Professionals’ Knowledge of and Attitudes about Eating Disorders Patients

Lack of training and bias were found in two studies.

Results from two recent studies of psychiatrists in the United Kingdom and the US highlight a number of gaps in overall knowledge about treating patients with eating disorders, as well as bias toward obese patients.

Knowledge and attitudes about eating disorders

In the UK, general psychiatrists have the major responsibility for managing patients with eating disorders. To test psychiatrists’ “mental literacy” about eating disorders, Dr. William R. Jones of the Yorkshire Centre for Eating Disorders, Leeds, and two colleagues conducted a study of attitudes toward and knowledge about eating disorders (Eur Eat Disorders Rev 2013; 21:84). An email with a link to an online questionnaire was sent to 329 psychiatrists, 126 of whom responded.

The online questionnaire contained 17 questions about attitudes toward eating disorders, and the respondents were asked to indicate their agreement with the statements by using a 5-point Likert scale. Another section contained 6 extended matching terms about eating disorders and their treatment, and addressed both anorexia nervosa (AN) and bulimia nervosa (BN), including diagnostic criteria, physical complications, and National Institute for Health and Care Excellence (NICE) guidelines on managing eating disorders.

Levels of knowledge

Psychiatrists who were members of the Royal College of Psychiatrists had higher scores than did those who were not members, and older psychiatrists had the lowest scores overall. Gender, age, locality, and grade level had no impact on total knowledge scores; however, “White British” psychiatrists had higher scores compared with psychiatrists from other ethnic backgrounds.

Diagnostic criteria

The most commonly identified diagnostic criterion for AN was “fear of fatness,” which was recognized by 87.6% of the respondents. While 81.8% recognized that the diagnostic body mass index (BMI, kg/m²) threshold for AN was below 17.5, 13% believed that it was even lower—16 kg/m². Only 41.2% recognized that 3 months of amenorrhea is currently a diagnostic criterion for AN. Recurrent episodes of binge-eating at last twice a week for 3 months and extreme weight-control behaviors were the most commonly identified diagnostic criteria for BN, but only slightly more than half of psychiatrists recognized overvaluation of shape and weight as diagnostic criteria for BN. Only about a third identified the diagnostic BMI threshold as 17.5 kg/m² or higher for patients with BN.

Physical complications

Most of the respondents (96.7%) correctly identified electrolyte abnormalities, bradycardia (77.7%), hypoglycemia (76%), osteoporosis (85.1%), and anemia (86%) as complications of AN. Fewer recognized proximal myopathy and edema as complications. While most identified electrolyte abnormalities, dental erosion, and parotid swelling as complications of BN, only a third knew about the possibility of oligomenorrhea.

Managing eating disorders

Most of the psychiatrists correctly identified family interventions and cognitive behavioral therapy, as recommended by NICE, for managing eating disorders. However, fewer were familiar with psychodynamic therapy, cognitive analytic therapy, and interpersonal therapy (ITP), and nearly 35% falsely believed that selective serotonin reuptake inhibitors (SSRIs) were recommended by NICE for managing patients with AN. Most correctly identified that SSRIs and self-help programs were therapies NICE currently recommends for treating persons with BN. Only 57% identified IPT as a recommended therapy for BN.

General attitudes toward persons with eating disorders

Among the psychiatrists who completed the survey, 41.6% saw AN as being “culturally determined by woman’s role in society,” while 61.7% viewed AN as “representing a form of neurotic mental disorder.” A total of 7.8% viewed AN as a form of “abnormal behavior in the context of a weak, manipulative, or inadequate personality,” and 1.7% saw AN as essentially impossible to treat. Significant differences in attitude toward AN emerged according to the respondent’s grade-more non-consultants viewed AN as being essentially untreatable than did consultants. More junior psychiatrists viewed BN as representing abnormal behavior in the context of a weak, manipulative, or inadequate personality than did psychiatrists with greater seniority.

Overall, the authors reported that the psychiatrists’ knowledge of eating disorders varied widely, with gaps in knowledge relating both to diagnosis and to management. Psychiatrists who worked in settings where they were more likely to come in contact with patients with eating disorders had better overall knowledge of eating disorders, and this appeared to increase with seniority and clinical experience. The authors were concerned about the fact that some diagnostic criteria for both AN and BN were familiar to only a few psychiatrists and some physical complications were not recognized at all.

According to the authors, their study results clearly underscore the need to improve the knowledge levels of general psychiatrists, to make certain that they are taking appropriate clinical actions when they are treating patient with eating disorders.

A second study finds weight bias even among eating disorders specialists

The results from a separate study at Yale University indicate that even professionals who specialize in treating eating disorders are not immune to weight bias. Weight-based stereotypes held by healthcare professionals may have important implications for the quality of care patients will receive, and some research also shows that weight bias in a healthcare setting serves as a barrier to care for obese individuals. The authors also pointed out that weight stigmatization itself increases the risk of maladaptive eating behaviors and eating disorder symptoms.

Dr. Rebecca M. Puhl and co-workers recruited 329 professionals who treat patients with eating disorders through professional organizations specializing in treatment of eating disorders (Int J Eat Disord 2014; 47:65). Participants completed anonymous online self-report questionnaires, which assessed their explicit weight bias, perceived causes of obesity, attitudes toward treating obese patients, perceptions of patient compliance, and treatment success of obese patients. Respondents were also asked about perceptions of weight bias among other practitioners. More than half of the professionals had witnessed other professionals in their field making negative comments about obese patients; 42% agreed that other practitioners who treat eating disorders often have negative stereotypes about obese patients; and 35% agreed that practitioners feel uncomfortable caring for obese patients.

Attitudes toward treatment success

The study participants expressed considerable pessimism about treatment outcomes. Slightly more than half indicated they believed that obese patients could successfully make behavioral changes and were motivated to change their diets. Only slightly more than a third felt that obese patients comply with treatment recommendations, and only 24% expressed confidence that obese patients can maintain weight loss. 

Thus, although the eating disorders professionals felt confident about treating obese patients, they had less confidence that obese patients would comply with treatment. In addition, some of those who exhibited stronger weight bias were more likely to believe that obesity was caused by behavioral factors such as overeating and lack of willpower rather than environmental or biological/genetic factors. These professionals also expressed negative attitudes and frustrations about treating obese patients and predicted poorer treatment outcomes.

The authors also identified certain personal characteristics associated with expressions of weight bias. Participants who had been a professional in the field longer expressed less bias compared to less-experienced professionals. Participants who had lower personal BMIs experienced stronger weight bias than did those with higher body weights, which is also consistent with previous research demonstrating a negative correlation between BMI and weight bias.

On the basis of their results, the authors believe that efforts to reduce weight bias in the eating disorders field are warranted, and can be accomplished through educational interventions that emphasize the complex nature of obesity.