYes76.47062.496, 10.114
No23.5294
Last YearLearned EDs through other meansYes50.0000
No50.0000
6First YearCan recognize ED symptoms?Above Average 6.2500 0.0244a
Average68.7500
Below Average25.0000
Last YearCan recognize ED symptoms?Above Average37.5000
Average62.5000
Below Average0.0000
7First YearAre you confident to prescribe ED treatment?Above Average 0.00000.0011a
Average18.7500
Below Average81.2500
Last YearAre you confident to prescribe ED treatment?Above Average 6.2500
Average75.0000
Below Average18.7500
8First YearShould PAs learn more about EDs?Very Important68.75000.4080
Important31.2500
Neutral0.0000
Last YearShould PAs learn more about EDs?Very Important50.0000
Important37.5000
Neutral12.5000
9First YearShould there be a mandatory ED training?Very Appropriate43.75000.4241
Appropriate37.5000
Neutral18.7500
Inappropriate0.0000
Last YearShould there be a mandatory ED training?Very Appropriate31.2500
Appropriate56.2500
Neutral6.2500
Inappropriate6.2500

aP≤0.05 = Statistically significant

Results were found using Chi-Squared test, except for questions with no test statistic. This means it did not meet assumptions for chi-squared, so Fishers Exact test was used. Only two questions resulted in statistically significant results between first year and last year students.

Table 5: Student free write response to final survey question, “What type of instruction would be beneficial for obtaining information on the screening and diagnosis of eating disorders?” 
– Case study discussions/ Learning about it in our modules/ seminar
– Talk to experts/ guest speakers (RDs, Psychiatrists, etc)
– Lecture during didactic year as well as clinical exposure
– I feel that the instruction on eating disorders that we receive is adequate. Could there be more? Yes. The problem is that so much is crammed into the PA program that we fly through a ton of material. If there were to be more time spent on something, I would rather it be spent on something more common such as heart disease, diabetes, COPD, etc.
– We have had one lecture on eating disorders during our nutrition module. Knowing signs and symptoms are important, as well as establishing healthy habits to control eating disorders, but knowing when to refer to a nutritionist and/or psychiatrist will be important clinically. I think the one lecture is enough, as this will be a small subset of our patients clinically. Having an extra module online during clinical year would be beneficial, but there is so much to learn that it would not be more important than a refresher module in depression/suicide, or anxiety, or behavior disorders that dramatically affect one’s life and can cause relationship loss, declined health, etc, which eating disorders might cause also.
aDoes not include all responses. Some have also been combined/reworded

Discussion

Increased prevalence of eating disorders in children and adolescents have made it progressively more important that primary care providers, especially pediatricians and physician assistants, be familiar with the early detection and appropriate management of this disease.18,19 However, education of eating disorders and nutrition for primary care providers is found to be inadequate, and seen in this study.

Following this further, prerequisites for GVSUs PA program admission does not include a nutrition class, but does include an introduction to Psychology course (psy 101). However, there is no time limit for when the course was taken (it could have been taken 5-10 years prior and still count towards admission requirement). However, a nutrition course and a medical ethics course is recommended but not required for admission to the program.

So, this is the first red flag, and forces the researcher to assume incoming students are not formally educated in nutrition and minimally in psychology, and assume this knowledge will come from experience in the program (a.k.a first year students are assumed to be uneducated in this area and results should show an increase in knowledge from first to last year students). As shown in this study, 68.8% of students in the last year of the program have not taken a nutrition course beyond the 100 level, and 18.8% have not taken a psychology course beyond the 100 level. Since psychology is a requirement, this is most likely why more students are slightly more educated in this area. We can also assume that these students are not meeting the 25-hour minimum nutrition instruction recommended by the National Academy of Science.

Differential responses between first year and last year students were not statistically significant (p-values were greater than 0.05) except for the two most important questions; how confident are you in recognizing the manifestations of EDs in patients (p=0.0244) and how confident are you in prescribing evidence based treatment to ED patients (p=0.011). Therefore, we can see a slight increase in confidence level with last year students compared to first year students in recognizing ED symptoms and prescribing treatment.

However, we do see that around 50% of last year, and 76.5% of first year students are seeking outside opportunities to learn about eating disorders. This show high interest in the topic, probably due to the fact that 81% of the student said they know or have known someone with an ED in their lifetime. As mentioned before, national surveys estimate that 20 million women and 10 million men in America will have an eating disorder at some point in their lives,3 so understanding this disease is extremely important.

This study does show a high confidence level in the ability to recognizing the manifestations of an eating disorder. However, when asked if they could prescribe the evidence based treatment to these ED patients, results shifted from seeing around 20% above average, to about 20% feeling below average in confidence level. This correlates with research findings completed with primary care physicians. Research shows that PCPs feel unprepared to identify and manage complex chronic disorders, such as the 2013 Canadian study finding that more than 90% of the PCPs said they encountered patients who presented with an ED, but were unable to treat due to lack of skill, case complexity, and/or a lack of recourses as their primary obstacles.5 Yet, we did see a statistically significant difference in confidence level in recognizing ED symptoms and prescribing treatment with last year students. Though, we do not know if this is because they are more confident in their medical knowledge in general, or have had more eating disorder education specifically.

With this lack of confidence in treatment, we do see an interest in further education on eating disorders with over 80% of both first and last year students thinking it would be useful as future PAs to learn more about this illness. Over 80% also think a mandatory module or work training in this area would also help. This correlates with the research showing that many pleas have been made over the past few decades to improve nutrition knowledge and skills.5 Many primary care providers are dissatisfied with the level of training they receive regarding assessment, diagnosis, and treatment of eating disorder with many rating their undergraduate and even postgraduate training as poor.5

Therefore, current research in the knowledge and education of nutrition and eating disorders in the medical profession match results seen in this study. Students are interested in this topic and have a desire to learn more, but are dissatisfied with training and do not feel confident in their ability to actually diagnose and treat patients with eating disorders.

Strengths and limitations:

Strengths of this study include being approved by GVSU IRB, having anonymous answers from students who wanted to participate, providing ample time to take the survey, having an even distribution of first and last year students. Limitations include having a small response to the survey resulting in a small sample size compared to PAs enrolled in the program (causing answers to not be statistically significant), only using students from one school (GVSU), and having the survey taken at the beginning of the school year for the last year students instead of the end (still have one full year to lean about EDs in school and clerkship phase).

Summary and future research needs

In final analysis, studies show that more research in eating disorders is needed. It has been found that not enough primary care providers have the knowledge and confidence it takes to screen, assess, and treat patients with eating disorders.23 Physicians do not have adequate knowledge in nutrition, especially in complex situations that also include mental health and nutrition deficiences.1 Basic training sessions, routine screening assessments, and increased awareness about eating disorders have been shown to produce great improvement towards the treatment of eating disorders in primary care settings.23,35 Further studies need to be done to find out more on how to improve treatment and awareness in the primary care settings.

Current research has shown barriers to treatment such as time constraint, lack of training, and negative attitudes that ultimately prevent the treatment of eating disorders. One way to change this is to deliver a holistic health care approach; upholding all aspects of people’s needs including psychological, physical, and social aspects by seeing them as a whole.36 Eating disorders are both physical and psychological disorders, so they need to be treated as such in the health care setting, and by using a collaborative approach with various types of primary care staff (such as nurses, physician assistants, and mental health providers).26,36 Incorporating mental or behavioral health services in primary care can also offer advantages in detection and treatment of eating disorders such as routine consultations, frequent patient follow-up, as well as less stigmatization. Mental health providers and medical health care providers should work as a team in assessing eating disorders and implementing efficient intervention.26

It has also been shown that primary care providers can help families and children implement proper nutrition and physical activity while avoiding an unhealthy emphasis on weight and dieting.37 Providers can screen to detect early onset as well as learn to avoid harmful statements (such as, “you could stand to lose a little weight”) that patients have said triggered the onset of their disorder. As a culture, healthy approaches to weight, dieting, and body image will need to improve to decrease the growing number of people developing eating disorders. However, this may be challenging due to the increasing obesity rate and the competing responsibility to address its health risk as well.38

Future research needs should focus on creating, identifying, and implementing a standard protocol for addressing eating disorders in primary care settings. This standard should include a brief treatment, a long-term evaluation component, and some sort of training. Once a standard protocol is implemented, there needs to be a way to assess the adherence, both with the patients and the treatment providers. Also, this protocol would be more beneficial if a variety of health care providers, such as therapists and psychiatrists, participated to allow for an expanded delivery of treatment.26,39

Due to time constraints and provider feedback, future studies should provide opportunities to do some pre-training online to limit face-to-face time, or have other incentives for getting more educated on the topic of eating disorders.31 When developing future randomized control trials, researchers should create a step-by-step protocol of treatment, assess the progress of all the treatment groups, and evaluate the outcomes right after treatment as well as at a three-months, six-months, and nine-month follow-up.26,40

References

1. Adams KM, Lindell KC, Koglmeier M, and Zeisel SH . “Status of nutrition education in medical schools.” The American Journal of Clinical Nutrition 83 (2006): 941-944.

2. Linville D, Aoyama T, Knoble NB, Gau J. The effectiveness of a brief eating disorder training programme in medical settings. Journal of Research in Nursing. 2012;18(6):544-558. doi:10.1177/1744987112452182.

3. Brenner T. The Joy Project – Minneapolis based non-profit organization dedicated to providing support and resources for eating disorders. The Joy Project Minneapolis based nonprofit organization dedicated to providing support and resources for eating disorders RSS. N.p., n.d. Web. 25 Jan. 2014. Retrieved from <http://joyproject.org/>.

4. Micali N, Hagberg KW, Petersen I, Treasure JL. The incidence of eating disorders in the UK in 2000–2009: findings from the General Practice Research Database. BMJ Open. 2013;3(5). doi:10.1136/bmjopen-2013-002646.

5. Robinson ACAL, Boachie A, Lafrance GA. “I want help!”: Psychologists’ and physicians’ competence, barriers, and needs in the management of eating disorders in children and adolescents in Canada. Canadian Psychology/Psychologie canadienne. 2013;54(3):160-165. doi:10.1037/a0032046.

6. Grange DL, Lock J. Eating disorders in children and adolescents: a clinical handbook. New York: Guilford Press; 2011, 3-10.

7. Sim LA, Mcalpine DE, Grothe KB, Himes SM, Cockerill RG, Clark MM. Identification and treatment of eating disorders in the primary care setting. Mayo Clinic Proceedings. 2010;85(8):746-751. doi:10.4065/mcp.2010.0070.

8. Satir D, Franko D, & Herzog D. Clinician reactions to patients with eating disorders: A Review of the Literature. Psychiatric Services, 2012;63 (01), 73-78 DOI: 10.1176/appi.ps.201100050

9. Sim LA, Mcalpine DE, Grothe KB, Himes SM, Cockerill RG, Clark MM. Identification and treatment of eating disorders in the primary care setting. Mayo Clinic Proceedings. 2010;85(8):746-751. doi:10.4065/mcp.2010.0070.

10. Johnston O, Fornai G, Cabrini S, Kendrick T; Feasibility and acceptability of screening for eating disorders in primary care. Fam Pract 2007; 24 (5): 511-517. doi: 10.1093/fampra/cmm029

11. Novotney, A. Eating disorders: New solutions. American Psychological Association, 2009; 40(4), 46–49.

12. Hach I, Ruhl UE, Rentsch A, Becker ES, Turke V, Margraf J, Kirch W. Recognition and therapy of eating disorders in young women in primary care. Journal of Public Health. 2005;13(3):160-165. doi:10.1007/s10389-005-0102-5.

13. New M. “Eating Disorders.” KidsHealth – the Web’s most visited site about children’s health. The Nemours Foundation, 1 Jan. 2011. Retrieved from http://kidshealth.org/teen/food_fitness/pro

14. Kessler RC, Berglund PA, Chiu WT, et al. The Prevalence and correlates of binge eating disorder in the world health organization world mental health surveys. Biological Psychiatry. 2013;73(9):904-914. doi:10.1016/j.biopsych.2012.11.020.

15. Schag K, Schönleber J, Teufel M, Zipfel S, Giel KE. Food-related impulsivity in obesity and binge eating disorder – a systematic review. Obesity Reviews. 2013;14(6):477-495. doi:10.1111/obr.12017.

16. Vashi NA. Obsession with perfection: Body dysmorphia. Clinics in Dermatology. 2016;34(6):788-791. doi:10.1016/j.clindermatol.2016.04.006.

17. Koven N, Abry A. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatric Disease and Treatment. 2015:385. doi:10.2147/ndt.s61665.

18. Rome ES. Identifying and treating eating disorders. Pediatrics. 2003;111(1):204-211. doi:10.1542/peds.111.1.204

19. Weber CC, Haller DM, Narring F. Is There a role for primary care physicians screening of excessive weight and eating concerns in adolescence? The Journal of Pediatrics. 2010;157(1):32-35. doi:10.1016/j.jpeds.2010.01.030.

20. Brownlow RS, Maguire S, O’Dell A, Dias-Da-Costa C, Touyz S, Russell J. Evaluation of an online training program in eating disorders for health professionals in Australia. Journal of Eating Disorders. 2015;3(1). doi:10.1186/s40337-015-0078-7.

21. Mahr F, Farahmand P, Bixler EO, Domen RE, Moser EM, Nadeem T, et al. A national survey of eating disorder training. International Journal of Eating Disorders. 2014;48(4):443-445. doi:10.1002/eat.22335.

22. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: Latest update of a national survey. Academic Medicine. 2010;85(9):1537-1542. doi:10.1097/acm.0b013e3181eab71b.

23. Currin L, Waller G, Schmidt U. Primary care physicians knowledge of and attitudes toward the eating disorders: Do they affect clinical actions? International Journal of Eating Disorders. 2009;42(5):453-458. doi:10.1002/eat.20636.

24. Wade T, Vall E, Kuek A, Altman E, Long R, Mannion J. Development of a new statewide eating disorder service: The role of evidence in a real world setting. International Journal of Eating Disorders. 2017;50(3):293-301. doi:10.1002/eat.22664.

25. Jones J, Larner M. An audit of training, competence and confidence among clinicians working in eating disorder services. Mental Health Practice. 2004;8(3):18-22. doi:10.7748/mhp2004.11.8.3.18.c1833.

26. Allen S, Dalton WT. Treatment of eating disorders in primary care: A systematic review. Journal of Health Psychology. 2011;16(8):1165-1176. doi:10.1177/1359105311402244.

27. Fisher M. Treatment of eating disorders in children, adolescents, and young adults. Pediatrics in Review. 2006;27(1):5-16. doi:10.1542/pir.27-1-5.

28. Girz L, Robinson AL, Tessier C. Is the next generation of physicians adequately prepared to diagnose and treat eating disorders in children and adolescents? Eating Disorders. 2014;22(5):375-385. doi:10.1080/10640266.2014.915692.

29. Kondo DG, Sokol MS. Eating disorders in primary care. Postgraduate Medicine. 2006;119(3):59-65. doi:10.1080/00325481.2006.11446052.

30. Yeo M, Hughes E. Eating disorders: Early identification in general practice. Aust Fam Physician. 2011;40(3):108-11

31. Banas DA, Redfern R, Wanjiku S, Lazebnik R, Rome ES. Eating disorder training and attitudes among primary care residents. Clinical Pediatrics. 2013;52(4):355-361. doi:10.1177/0009922813479157.

32. Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. American Family Physician. 2008;77:187.

33. Swenne I, Engström I. Medical assessment of adolescent girls with eating disorders: An evaluation of symptoms and signs of starvation. Acta Paediatrica. 2007;94(10):1363-1371. doi:10.1111/j.1651-2227.2005.tb01805.x.

34. Walsh JME, Wheat ME, Freund K. Detection, evaluation, and treatment of eating disorders. Journal of General Internal Medicine. 2000;15(8):577-590. doi:10.1046/j.1525-1497.2000.02439.x.

35. Thompson-Brenner H, Satir DA, Franko DL, Herzog DB. Clinician reactions to patients with eating disorders: A review of the literature. Psychiatric Services. 2012;63(1):73-78. doi:10.1176/appi.ps.201100050.

36. Thompson C, Park S. Barriers to access and utilization of eating disorder treatment among women. Archives of Womens Mental Health. 2016;19(5):753-760. doi:10.1007/s00737-016-0618-4.

37. Zucker NL, Marcus M, Bulik C. A group parent-training program: A novel approach for eating disorder management. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity. 2006;11(2):78-82. doi:10.1007/bf03327755.

38. Rosen DS. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126(6):1240-1253. doi:10.1542/peds.2010-2821.

39. Puhl RM, Latner JD, King KM, Luedicke J. Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders. 2013;47(1):65-75. doi:10.1002/eat.22186.

40. Heath O, English D, Simms J, Ward P, Hollett A, Dominic A. Improving collaborative care in managing eating disorders: A pilot study. Journal of Continuing Education in the Health Professions. 2013;33(4):235-243. doi:10.1002/chp.21187.

Appendix

DSM criteria:

Anorexia nervosa
1. Refusal to maintain body weight at or above a minimally normal weight for age and height (eg. weight loss leading to maintenance of body weight less than 85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected)
2. Intense fear of gaining weight or becoming fat, even though underweight
3. Disturbance in the way that body weight, size or shape is experienced, undue influence of body shape and weight on self-evaluation, or denial of the seriousness of current low body weight
4. In postmenarchal females, amenorrhoea, ie. the absence of at least three consecutive menstrual cycles
Types
* Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge eating or purging behavior (self-induced vomiting, misuse of laxatives, diuretics, or enemas)
* Binge eating/purging type: during the current episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behavior (ie. self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
Bulimia nervosa
1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
* Eating in a discrete period of time (eg. within any 2-hour period) an amount of food that is larger than most people would eat during a similar period of time and under similar circumstances
* A sense of lack of control over eating during the episode (eg. a feeling that one cannot stop eating or control what, or how much, one is eating)
2. Recurrent inappropriate compensatory behavior in order to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise
3. Binge eating and inappropriate compensatory behaviors both occur on average at least twice a week for 3 months
4. Self-evaluation is unduly influenced by body shape and weight
5. The disturbance does not occur exclusively during episodes of anorexia nervosa
Types
* Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
* Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Script of consent:

“Hello, my name is Emily Marr and I am a part of the combined masters in clinical nutrition/ dietetic internship here at GVSU. I am conducting a survey for my master’s project on ‘knowledge of the Screening for Eating Disorders in the Education of Primary Care Providers.’ This survey is completely anonymous and you have the right not to participate. The survey should take no more then 5-10 minutes, just follow the link provided below. This survey is for my knowledge and to better understand the areas that may be lacking in eating disorder care. Results will be part of my final paper and presentation.

You are asked to voluntarily provide specific information to this web site. You may skip any question, or stop participating at any time. The information collected will be used for the stated purposes of this research project only and will not be provided to any other party for any other reason at any time except and only if required by law. You should be aware that although the information you provide is anonymous, it is transmitted in a non-secure manner. There is a remote chance that skilled, knowledgeable persons unaffiliated with this research project could track the information you provide to the IP address of the computer from which you send it. However, your personal identity cannot be determined.

You can access the survey through the following link…”

Survey:

– Are you a First year or last year PA student?

 First
 Last
  1. How old are you?
 <20
 20-25
 26-30
 31-40
 >40

2. What is your declared gender?

 Male
 Female
 Transgender
 Gender non-conforming

3.  Is this your first career/degree path?  

 Yes
 No

If no list other degrees or careers

4. Have you taken any nutrition courses beyond the 100 level?     

 Yes
 No

4a. If yes…

 Mandatory
 Elective
 Both

4b. How many nutrition classes have you taken?

 1-2
 3-5
 >5

5. Have you taken a psychology course beyond the 100 level? 

 Yes
 No

5a. In yes…

 Mandatory
 Elective
 Both

5b.  How many psychology classes have you taken?

 1-2
 3-5
 >5

6. Will you work with children or adolescence in your chosen career path?

 Yes
 No
 Unsure

7. Have you received lectures on eating disorders in your PA coursework during the didactic phase of the program? (More than a quick mention of EDs!)

 Yes
 No
 Not sure

8. If you currently in the clerkship phase of the program, have you discussed eating disorders in your clerkship (either within your clerkship rotation or in the End-of-Rotation lectures)?

 Yes
 No
 Not sure
 N/A (have not started clerkship phase)

9. Have you learned about eating disorders through other means?

 Yes
 No

If Yes, how?

10. Have you ever known someone with an eating disorder?

 Yes
 No

i. If yes was it family _____ friend _____ other _____

11. How confident are you in recognizing the manifestations of an eating disorder in a patient?

 Above Average
 Average
 Below Average

12. How confident are you in prescribing the evidence based treatment in a patient with an eating disorder?

 Above Average
 Average
 Below Average

13. Do you think it is useful for you as a future PA to learn more about eating disorders?

 Very Important
 Important
 Neutral
 Unimportant
 Very Unimportant

14. Do you think a mandatory module or work training on how to screen and diagnosis eating disorders would be beneficial in your field?

 Very Appropriate
 Appropriate
 Neutral
 Inappropriate
 Very Inappropriate

15. What type of instruction would be beneficial for your obtaining information on the screening and diagnosis of eating disorders? 

 Use txt box
 Free write

Result tables:

Have you taken any nutrition courses beyond the 100 level?
YesNo
Are you a First year or last year PA student?First YearCount89
% within Are you a First year or last year PA student?47.1%52.9%
Fourth YearCount511
% within Are you a First year or last year PA student?31.3%68.8%
TotalCount1320
% within Are you a First year or last year PA student?39.4%60.6%
Have you taken a psychology course beyond the 100 level?
YesNo
Are you a First year or last year PA student?First YearCount161
% within Are you a First year or last year PA student?94.1%5.9%
Fourth YearCount133
% within Are you a First year or last year PA student?81.3%18.8%
TotalCount294
% within Are you a First year or last year PA student?87.9%12.1%

Have you learned about eating disorders through other means?
YesNo
Are you a First year or last year PA student?First YearCount134
% within Are you a First year or last year PA student?76.5%23.5%
Fourth YearCount88
% within Are you a First year or last year PA student?50.0%50.0%
TotalCount2112
% within Are you a First year or last year PA student?63.6%36.4%
How confident are you in recognizing the manifestations of an eating disorder in a patient?
Above AverageAverage
Are you a First year or last year PA student?First YearCount1114
% within Are you a First year or last year PA student?6.3%68.8%25.0%
Fourth YearCount6100
% within Are you a First year or last year PA student?37.5%62.5%0.0%
TotalCount7214
% within Are you a First year or last year PA student?21.9%65.6%12.5%
How confident are you in prescribing the evidence based treatment in a patient with an eating disorder?
Above AverageAverageBelow Average
Are you a First year or last year PA student?First YearCount0313
% within Are you a First year or last year PA student?0.0%18.8%81.3%
Fourth YearCount1123
% within Are you a First year or last year PA student?6.3%75.0%18.8%
TotalCount11516
% within Are you a First year or last year PA student?3.1%46.9%50%
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