Eating disorders are complex brain-based illnesses with both psychological and physical components. They affect almost 10% of the population and have become much more prevalent since the COVID-19 pandemic began.[1] They are characterized by significant disturbances in behaviors and attitudes that surround eating, body weight, and body shape[2] and include anorexia nervosa, bulimia nervosa, binge-eating disorder, night-eating syndrome, and other specified feeding and eating disorders. Eating disorders can lead to life-threatening medical complications and frequently co-occur with other debilitating mental illnesses such as bipolar, depressive, and anxiety disorders.[3] People with a family history of an eating disorder or any other significant mental illness are at increased risk of developing an eating disorder. Other factors affecting the onset of an eating disorder include the influence of media and diet culture, a history of trauma, and stressful life transitions and certain personality traits such as perfectionism.[4] Eating disorders occur across the gender spectrum, and people identifying as nonbinary or transgender are particularly at risk. Dieting for weight loss increases susceptibility to the development of these conditions. Since the COVID-19 pandemic began, the prevalence of eating disorders has increased dramatically as social isolation, job losses, financial insecurity, and uncertainty about the future have created a fertile environment where eating disorders can develop and thrive.

In Canada, wait times for treatment of eating disorders are unacceptably long—months or even years. Treatment programs are usually located in large urban centres, creating barriers for people living in remote and rural areas. Only when people become extremely ill are they eligible for inpatient treatment. People with serious eating disorders are at high risk for suicide, and difficulty in accessing services exacerbates this problem. Since the start of the pandemic, many hospital-based eating disorder treatment programs have cut back their services, deploying personnel to other areas of need. Many of these programs were slow to transition to a virtual format, leaving a critical gap in services.

What can physicians do?

Among adults with eating disorders, at least half had their first diagnosis by their primary care physician.[5] Yet too many physicians feel unprepared to diagnose and manage these patients. Training for professionals involved in the care and treatment of eating disorders is suboptimal.[6,7] Canadian medical students receive only 3 to 5 hours of education about eating disorders in their undergraduate years.

By increasing their knowledge about eating disorders, family physicians will be better able to recognize the presenting symptoms of an eating disorder, make a diagnosis, and monitor their patient appropriately. The well-informed physician will also know how to recognize complications and make appropriate referrals for higher levels of care. Timely diagnosis and early intervention markedly improve treatment success rates.[8]

Physicians can also educate themselves about the linkage between dieting and the development of an eating disorder. Physicians prescribe weight-loss diets for many conditions, even if a clear link between weight and the health condition in question has not been demonstrated. People in larger bodies often describe feeling humiliated by judgmental remarks by physicians about their body size.[9] As physicians, we need to be aware of the way we speak with people about their bodies, ensuring that we respect their dignity and their autonomy to make health care decisions.

The need for community-based services

Community-based approaches that provide rapid access to resources and support are essential components in a stepped-care approach to treatment.[10] For people with more severe eating disorders, community-based treatment can provide valuable support while they wait for more intensive treatment.

Australia has been a world leader in eating disorder treatment. In the last 12 months alone, there has been an A$200 million ($184 million) investment in eating disorders. In 2018, the National Agenda for Eating Disorders was released, highlighting the critical role of community-based care for eating disorders. The report stated that the “gap in community-based care directly contributes to the escalation of both physical and psychological health problems and the risk of suicide.”[11] The advantages of this approach include accessibility, cost-effectiveness, and user satisfaction. Unfortunately, most eating disorder treatment programs in Canada are based in hospitals and have rigid eligibility criteria and long wait lists. Also, only certain programs have transition programs, which are essential to prevent relapse.

Community-based care in Canada is often provided by not-for-profit or charitable organizations, with few of them receiving sustainable government funding. Despite an ongoing struggle with financial stability, these community organizations have made many contributions to eating disorder treatment and support. In British Columbia, the Looking Glass Foundation has provided support for people with eating disorders for many years (www.lookingglassbc.com [10]). Its Hand in Hand program connects people who have recovered from an eating disorder with someone who is struggling. This peer support program taps into the power of lived experience as an aid to recovery. Recently, the Looking Glass Foundation received significant government funding to expand its peer support programming.

On the opposite side of the country, Eating Disorders Nova Scotia also offers a peer support program including a chat line, peer mentoring, and workshops (www.eatingdisordersns.ca [11]). All its services were rapidly transitioned to an online format when the pandemic began. In Saskatchewan, BridgePoint offers a unique model of stepped-care treatment for people with eating disorders, beginning with educational resources and a texting service, and leading up to a residential program (www.bridgepointcenter.ca [12]). In Ontario, the National Initiative for Eating Disorders plays an important role in linking the many community-based organizations across the country, allowing for sharing of innovations and expertise (www.nied.ca [13]). People searching for information about eating disorders can find a wealth of resources on the website of the National Eating Disorder Information Centre (www.nedic.ca [14]).

Body Brave is a charitable organization in Hamilton, Ontario, focused on providing treatment and support for people suffering from eating disorders (www.bodybrave.ca [15]). A team of health care professionals run online groups and offer individual consultations, providing services for over 1500 people yearly.

Technology’s role

Technology-enabled support for eating disorders is showing considerable promise.[12] When requests for services spiked threefold after the pandemic began, Body Brave formed a partnership with Careteam Technologies, founded by BC physician-innovator Dr Alexandra Greenhill. Using the Careteam app, patients can access a virtual suite of services that includes a self-assessment and an evidence-based self-help program. If the self-assessment suggests a significant eating disorder, patients are then guided through the complex landscape of eating disorder treatment programs. Since launching in March 2021, Body Brave has onboarded close to 800 patients onto the platform, increasing capacity by 500% while reducing wait times from 2 or more weeks to within 24 hours. By employing the Careteam app, people can get help immediately and be supported while on the wait list for more intensive services. Several hospital treatment programs and community organizations have expressed interest in employing the app to help manage wait times. Because of the scalable technology backbone, the Careteam app could be rolled out nationally to provide community-based support for patients with eating disorders from coast to coast to coast.

Summary

Physicians play an essential role in providing timely diagnosis and ongoing medical monitoring of people with eating disorders. Formal medical education about these complex brain-based disorders is inadequate, often consisting of just a few hours in undergraduate training. Continuing medical education is needed to equip practising physicians with the knowledge to manage their patients with eating disorders.

Wait lists for hospital-based treatment programs for eating disorders in Canada have lengthened significantly since the pandemic began, extending to many months or years. Innovative approaches are urgently needed to respond to the dramatically increased demand for services caused by the pandemic. A stepped-care approach to the treatment of eating disorders is widely used in many countries, in which community-based organizations provide an essential first step. However, Canadian eating disorder treatment is still primarily focused on hospital-based programs. Community-based organizations have responded to the challenges posed by the pandemic in many innovative ways, strengthening a stepped-care approach to the treatment of eating disorders.

Competing interests

Dr Trollope-Kumar is the chief medical officer of Body Brave, a federally registered charitable organization mentioned in this article, and receives a small annual honorarium for this work.

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This article has been peer reviewed.

[16]

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License [16].

References

1.    Tavolacci MP, Ladner J, Déchelotte P. Sharp increase in eating disorders among university students since the COVID-19 pandemic. Nutrients 2021;13:3415.

2.    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.

3.    Aardoom JJ, Dingemans AE, Van Furth EF. E-health interventions for eating disorders: Emerging findings, issues, and opportunities. Curr Psychiatry Rep 2016;18:42.

4.    National Eating Disorders Association. Risk factors. Accessed 8 October 2021. www.nationaleatingdisorders.org/risk-factors [17].

5.    Sim LA, McAlpine DE, Grothe KB, et al. Identification and treatment of eating disorders in the primary care setting. Mayo Clin Proc 2010;85:746-751.

6.    Boulé CJ, McSherry JA. Patients with eating disorders. How well are family physicians managing them? Can Fam Physician 2002;48:1807-1813.

7.    Clarke DE, Polimeni-Walker I. Treating individuals with eating disorders in family practice: A needs assessment. Eat Disord 2004;124:293-301.

8.    AED Report. Eating disorders: Critical points for early recognition and medical risk management in the care of individuals with eating disorders. IL, US: Academy of Eating Disorders; 2011.

9.    Hebl MR, Xu J. Weighing the care: Physicians’ reactions to the size of a patient. Int J Obes 2001;25:1246-1252.

10.    Wilson GT, Vitousek KM, Loeb KL. Stepped care treatment for eating disorders. J Consult Clin Psychol 2000;68:564.

11.    The Butterfly Foundation. The national agenda for eating disorders 2017 to 2022. Accessed 8 October 2021. https://butterfly.org.au/wp-content/uploads/2020/05/National-Agenda-for-Eating-Disorders-2018.pdf [18].

12.    Milton AC, Hambleton A, Dowling M, et al. Technology-enabled reform in a nontraditional mental health service for eating disorders: Participatory design study. J Med Internet Res 2021;23:e19532.

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Dr Trollope-Kumar is the chief medical officer of the Body Brave eating disorder treatment and support program and an associate clinical professor of family medicine at McMaster University in Hamilton, Ontario.