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DOI: 10.7759/cureus.71552
Educational Method to Promote Recognition,
Diagnosis, and Treatment of Eating Disorders: A
Cluster-Randomized Study of the Effects of
Retrieval Practice Amongst Medical Trainees
Maria D. Ash , Cynthia Holland-Hall , Kenneth Jackson , Guy N. Brock , Andrea E. Bonny
1. Adolescent Medicine, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, USA 2.
Biomedical Informatics, Ohio State University College of Medicine, Columbus, USA 3. Center for Biostatistics, Ohio
State University Wexner Medical Center, Columbus, USA 4. Biostatistics Resource at NCH (BRANCH), Nationwide
Children’s Hospital, Ohio State University, Columbus, USA 5. Pediatrics, Nationwide Children’s Hospital, Ohio State
University, Columbus, USA
Corresponding author: Maria D. Ash, maria.ash@nationwidechildrens.org
Abstract
Background
Eating disorder (ED) education during medical training is lacking. Few medical trainees feel comfortable
managing EDs, and an alarming 78% of healthcare providers report feeling insecure in treating
EDs. Recognizing EDs early is crucial as the standardized mortality ratio for patients with anorexia nervosa
is more than five times higher than that of the general population. Retrieval practice is a powerful tool in
producing meaningful learning of complex concepts in education. We investigated the effectiveness of
retrieval practice in ED education among medical trainees to improve recognition, diagnosis, and treatment
of EDs among adolescent patients.
Methods
This exploratory, prospective, cluster-randomized trial enrolled residents and medical students over 14,
four-week blocks. Participants were randomized by block to either the conventional lecture-based format
(control group) or the retrieval-based educational format (intervention group). The control group received
case-based lectures. The intervention group received education via 21 case-based quiz questions over the
block with immediate feedback. Groups completed nine-item, multiple choice pre (T1)- and post (T2)-
rotation knowledge tests, covering recognizing, diagnosing, and treating EDs. All participants also
completed pre- and post-rotation surveys designed to measure self-perceived comfort, confidence in
training, knowledge, and skills on the topic of EDs.
Results
The study’s primary outcome was the difference between T1 and T2 scores between study groups. The
intervention group showed greater improvement from T1 to T2 (5.8 to 7.4, respectively) than the control
group (5.1 to 6.0, respectively). The difference between mean T1 and T2 scores in the control group versus
the intervention group was significant (p=0.020). Despite the control group reporting improvements in
confidence regarding training on EDs, this increased confidence was inversely correlated with scores on T2
(r=-0.502, p=0.011).
Conclusions
Trainees benefit from retrieval practice to improve knowledge acquisition regarding EDs. Standard lectures
may confer false confidence to learners, which may not accurately align with actual knowledge acquisition.
Categories: Pediatrics, Medical Education
Keywords: adolescent medicine, eating disorders (eds), medical education research, retrieval practice, teaching and
training residents and medical students
Introduction
Eating disorder (ED) education has long lacked appropriate instruction during medical training [1,2]. A
persistent eating disturbance that results in altered food consumption characterizes EDs and significantly
impairs physical health and psychosocial functioning [3]. The lifetime prevalence of any ED among a
community cohort of adolescents is 5.7% among women and 1.2% among men [4]. The standardized
mortality ratio for anorexia nervosa (AN) is more than five times higher than that in the general population
matched for age and sex [5]. Complications of AN include derangement in hematologic parameters,
impairment of bone mass accrual, and primary or secondary menstruation suppression [6,7]. Cardiovascular
1 1 2, 3, 4 2, 3, 4, 5 1
Open Access Original Article
How to cite this article
Ash M D, Holland-Hall C, Jackson K, et al. (October 15, 2024) Educational Method to Promote Recognition, Diagnosis, and Treatment of Eating
Disorders: A Cluster-Randomized Study of the Effects of Retrieval Practice Amongst Medical Trainees. Cureus 16(10): e71552. DOI
10.7759/cureus.71552
changes noted in patients with AN include bradycardia, hypotension, orthostatic vital sign changes, QT
interval prolongation, myocardial atrophy, and pericardial effusion [7,8].
Given the morbidity and mortality associated with EDs, early recognition and intervention are crucial [9]. A
long duration substantially raises the risk of mortality [9,10]. Primary care providers are often the first point
of contact with patients struggling with EDs, yet these providers lack knowledge of specific characteristics of
these illnesses such as enlarged parotid glands and delayed gastric emptying, both of which could be
presenting symptoms of patients [11]. An alarming 78.0% of providers were unsure how to treat patients
with an ED, and 92.0% felt they had missed an ED diagnosis [12]. Medical trainees lack basic knowledge and
training in EDs, including diagnostic criteria, prevalence rates, and effective treatment. Only a minority of
trainees, 11.4%, felt comfortable managing patients with EDs [2]. Medical trainees require educational
intervention to improve the recognition, diagnosis, and treatment of EDs.
Under the umbrella of cognitive learning theory, retrieval practice is a well-studied concept. Retrieval
practice, also known as “testing,” “testing effect,” or “test-enhanced learning,” is a learning strategy that
demands effortful recall to consolidate memories into a connected fluid representation in the brain and to
strengthen and multiply the neural routes for later knowledge recall [13]. Retrieval practice is a successful
and powerful tool in promoting and producing the learning of complex concepts found in science education
and professional development [14,15]. The use of multiple-choice questions can construct knowledge and
significantly improve and enhance meaningful learning [15-17]. Retrieval practice has been used
successfully in secondary classrooms, post-secondary pharmacy and anatomy classes, and in continuing
professional development for physicians [14,18-23]. Cognitive learning theory, in particular, retrieval
practice, was chosen as the foundation for this study due to the ease with which this theory can be applied in
clinical teaching and its implications for long-term retention and hoped-for translation into medical
knowledge and practice [24].
Feedback is an essential element of effective retrieval practice [25-27]. The timing of feedback has been a
nuanced topic. Immediate, timely feedback is appropriate in some situations such as during task acquisition,
and less superior in other cases such as in simulation-based education [28-30]. Importantly, as students
make errors in test-like events during instruction, feedback has a more substantial effect on the later
retrieval of correct information [31]. Trainees in higher-level medical courses who receive detailed feedback
after retrieval demonstrate increased knowledge and improved performance [32,33].
This exploratory study’s primary objective was to assess the impact of an educational method that utilizes
retrieval practice with immediate feedback compared to the standard lecture format on medical trainee
knowledge acquisition regarding proper recognition, diagnosis, and treatment of EDs. We hypothesized that
medical trainees receiving retrieval-based learning would acquire more knowledge than the control group as
measured by a nine-item knowledge test measuring correct ED recognition, diagnosis, and treatment
administered at the beginning and end of the four-week adolescent medicine rotation.
A secondary aim was to explore retrieval practice’s efficacy in improving medical trainee self-perceived
comfort, knowledge, and skills regarding managing EDs, as well as confidence in their training. We
hypothesized that medical trainees receiving retrieval-based learning would have a more pronounced
improvement in self-perceived comfort, confidence in training, knowledge, and skills than the control group
as assessed by a five-point Likert scale on a survey administered at the beginning and end of the four-week
adolescent medicine rotation.
Materials And Methods
Participants
The Accreditation Council for Graduate Medical Education (ACGME) requires that all residents complete a
one-month rotation in adolescent medicine as a pediatric residency program requirement or combined
internal medicine-pediatrics residency program requirement [34,35]. Fourth-year medical students can elect
to complete a four-week elective rotation in adolescent medicine. Medical trainees were prospectively
invited to participate in a cluster-randomized educational pilot study during their adolescent medicine
rotation at a large pediatric health and research institution in the Midwestern United States during the
academic years 2018-2019 and 2019-2020. These participants were recruited over 14, four-week blocks. Each
block contained one to five learners. Blocks were not enrolled consecutively due to holiday block rotations or
other conflicts. Learners on two-week split blocks (e.g., 2-Week Adolescent Medicine/2-Week
Developmental-Behavioral Pediatrics block) were welcome to participate in educational activities but were
excluded from the study. Consented participants who completed the study included fourth-year medical
students (MS4) (15.2%), first-year residents (post-graduate year, PGY1) (19.6%), second-year residents
(PGY2) (4.3%), third-year residents (PGY3) (43.5%), and fourth-year residents (PGY4) (17.4%). The
institutional review board provided exempt status for this study under 45 CFR 46.101(b)(1).
Power calculation
Detectable effect sizes (80% power, alpha = 0.05) were determined for the cluster-randomized design with
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 2 of 42
eight clusters per arm, an average cluster size of three to four, and an intraclass correlation ranging between
0.01 and 0.05. The design has 80% power to detect an effect size of roughly 0.85, with three residents per
cluster (n=48) and 0.75 with four residents per cluster (n=64). Recruitment ended prior to reaching eight
clusters per arm secondary to external time constraints and the COVID-19 pandemic. PASS2020 (Power
Analysis and Sample Size, version 16) software (NCSS Statistical Software, NCSS, LLC, Kaysville, UT)
calculated power.
Design and randomization
Learners were provided with a study description before verbally consenting. The medical trainees were
randomly assigned using concealed allocation by block to either the conventional lecture-based format
(control group) or the retrieval-based educational format (intervention group) using a block randomization
scheme with block sizes of two and four. Groups were blinded to intervention and control procedures. Both
groups completed nine-item, multiple-choice, pre (T1)- and post (T2)-rotation knowledge tests on the first
Wednesday (week 1) and last Wednesday (week 4) of the rotation. Additionally, all participants completed a
pre (S1)- and post (S2)-rotation attitude survey, which was designed to measure self-perceived comfort,
confidence in training, knowledge, and skills in managing EDs.
Physician learning begins with an individual becoming aware of a problem or challenge [36]. Both the control
and intervention groups participated in a case-based interactive learning activity during week 1. This
introduction to the block allowed trainees the opportunity to become aware of their specific knowledge gaps
in EDs. Because the participants were coming onto the rotation at different points in their training, the
activity also served to provide all trainees with a comparable starting point before beginning their respective
learning activities for the block. The Society for Adolescent Health and Medicine website section on the
Eating Disorders & Overweight/Obesity education page provided this case-based activity [37].
The control group received lectures on ED recognition and diagnosis based on data supplements released in
conjunction with an article published in Pediatrics in Review, entitled “Eating Disorders” on the second
Wednesday of the rotation (week 2) [38,39]. During the third Wednesday of the rotation (week 3), the control
group received education on treating EDs using the lecture format created by the same literature [38,39]. The
intervention group received education via 21 case-based quiz questions over the block with immediate
feedback. Week 2 of the rotation covered recognizing and diagnosing EDs, and week 3 contained treating
EDs. The same literature was used in creating this material to ensure each group was exposed to the same
information in the experimental protocol (Figure 1).
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FIGURE 1: CONSORT flow chart of the randomized controlled trial.
Students were defined as discontinuing participation if they were absent or did not complete outcome measures.
Attrition was similar between groups.
CONSORT: Consolidated Standards of Reporting Trials
Outcome measures
Pre (T1)- and Post (T2)-Rotation Knowledge Test
The study’s primary outcome was the difference between the pre (T1)- and post (T2)-rotation nine-item
knowledge test scores between study groups. The nine-item knowledge test contained three questions each
on ED recognition, diagnosis, and treatment. The test was multiple choice with a “best answer.” The
American Board of Pediatrics objectives guided developing questions in their various content outlines and
content specification resources [40,41]. Medical trainees tested pilot questions from July to October 2018 to
demonstrate discriminatory capacity. In addition, three versions of each query were developed to randomly
assign each medical trainee a unique rendering of each question at each assessment point to decrease
intraclass correlation.
Pre (S1)- and Post (S2)-Rotation Attitude Survey
A secondary outcome was the difference between study groups in self-perceived comfort, confidence in
training, knowledge, and skills from the beginning to the end of the rotation. The survey was adapted from
previous studies and consisted of various items, including the Likert scale and dichotomous items [11,12].
The pre-rotation survey included additional questions to obtain demographic information.
Statistical analysis
Learners who completed the entire study (no absences, completed outcome measures) were included in the
analysis. Attrition was similar between groups. Descriptive analyses, including counts, percentages, means
and standard deviations, were performed to illustrate distributions of key variables. Linear models were used
to compare the change in the following outcome measures from the beginning of the rotation to the end of
the rotation between groups: knowledge totals on T1-T2, skills items on S1-S2, and knowledge items on S1
and S2. For each, the second value was considered a response with the baseline value and group assignment
as covariates. Due to fitting issues, the block was not included as a random effect for any model, except the
knowledge totals on T1-T2. Estimates and 95% confidence intervals (CI) were reported along with p-values
for these tests. Concerning the change in knowledge totals on T1-T2, an individual p-value of <0.05 was
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 4 of 42
considered statistically significant. Spearman’s rank correlation quantified the degree to which differences
in reported comfort managing patients with EDs on S2 corresponded to differences in T2 score (without
assuming a particular relationship); associated t-tests were run to enable inferences regarding those
values. Using a Bonferroni correction across five tests overall, an individual p-value of <0.01 was deemed
statistically significant for that specific instance. All statistical analyses were conducted using SAS 9.4 (SAS
Institute, Cary, NC).
Results
Demographics
Of the 46 enrolled medical trainees who completed the study, the control group included 25 participants and
the intervention group included 21 participants (Table 1). One resident in each group did not disclose race;
one participant in the control group did not divulge age. The majority of learners in both groups were white,
pediatric trainees. PGY3 residents outnumbered other training years in both groups. The participant’s ages
were similar in each group. The control group was comprised of more residents in their PGY1 year of
training than the intervention group, which included slightly more PGY4 residents in a combined internal
medicine-pediatrics residency program. Regarding formal education on EDs, 36.9% (17/46) of participants
reported receiving “0” hours during their medical/residency training, while about 58.7% (27/46) reported
receiving one to four hours of formal ED education. In terms of experience treating patients with EDs, 67.4%
of learners reported treating five or fewer patients throughout their training.
Characteristic Control, n (%) Intervention, n (%)
Mean Age, y 28.5‡30.4
Race†
White 21 (84.0) 14 (66.7)
Non-White 3 (12.0) 6 (28.6)
Training Year
MS4 4 (16.0) 3 (14.3)
PGY1 7 (28.0) 2 (9.5)
PGY2 2 (8.0) 0 (0.0)
PGY3 10 (40.0) 10 (47.6)
PGY4 2 (8.0) 6 (28.6)
Residency Type
N/A (medical student) 4 (16.0) 3 (14.3)
Family Medicine 3 (12.0) 2 (9.5)
Internal Medicine/Pediatrics 2 (8.0) 5 (23.8)
Pediatrics 16 (64.0) 11 (52.4)
TABLE 1: Demographics of participating students.
†One participant in each group was missing a value identifying race; ‡ One participant in the control group was missing a value identifying age
MS4 = Medical Student, 4th year; PGY = Post-Graduate Year
Knowledge test results
All knowledge tests had a maximum possible score of 9.0. The control group’s mean score was 5.1 at T1, and
6.0 at T2. The intervention group’s mean score was 5.8 at T1, and 7.4 at T2 (Figure 2).
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 5 of 42
FIGURE 2: Change in the mean score and difference between pre- and
post-rotation knowledge test scores.
* represents mean; | represents mode
The difference between the mean scores in the control group versus the intervention group was significant
based on a linear model (beta=1.308; 95% CI: 0.217, 2.398; p=0.020; ICC=0.17). The means and standard
deviations for each group are listed in Table 2.
Control (n=25) Intervention (n=21)
Total Score T1, mean +/- SD 5.1 +/- 1.6 5.8 +/- 1.5
Total Score T2, mean +/- SD 6.0 +/- 1.6 7.4 +/- 1.3
Difference Between T1 and T2, mean +/- SD* 0.9 +/- 2.0 1.2 +/- 2.3
TABLE 2: Mean knowledge test scores.
Survey results
Participants were asked, “How comfortable are you in managing patients with eating disorders?” In the
control group, 12 of 25 (48.0%) showed greater comfort managing patients with EDs by the end of the
rotation; 11 of 25 (44.0%) did not have a change in their comfort level; and 2 of 25 (8.0%) showed worsened
comfort in managing patients with EDs. In the intervention group, 13 of 20 (65.0%) trainees showed greater
comfort managing patients with EDs; six of 20 (30.0%) did not have a change in their comfort level; and one
of 20 (5.0%) showed worsened comfort.
Trainees were assessed on confidence in their training pertaining to EDs. Participants were asked whether
they felt well-trained to recognize, diagnose, and treat patients with EDs. Control group responses had a
negative correlation between the reported level of confidence regarding training on EDs on S2 and
performance on T2 (r=-0.502, p=0.011). No such correlation was found for the intervention group (r=0.089,
p=0.709).
Both the control and intervention groups showed improvement in self-perceived knowledge and skills
(Figure 3). The values were similar across groups, with no statistically significant difference between groups
in mean change in scores from S1 to S2 self-perceived knowledge scores (beta=0.069; 95% CI: -0.268, 0.407;
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p=0.680) or self-perceived skills scores (beta=-0.009; 95% CI: -0.377, 0.360; p=0.962).
FIGURE 3: Change in the mean score of self-perceived knowledge and
skills.
* represents mean; | represents mode
Trainees provided feedback on S2 regarding their satisfaction with the educational format. In the control
group, 17 of 25 (68.0%) respondents were extremely satisfied with their learning experience, six of 25
(24.0%) were somewhat satisfied, and two of 25 (8.0%) were extremely unsatisfied. In the intervention
group, seven of 20 (35.0%) respondents were extremely satisfied with their learning experience, nine of 20
(45.0%) were somewhat satisfied, 1 of 20 (5.0%) was somewhat unsatisfied, and three of 20 (15.0%) were
extremely unsatisfied.
Discussion
The current study is the first published using a prospective cluster-randomized trial design to pilot a
potential method for educating residents and medical students on ED recognition, diagnosis, and treatment.
In education specific to EDs, few trainees receive adequate lecture time on the topic, and even fewer can
gain experience by directly treating patients with EDs [1,2]. Our results, unfortunately, confirmed this
finding, with almost all trainees reporting receiving less than four hours of formal education and nearly 70%
having treated only five patients or less up to that point in their training.
A common theme in medical education reform is the need for research on best practices in medical
education [42]. Research supports active learning, which is learning that introduces activity and promotes
student engagement [43]. ED education has not met students’ needs in medical education and reflects the
lack of preparedness in primary care physicians and other healthcare providers [2,11,12,44-48]. Our study
demonstrates that retrieval practice may be a viable method to educate medical trainees on EDs. The
difference between mean scores in the control group versus the intervention group was significant,
suggesting a possible benefit to using retrieval practice in medical trainees’ education on EDs. A possible
explanation for the improved performance of the intervention group is that evaluating one’s own knowledge
base through retrieval practice may result in a more engaged learner. Immediate feedback given during
instruction in the intervention group further strengthened knowledge by correcting previously
misunderstood information [32,33].
The control group began the rotation with more participants reporting comfort managing patients with EDs
than the intervention group. By the end of the rotation, post-rotation survey scores showed more movement
towards increasing comfort in the intervention group as compared to the control group. This increase is
likely because retrieval practice recalibrates one’s understanding of what they do and do not know [13]. This
recalibration allows for increased comfort in one’s knowledge base.
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While the control group showed a shift towards increased confidence regarding training on EDs during the
rotation, our data show a negative correlation between displaying increased confidence in training on EDs
and final test scores in the control group; as confidence increased, knowledge test scores decreased. This
finding may stem from the control group lacking the opportunity to test and refine their knowledge, falsely
inflating their abilities, leading them to confuse their familiarity with presented information for the true
understanding of content [13]. Previous work has demonstrated the idea of a “beginner’s bubble” [49].
Learners are initially cautious and lack comfort in what they know before education. Small increases in
learning may result in large leaps of confidence, which may not accurately align with actual knowledge
increase [49], likely explaining the control group’s negative correlation. Continued education and
challenging and refining of knowledge lead to a leveling of confidence with incremental performance
improvement. Girz et al. confirmed this notion by demonstrating that, with intense training, increased
comfort in identifying ED symptoms and diagnosing and managing EDs does relate more accurately to
increased knowledge [45].
Patients with EDs present to their healthcare providers significantly more frequently than their peers five
years before the ED diagnosis [50]. Patients present to their provider for gynecological, gastrointestinal, and
psychological complaints, symptoms directly related to an ED, but the diagnosis is often missed. Even in
cases where the diagnosis is identified, an alarming number of providers fail to provide appropriate
treatment referrals [51]. While improvement in providers’ self-perceived knowledge and skills demonstrated
in this study is promising, these results may not truly reflect actual practice and management change,
requiring further research.
While most participants were satisfied with their learning experience, more participants in the control group
reported being satisfied with their learning experience than the intervention group. Despite this difference
in satisfaction, the intervention group performed better. Previous literature supports that learning style
preference does not necessarily correlate with improved grades or course scores [52]. Additionally, student
satisfaction with an educational method does not correlate with greater effectiveness of the technique
[53]. The current study measured satisfaction to assess how acceptable retrieval practice was among
trainees; however, our results support that satisfaction with a learning method alone should not be used to
indicate the effectiveness or value of a learning method.
Limitations of the study
In this study, the intervention group had more higher-level trainees than the control group. This discrepancy
may have influenced the overall knowledge base, affecting the knowledge base trainees had to draw upon,
and impacting scores on the pre- and post-rotation knowledge tests. This difference could also influence
self-perceived comfort in treating patients with EDs. More seasoned residents have more practice
incorporating new evidence into illness scripts, which could, in turn, affect the amount of comfort they
would express on the post-rotation survey. However, prior studies have refuted this concept, showing that
the year of residency did not predict comfort with diagnosing or treating EDs, rather the intensity of training
had a far larger impact in predicting comfort with diagnosing and treating EDs [45]. Our study likely reflects
this finding since most trainees lacked both training and patient experience before the rotation.
Our study contained a small number of participants and a limited number of clusters. The intraclass
correlation for the knowledge test model was 0.17, which indicates that 17% of the variance in the data is
explained by the random effect for the block. This is higher than the estimate in the power calculation of
0.01-0.05. The size of clusters was limited due to resident assignment onto the rotation. The number of
clusters was limited due to time constraints and the COVID-19 pandemic.
Our data represent only one institution and only test the concept of retrieval practice within the confines of
eating disorder education. A multi-center study using retrieval practice in broader contexts may provide
better insight into the feasibility of incorporating retrieval practice into existing curricula and make results
more generalizable.
Strengths of study
Each participant received unique knowledge tests at each point throughout the rotation (start and finish),
thus eliminating the possibility of either the control or the intervention group remembering previous
responses. Groups were blinded to intervention and control procedures. Participants were only informed
that they were taking part in an educational study to improve their understanding of EDs. Trainees joined
the rotation at all points of training. During the block’s first learning session, all trainees participated in a
case-based discussion on a theoretical ED patient as an introduction. During this session, participants
reviewed diagnosing, working up, and treating EDs so that all participants went into the remaining learning
sessions with a similar knowledge base.
Conclusions
This is the first prospective, cluster-randomized trial evaluating a potential method for educating residents
and medical students on ED recognition, diagnosis, and treatment. Recent studies have focused on
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improving ED education for healthcare professionals who have completed their post-graduate training.
Among primary care providers, formal ED curricula and interventions that utilize active learning have the
potential to increase providers’ knowledge of ED assessment and treatment significantly and may also
improve practice behaviors. Our results show promise in using retrieval practice to educate our trainees
while in medical school and residency. Future research should focus on determining if increased knowledge
correlates with improvements in medical practice. Studies are needed to determine if improvement in self-
reported comfort, confidence, knowledge, and skills results in improved outcomes through earlier
recognition, diagnosis, and treatment of patients with EDs.
Appendices
Pre-rotation attitudes survey [1,2]
Name:
Email address:
Year of Training:
Medical Student Year 3 ____
Medical Student Year 4 ____
Resident PGY-1 ____
Resident PGY-2 ____
Resident PGY-3 _____
Resident PGY-4 _____
Resident PGY-5 _____
What is your current training program:
_____ Medical school. If so, name of Medical school: __________________________________
_____ Residency program. If so, what Residency program and specialty:
______________________________________________________________________________
Preferred specialty upon completion of training:
Age:
Ethnicity:
Gender:
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 9 of 42
What is your preferred learning style? Select the top two that apply:
· Visual (spatial): You prefer using pictures, images and spatial understanding.
· Aural (auditory-musical): You prefer using sound and music.
· Verbal (linguistic): You prefer using words, both in speech and writing.
· Physical (kinesthetic): You prefer using your body, hands and sense of touch
· Logical (mathematical): You prefer using logic, reasoning and systems
· Social (interpersonal): You prefer to learn in groups our with other people
· Solitary (intrapersonal): You prefer to work alone and use self-study
Have you treated patients with eating disorders during your medical/residency training?
___ yes ___no
If yes, how many cases have you participated in diagnosis or treatment?
____ 0
____ 1-5
____ 6-10
____ 11-15
____ More than 15
Have you received formal education on eating disorders during your medical/residency training?
___ yes ___no
If yes, approximately how many hours of training have you received so far?
____ 0
____ 1-2
____ 3-4
____ 5-6
____ More than 6
How comfortable are you in managing patients with eating disorders?
___ Extremely uncomfortable
___ Somewhat uncomfortable
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___ Neither comfortable or uncomfortable
___ Somewhat comfortable
___ Extremely comfortable
How important is it to you to be knowledgeable about eating disorders?
___ Extremely unimportant
___ Somewhat unimportant
___ Neither important or unimportant
___ Somewhat important
___ Extremely important
How comfortable are you in treating adolescents?
___ Extremely uncomfortable
___ Somewhat uncomfortable
___ Neither comfortable or uncomfortable
___ Somewhat comfortable
___ Extremely comfortable
Have you ever found out that a patient had a severe eating disorder, but you had missed the signs and
diagnosis?
___ yes ___ no
If yes, what do you think prevented you from recognizing the signs and diagnosing the eating disorder?
(Check all that apply)
___ Weight was within the normal range
___ Unsure about what questions to ask the patient and their family
___ Patient was not forthcoming or honest with their answers when you did ask about diet, exercise, and/or
body image
___ Eating disorder symptoms were not the presenting concern, so you did not think to screen
___ Insufficient training in the skills necessary to adequately screen for an eating disorder
___ Upon questioning, the patient denied having any kind of eating disorder or becoming defensive
Other: _____________________________________________
Please rate your current knowledge regarding each of the following items with the following scale:
1: Very low (i.e. very uninformed)
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2: Low
3: Moderate
4: High
5: Very High (i.e. very informed)
· The prevalence rates of eating disorders in the United States _____
· The local resources available to patients struggling with an eating disorder_____
· The current best practices for working with eating disorders_____
· The other conditions that often co-occur with eating disorders_____
· The most effective ways to talk about weight management and weigh-ins with patients struggling with
eating disorders_____
· The common presenting complaints of patients struggling with an eating disorder_____
· The risk factors associated with developing eating disorders_____
· The indicators of recovery for patients with eating disorders_____
· The factors contributing to relapse in patients with eating disorders_____
Please rate your current skill level regarding each of the following items with the following scale:
1: Very low (i.e. very uninformed)
2: Low
3: Moderate
4: High
5: Very High (i.e. very informed)
· Asking a patient about their eating habits, weight, and body image without unduly raising their
defenses _____
· Talking with a patient about their eating disorder _____
· Making appropriate referrals to eating disorder specialists _____
· Handling a situation where you believe a patient has an eating disorder, but they are denying it or
minimizing the impact on their physical and emotional functioning/well-being _____
· Handling a patient’s disclosure that they have an eating disorder _____
· Conducting an eating disorder screening _____
Rate how strongly you agree or disagree with the following statements.
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 12 of 42
Universal screening for eating disorders is appropriate even when an eating disorder or weight is not the
presenting concern.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to recognize eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to diagnose eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to treat eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition is psychological rather than medical.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 13 of 42
___Mildly Disagree
___Strongly Disagree
Symptoms of this illness are fairly common and will resolve over time, without specific treatment.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This illness is a “severe and enduring” mental illness.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Patients with this illness are largely responsible for his/her own condition.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This illness has major consequences on a patient’s quality of life.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition causes difficulties for a patient’s family and friends.
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 14 of 42
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition is likely to be chronic.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Treatment is highly effective for patients with these symptoms.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Patients can do a lot to control these symptoms.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
I enjoy working with eating disorder patients and their families.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 15 of 42
___Strongly Disagree
The author adapted the survey from Currin et al. [11] and Linville et al. [12].
Post-rotation attitude survey (intervention) [1,2]
Name:
Preferred specialty upon completion of training:
Have you treated patients with eating disorders during this rotation?
___ yes ___no
If yes, how many cases have you participated in diagnosis or treatment?
____ 0
____ 1-5
____ 6-10
____ 11-15
____ More than 15
How comfortable are you in managing patients with eating disorders?
___ Extremely uncomfortable
___ Somewhat uncomfortable
___ Neither comfortable or uncomfortable
___ Somewhat comfortable
___ Extremely comfortable
How important is it to you to be knowledgeable about eating disorders?
___ Extremely unimportant
___ Somewhat unimportant
___ Neither important or unimportant
___ Somewhat important
___ Extremely important
How comfortable are you in treating adolescents?
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 16 of 42
___ Extremely uncomfortable
___ Somewhat uncomfortable
___ Neither comfortable or uncomfortable
___ Somewhat comfortable
___ Extremely comfortable
Have you ever found out that a patient had a severe eating disorder, but you had missed the signs and
diagnosis?
___ yes ___ no
If yes, what do you think prevented you from recognizing the signs and diagnosing the eating disorder?
(Check all that apply)
___ Weight was within the normal range
___ Unsure about what questions to ask the patient and their family
___ Patient was not forthcoming or honest with their answers when you did ask about diet, exercise, and/or
body image
___ Eating disorder symptoms were not the presenting concern, so you did not think to screen
___ Insufficient training in the skills necessary to adequately screen for an eating disorder
___ Upon questioning, the patient denied having any kind of eating disorder or becoming defensive
Other: _____________________________________________
Please rate your current knowledge regarding each of the following items with the following scale:
1: Very low (i.e. very uninformed)
2: Low
3: Moderate
4: High
5: Very High (i.e. very informed)
· The prevalence rates of eating disorders in the United States _____
· The local resources available to patients struggling with an eating disorder_____
· The current best practices for working with eating disorders_____
· The other conditions that often co-occur with eating disorders_____
· The most effective ways to talk about weight management and weigh-ins with patients struggling with
eating disorders_____
· The common presenting complaints of patients struggling with an eating disorder_____
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 17 of 42
· The risk factors associated with developing eating disorders_____
· The indicators of recovery for patients with eating disorders_____
· The factors contributing to relapse in patients with eating disorders_____
Please rate your current skill level regarding each of the following items with the following scale:
1: Very low (i.e. very uninformed)
2: Low
3: Moderate
4: High
5: Very High (i.e. very informed)
· Asking a patient about their eating habits, weight, and body image without unduly raising their
defenses _____
· Talking with a patient about their eating disorder _____
· Making appropriate referrals to eating disorder specialists _____
· Handling a situation where you believe a patient has an eating disorder, but they are denying it or
minimizing the impact on their physical and emotional functioning/well-being _____
· Handling a patient’s disclosure that they have an eating disorder _____
· Conducting an eating disorder screening _____
Rate how strongly you agree or disagree with the following statements.
Universal screening for eating disorders is appropriate even when an eating disorder or weight is not the
presenting concern.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to recognize eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 18 of 42
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to diagnose eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to treat eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition is psychological rather than medical.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Symptoms of this illness are fairly common and will resolve over time, without specific treatment.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This illness is a “severe and enduring” mental illness.
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 19 of 42
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Patients with this illness are largely responsible for his/her own condition.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This illness has major consequences on a patient’s quality of life.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition causes difficulties for a patient’s family and friends.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition is likely to be chronic.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 20 of 42
___Strongly Disagree
Treatment is highly effective for patients with these symptoms.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Patients can do a lot to control these symptoms.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
I enjoy working with eating disorder patients and their families.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
How satisfied were you with intermittent quizzes as a learning technique?
___Extremely unsatisfied
___Somewhat unsatisfied
___Neither satisfied or unsatisfied
___ Somewhat satisfied
___ Extremely satisfied
If so, what part did you find most conducive to learning?
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 21 of 42
How much do you feel you are likely to retain knowledge attained with this method of learning?
___Extremely unlikely
___Somewhat unlikely
___Neither likely or unlikely
___ Somewhat likely
___ Extremely likely
How often have you used the quizzing technique in the past as a learning/study tool?
___Never
___Not often
___Somewhat often
___Often
___I always use this method for learning
How likely are you to use the quizzing technique in the future as a learning or study tool?
___Extremely unlikely
___Somewhat unlikely
___Neither likely or unlikely
___ Somewhat likely
___ Extremely likely
The author adapted the survey from Currin et al. [11] and Linville et al. [12].
Post-rotation attitude survey (standard) [1,2]
Name:
Preferred specialty upon completion of training:
Have you treated patients with eating disorders during this rotation?
___ yes ___no
If yes, how many cases have you participated in diagnosis or treatment?
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 22 of 42
____ 0
____ 1-5
____ 6-10
____ 11-15
____ More than 15
How comfortable are you in managing patients with eating disorders?
___ Extremely uncomfortable
___ Somewhat uncomfortable
___ Neither comfortable or uncomfortable
___ Somewhat comfortable
___ Extremely comfortable
How important is it to you to be knowledgeable about eating disorders?
___ Extremely unimportant
___ Somewhat unimportant
___ Neither important or unimportant
___ Somewhat important
___ Extremely important
How comfortable are you in treating adolescents?
___ Extremely uncomfortable
___ Somewhat uncomfortable
___ Neither comfortable or uncomfortable
___ Somewhat comfortable
___ Extremely comfortable
Have you ever found out that a patient had a severe eating disorder, but you had missed the signs and
diagnosis?
___ yes ___ no
If yes, what do you think prevented you from recognizing the signs and diagnosing the eating disorder?
(Check all that apply)
___ Weight was within the normal range
___ Unsure about what questions to ask the patient and their family
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 23 of 42
___ Patient was not forthcoming or honest with their answers when you did ask about diet, exercise, and/or
body image
___ Eating disorder symptoms were not the presenting concern, so you did not think to screen
___ Insufficient training in the skills necessary to adequately screen for an eating disorder
___ Upon questioning, the patient denied having any kind of eating disorder or becoming defensive
Other: _____________________________________________
Please rate your current knowledge regarding each of the following items with the following scale:
1: Very low (i.e. very uninformed)
2: Low
3: Moderate
4: High
5: Very High (i.e. very informed)
· The prevalence rates of eating disorders in the United States _____
· The local resources available to patients struggling with an eating disorder_____
· The current best practices for working with eating disorders_____
· The other conditions that often co-occur with eating disorders_____
· The most effective ways to talk about weight management and weigh-ins with patients struggling with
eating disorders_____
· The common presenting complaints of patients struggling with an eating disorder_____
· The risk factors associated with developing eating disorders_____
· The indicators of recovery for patients with eating disorders_____
· The factors contributing to relapse in patients with eating disorders_____
Please rate your current skill level regarding each of the following items with the following scale:
1: Very low (i.e. very uninformed)
2: Low
3: Moderate
4: High
5: Very High (i.e. very informed)
· Asking a patient about their eating habits, weight, and body image without unduly raising their
defenses _____
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 24 of 42
· Talking with a patient about their eating disorder _____
· Making appropriate referrals to eating disorder specialists _____
· Handling a situation where you believe a patient has an eating disorder, but they are denying it or
minimizing the impact on their physical and emotional functioning/well-being _____
· Handling a patient’s disclosure that they have an eating disorder _____
· Conducting an eating disorder screening _____
Rate how strongly you agree or disagree with the following statements.
Universal screening for eating disorders is appropriate even when an eating disorder or weight is not the
presenting concern.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to recognize eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to diagnose eating disorders?
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Do you feel well-trained to treat eating disorders?
___Strongly Agree
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 25 of 42
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition is psychological rather than medical.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Symptoms of this illness are fairly common and will resolve over time, without specific treatment.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This illness is a “severe and enduring” mental illness.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Patients with this illness are largely responsible for his/her own condition.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 26 of 42
This illness has major consequences on a patient’s quality of life.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition causes difficulties for a patient’s family and friends.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
This condition is likely to be chronic.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Treatment is highly effective for patients with these symptoms.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
Patients can do a lot to control these symptoms.
___Strongly Agree
___Mildly Agree
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 27 of 42
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
I enjoy working with eating disorder patients and their families.
___Strongly Agree
___Mildly Agree
___Neither Agree nor disagree
___Mildly Disagree
___Strongly Disagree
How satisfied were you with lectures as a learning technique?
___Extremely unsatisfied
___Somewhat unsatisfied
___Neither satisfied or unsatisfied
___ Somewhat satisfied
___ Extremely satisfied
If so, what part did you find most conducive to learning?
How much do you feel you are likely to retain knowledge attained with this method of learning?
___Extremely unlikely
___Somewhat unlikely
___Neither likely or unlikely
___ Somewhat likely
___ Extremely likely
How often have you used lectures in the past as a learning/study tool?
___Never
___Not often
___Somewhat often
___Often
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 28 of 42
___I always use this method for learning
How likely are you to use lectures in the future as a learning or study tool?
___Extremely unlikely
___Somewhat unlikely
___Neither likely or unlikely
___ Somewhat likely
___ Extremely likely
The author adapted the survey from Currin et al. [11] and Linville et al. [12].
Knowledge test - All question version ABC w/ answers
Objectives:
Understand the differences between DSM-5 and prior diagnostic criteria for eating disorders.
Recognize clinical presentations characteristic of anorexia nervosa, bulimia nervosa, and binge-eating
disorder.
1A. You are seeing a 14-year-old female in your office for a yearly well-check. She is a dancer in a local
troupe and practices 6-7 days a week with competitions 2 weeks away. She has always been small but
consistently tracked along the 35th percentile for BMI. Today, she is below the 5th percentile for BMI. A
review of systems is positive for fatigue, constipation, and bloating. She attributes the weight loss to a “lack
of appetite” due to “nerves” over the upcoming competition season. Alone, she admits to fear of weight
gain especially with competitions approaching and desire for more weight loss to be “healthy” and to look
like “the other girls”. You suspect an eating disorder and obtain an EKG in the office.
Which EKG findings are most likely to occur in patients with Anorexia Nervosa?
A. Normal EKG with sinus rhythm and/or shortening of the QT interval with Osborn waves (J waves).
B. Peaked T waves with a narrow base, depressed ST segment, short QT interval and/or prolongation and
increased dispersion of the QT interval.
C. Sinus bradycardia with low-voltage on EKG and/or tall, peaked T waves with a narrow base, depressed
ST segment, and short QT interval.
D. Sinus bradycardia with low-voltage on EKG and prolongation and/or increased dispersion of the QT interval.
1B. You are seeing a 15-year-old female in your office for a yearly well-check. She is a gymnast in a local
club and practices 2-3 hours a day, 6-7 days a week. She has always been small but consistently tracked
along the 37th percentile for BMI. Today, she is below the 5th percentile for BMI. A review of systems is
positive for hair thinning, constipation, and bloating. She attributes the weight loss to a “lack of appetite”
due to “nerves” over the upcoming qualifying season. Alone, she admits she’s afraid to gain weight,
especially with qualifiers only two weeks away. She states the “smaller” she is, the better she’ll do on beam
and floor routine. You suspect an eating disorder and obtain an EKG in the office.
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 29 of 42
Which EKG finding is least likely to occur in patients with Anorexia Nervosa?
A. Prolongation of the QT interval with increased dispersion.
B. Shortened QT interval with narrow-based peaked T waves and depressed ST segment.
C. Normal EKG with sinus rhythm.
D. Sinus bradycardia with low-voltage on EKG.
1C. You are seeing a 13-year-old female in your office for a yearly sports physical. She has no significant
family history. She is a dancer in the BalletMet and practices 7 days a week. She has previously tracked
along the 35th percentile for BMI. Today, she is at the 9th percentile. A review of systems is positive for cold
intolerance, constipation, and thinning hair. She attributes the weight loss to “healthy eating” as
performances are 2 weeks away and she wanted to “get in shape”. Alone, she admits to a fear of fat on her
body and that she body checks in mirrors when no one is looking.
You suspect an eating disorder. Due to concerning vitals in a clinic, an EKG is obtained. Which of the
following EKG findings is most likely in this patient?
A. Normal EKG with a heart rate of 75 BPM.
B. Sinus bradycardia with a heart rate of 42 BPM and low voltage.
C. Abnormal EKG with sinus tachycardia and a heart rate of 109 BPM.
D. Normal EKG with a heart rate of 61 BPM with sinus arrhythmia.
Objective: Plan appropriate management for anorexia nervosa, bulimia nervosa, and binge-eating disorder
2A. You are seeing a 15-year-old male in your clinic for a Well Adolescent Exam. He has a prior history of
being teased at school for being “chunky”. He had always tracked close to the 88th percentile for BMI. The
family has recently returned from a vacation in California, where they saw him in a swimsuit and noticed
weight loss. Today his BMI is at the 50th percentile. Mom and dad state he’s “restricting” and will only eat
potato chips and pretzels. He always complains of being tired. They’ve also noticed he complains of
dizziness more often. In private, he tells you he has decreased morning erections. On exam, he appears tan
and has symptomatic orthostatic hypotension with dizziness. Otherwise, the exam is unremarkable.
Which set of lab testing is most likely to lead to diagnosis?
A. Total testosterone, free testosterone and sex hormone binding globulin.
B. Electrolytes, calcium, magnesium, phosphorus and prealbumin.
C. TSH, Free T4 and thyroid peroxidase antibody.
D. Chem 10, serum cortisol, morning plasma ACTH.
2B. You are seeing a 14-year-old male in your clinic for a well-child check. He has frequently tracked along
the 92nd percentile for BMI. Today he comes in, and over the past year has dropped to the 50th percentile
for BMI. Mom and dad praise him for all the “hard work” he has put into losing weight. He has joined the
baseball team and even runs every morning before school, which parents say speaks to his “dedication” and
“work ethic”.
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 30 of 42
What constellation of symptoms would make you most concerned about an eating disorder in this patient?
A. Fatigue, elevated blood pressure, loss of appetite, malaise, changes in urination
B. Increased muscle growth, hyperactivity, disrupted sleep patterns, increased acne
C. Abdominal pain, chronic diarrhea, fatigue, behavioral issues, vomiting
D. Fatigue, constipation, loss of morning erections and bradycardia
2C. You are seeing a 16-year-old male in your clinic for a well-child check. His family describes him as being
“chubby” previously. He has always tracked close to the 90th percentile for BMI. The family became
concerned while on vacation in Florida, where they saw him in swim trunks and noticed weight loss. Today
his BMI is at the 45th percentile. Mom and dad state he’s “not eating anymore,” preferring only to eat
seasalt chips and pretzels. He always complains of being tired. They’ve also noticed he complains of
dizziness. In private, he tells you he has decreased morning erections. On exam, he is tired appearing, has
tan skin, a flat affect, and has symptomatic orthostatic hypotension on vitals with reported dizziness.
Which set of lab testing is most likely to lead to diagnosis?
A. Blood urea nitrogen, serum creatinine, and urinalysis.
B. Electrolytes, magnesium, phosphorus, and prealbumin.
C. Total testosterone, free testosterone, and sex hormone-binding globulin.
D. Chem 10, serum cortisol, and morning plasma ACTH.
Objective: Recognize clinical presentations characteristic of anorexia nervosa, bulimia nervosa, and binge-
eating disorder.
3A. A 15-year-old female is taken to the emergency department after a finding of bradycardia to 52 BPM was
discovered by her pediatrician. She has a history of weight loss of 30 pounds over the last 4-5 months and
mom is certain she has heard her daughter vomit after meals quite frequently. She’s made comments about
wishing to be “thinner”. In the emergency room, she is defensive. Vitals show bradycardia and orthostatic
hypotension with reported dizziness.
Which of the following EKG findings is most likely in this situation?
A. Sinus tachycardia, short PR interval, and diffuse ST depressions.
B. Shortening of the QT interval with Osborn waves (J waves).
C. Tall, peaked T waves with a narrow base, depressed ST segment, and short QT interval.
D. Flattened T wave, depressed ST segment, and U wave.
3B. A 13-year-old female is taken to the emergency department after being found lying on the kitchen floor,
unresponsive, by her sister. She has a history of weight loss of 30 pounds over the last 4-5 months and mom
is quite certain she secretly exercises in her room after meals. Mom found Snapchat messages to friends that
she wants to be “skinny”. At the emergency room, she is defensive and states that she “just passed out for a
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 31 of 42
second” due to “dehydration”.
Which of the following EKG findings is most likely in this situation?
A. Shortening of the QT interval with Osborn waves (J waves).
B. Sinus tachycardia, short PR interval, and diffuse ST depressions.
C. Prolongation and increased dispersion of the QT interval.
D. Tall, peaked T waves with a narrow base, depressed ST segment, and short QT interval.
3C. A 17-year-old female is taken to the Urgent Care with symptoms of weakness and fatigue. She has a
history of weight loss and mom is concerned “something is wrong with her”. Mom asks about acute flaccid
myelitis because she “heard about it on the TV”. When questioned separately, the patient admits she
sometimes “makes herself sick” if she “eats too much”. An EKG is obtained.
Which of the following EKG findings is most likely to be found on further evaluation?
A. Sinus tachycardia, short PR interval, and diffuse ST depressions.
B. Flattened T wave, depressed ST segment, and U wave.
C. Shortening of the QT interval with Osborn waves (J waves).
D. Tall, peaked T waves with a narrow base, depressed ST segment, and short QT interval.
Objective: Understand the differences between DSM-5 and prior diagnostic criteria for eating disorders.
4A. A 14-year-old girl presents to your office with her mother with a chief complaint of “fatigue”. Mom also
feels her daughter is getting “thin” and is concerned that her daughter could have an “overactive thyroid”
because the patient’s great aunt also had thyroid issues. Upon further examination, it is found that her BMI
has decreased from the 75th to the 23rd percentile in the last 6 months, to which the patient states “I
haven’t had an appetite, I can only get breakfast down”. You complete a physical exam. Pertinent findings
include thin appearance, heart rate of 49 BPM supine, and dry skin. You order labs, including a Chem 10,
LFTs, CBC, TSH, Free T4, amylase, vitamin D and an EKG.
What additional piece of information would lead to the diagnosis of Anorexia Nervosa in this patient?
A. She has experienced increased anxiety and irritability, changes in her menstrual pattern, changes in
bowel patterns, and fine, brittle hair that breaks easily.
B. She engages in recurrent episodes of out-of-control eating involving an amount of food that is
definitely larger than what most individuals would eat in a similar period of time.
C. Patient conf ides in private that she’s afraid of seeing fat on her body.
D. Food avoidance is influenced by food texture and a fear of choking.
4B. A 16-year-old girl presents to your office with her grandmother due to weight loss. Grandmother feels
her granddaughter is getting “thin” and is concerned that she could have “gluten intolerance” because she
2024 Ash et al. Cureus 16(10): e71552. DOI 10.7759/cureus.71552 32 of 42
saw on tv this could cause “abdominal issues”. Upon further examination, it is found that the patient’s
weight has decreased from 61.2 kg to 48 kg in the last 6 months, to which the patient states “I haven’t had an
appetite, my stomach hurts whenever I eat anything”. You complete a physical exam. Pertinent findings
include a supine heart rate of 55 BPM, thin appearance, and thinning hair. You order labs, including a Chem
10, LFTs, CBC, TSH, Free T4, amylase, vitamin D.
What additional piece of information would confirm your suspicion of anorexia nervosa, restricting type in
this patient?
A. History and lab findings confirming a significant nutritional deficiency.
B. Menses was at 12 years old, but has not had a menstrual period in greater than three consecutive
months.
C. Patient voices fear of weight gain.
D. Labs reveal a K of 2.8 and an elevated amylase.
4C. A 13-year-old girl presents to your office with her mother with a chief complaint of “fatigue”. Mom
states her daughter is “too skinny” and is concerned that she could have “thyroid issues” because the
patient’s cousin had an “overactive thyroid gland”. Upon further examination, it is found that her BMI has
decreased from the 75th to the 25th percentile in the last 6 months, to which the patient states “I’m just not
hungry.” You complete a physical exam. Pertinent findings include a supine heart rate of 60 BPM, thin
appearance, and lanugo. You order labs, including a Chem 10, LFTs, CBC, TSH, Free T4, amylase and
vitamin D.
What additional piece of information would support a diagnosis of Anorexia Nervosa in this patient?
A. Physical exam and lab findings confirming significant nutritional deficiency.
B. She has not had a period in greater than three months consecutively.
C. Dependence on enteral feeding or oral nutritional supplements.
D. Patient hyper-exercises despite having already lost an unhealthy amount of weight.
Objectives:
Understand the differences between DSM-5 and prior diagnostic criteria for eating disorders.
Distinguish avoidant/restrictive food intake disorder from other eating disorders.
5A. A father brings his 15-year-old son to your clinic with complaints that his son has a 5-month history of
“feeling tired” and “losing weight”. He’s concerned that “something is wrong with him” because he has lost
19 lbs. after an episode of vomiting after eating “bad potato salad” at a family picnic 5 months ago. He is
active in basketball and currently goes to practice 5 times a week for about 2 hours each practice. He states
he just “hasn’t had an appetite” but that he wants to “gain some muscle” before the season starts. On
review of systems, he complains of constipation and loss of morning erections. He denies recent vomiting.
Vital signs reveal heart rate of 54 beats per minute, respiratory rate of 14 breaths per minute, and blood
pressure of 94/54 mmHg. The father raises the issue of an eating disorder.
Which of the following eating disorders is the most likely diagnosis for this patient?
A. Anorexia nervosa, restricting type.
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B. Avoidant/restrictive food intake disorder.
C. Atypical anorexia nervosa.
D. Eating Disorder Not Otherwise Specified.
5B. A father brings his 14-year-old daughter to your office with complaints that his daughter has a 7-month
history of fatigue and weight loss. He’s concerned that she has lost 19 lbs after an episode of vomiting after
eating “bad chicken salad” at a family picnic 8 months ago. She is active in sports and currently goes to
volleyball practice 5 times a week for about 1-2 hours each practice. His daughter denies fear of becoming
fat and denies purposefully cutting down on meals, stating she just “doesn’t feel hungry” and doesn’t want
to “be sick”. On review of systems, she complains of constipation and she has not had a menstrual period for
4 months. Menarche was at age 11 years. She denies recent vomiting. Vital signs reveal heart rate of 51 beats
per minute, respiratory rate of 12 breaths per minute, and blood pressure of 102/56 mmHg. The father raises
the issue of an eating disorder.
Which of the following eating disorders is the most likely diagnosis for this patient?
A. Eating Disorder Not Otherwise Specified.
B. Anorexia nervosa, restricting type.
C. Avoidant/restrictive food intake disorder.
D. Atypical anorexia nervosa.
5C. A father brings his 14-year-old son to your office with complaints that his son has a 6-month history of
weight loss and irritability. His son has lost 26 lbs. over the last 6 months. He is active in sports and
currently goes to football practice 4 times a week with scrimmages on the weekend. He also runs 4 miles on
days he doesn’t have practice. He admits he is scared of becoming fat and only eats before practices. On
review of systems, he complains of constipation and fatigue. He denies vomiting. Vital signs reveal a heart
rate of 49 beats per minute, respiratory rate of 14 breaths per minute, and blood pressure of 85/40mmHg.
The father raises the issue of an eating disorder.
Which of the following eating disorders is the most likely diagnosis for this patient?
A. Atypical anorexia nervosa.
B. Eating Disorder Not Otherwise Specified.
C. Anorexia nervosa, restricting type.
D. Avoidant/restrictive food intake disorder.
Objective: Understand the differences between DSM-5 and prior diagnostic criteria for eating disorders.
6A. A 17-year-old girl presents for a routine well check before starting college this fall. She reports that she
has received a full scholarship for academics and soccer. She is dressed in layers and is noted to weigh 105
lbs. During a comprehensive history and review of systems, she becomes immediately defensive when
questioned about her diet. Mom states she became vegan about 5 months ago. You suspect an eating
disorder.
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Which of the following is included in the DSM-5 diagnostic criteria for anorexia nervosa?
A. Absence of period for 3 or more months in a patient who previously achieved menarche.
B. Weight less than 80% of expected body weight.
C. Disturbance in the way one’s body weight or shape is experienced.
D. Presence of bradycardia or other serious physical manifestations of malnutrition.
6B. A 16-year-old girl presents for routine sports physicals before starting soccer. She is dressed in layers
and is noted to be at the 8th percentile for BMI. During a comprehensive history and review of systems, she
becomes immediately defensive when questioned about her diet. Dad states she became a pescatarian about
6 months ago. You suspect an eating disorder.
Which of the following is included in the DSM-5 diagnostic criteria for anorexia nervosa?
A. Persistent exercise twice a day even though current weight is signif icantly low.
B. Weight less than 85% of expected body weight.
C. Heart rate <55 bpm.
D. Persistent absence of a period for 3 or more consecutive months.
6C. A 17-year-old girl presents for a routine well-check before starting college this fall. She reports that she
has received a full scholarship for academics and basketball. She is dressed in baggy clothes and is noted to
have dropped from the 45th percentile for BMI to the 6th percentile for BMI. During a comprehensive
history and review of systems, you suspect an eating disorder.
Which of the following is included in the DSM-5 diagnostic criteria for anorexia nervosa?
A. BMI below the 30th percentile for adolescents.
B. Evidence of nutritional deficiency on the exam.
C. Persistent restriction of energy intake that leads to signif icantly low body weight.
D. Absence of the period for 3 or more months in a patient who previously achieved menarche.
Objectives:
Describe the multidisciplinary nature of treatment teams
Describe the goals of treatment for eating disorder patients
Describe basic levels of care (medical hospitalization, residential treatment, and levels of outpatient
treatments)
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7A. Which of the following is false of treatment and recovery of eating disorders?
A. Use of medications such as fluoxetine or topiramate may reduce binge eating and purging in patients
with bulimia nervosa.
B. Weight gain in the f irst year is predictive of success in restrictive eating disorders.
C. With binge-eating disorder it’s important to institute a weight management plan.
D. Being obese, younger, and having a chronic illness are risk factors for delayed diagnosis or anorexia
nervosa.
7B. Which of the following is false of treatment and recovery of eating disorders?
A. Being young, obese, or having a chronic illness are risk factors for delayed diagnosis of anorexia
nervosa.
B. With binge-eating disorder it’s important to institute a weight management plan.
C. Higher BMI at the transition to outpatient care is predictive of relapse in anorexia nervosa.
D. Weight gain in the first month is predictive of success in restrictive eating disorders.
7C. Which of the following is true of treatment and recovery of anorexia nervosa?
A. Treatment outcomes are generally superior in the inpatient setting.
B. Failure to gain weight in the f irst month of illness for patients with restrictive eating disorders corresponds
with a lower likelihood of recovery at one year.
C. Certain psychotherapies such as family-based treatment and cognitive behavioral therapy are
ineffective when treating anorexia nervosa in adolescents.
D. There is clear evidence to support the use of anti-depressants to promote weight gain in adolescent
patients with anorexia nervosa (Grade B).
Objectives: Recommend appropriate management of eating disorders based on
v Criteria necessitating inpatient medical admission for a patient with anorexia nervosa
v Presence or absence of medical manifestations of refeeding syndrome in an adolescent with severe
malnutrition
8A. A 16-year-old female presents with a significant history of weight loss (50 pounds over the past 6
months), excessive exercise, and restricted intake of food. Her last menstrual period was 4 months ago. She
denies self-induced vomiting or diuretic use.
Upon additional evaluation, which of the following findings is considered criteria for hospital admission in
this patient?
A. 74% of ideal body weight.
B. Blood pressure 90/52 mmHg.
C. Heart rate 55 bpm.
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D. Temperature 97.0F (36.1C).
8B. A 15-year-old male presents with a significant history of weight loss (50 pounds over the past 6 months),
excessive exercise, and restricted intake of food. He has a loss of morning erections. He denies self-induced
vomiting or diuretic use.
Upon additional evaluation, which of the following findings is considered an indication for hospitalization
in this patient?
A. 85% of ideal body weight
B. Blood pressure 78/48 mmHg
C. Heart rate 55 bpm
D. Temperature 97.0F (36.1C)
8C. 4. A 17-year-old female presents with a significant history of weight loss, falling from the 35th percentile
for BMI to the 9th percentile. She participates in excessive exercise, and restricted intake of food. Her last
menstrual period was 6 months ago. She denies self-induced vomiting or diuretic use.
Upon additional evaluation, which of the following findings is considered criteria for hospital admission in
this patient?
A. Blood pressure 90/52 mmHg.
B. Heart rate 45 bpm.
C. 77% of ideal body weight.
D. Temperature 96.5F (35.8C).
Objectives:
Recommend appropriate management of eating disorders based on:
- Criteria necessitating inpatient medical admission for a patient with anorexia nervosa
- Presence or absence of medical manifestations of refeeding syndrome in an adolescent with severe
malnutrition
9A. You are called to consult on a 13-year-old female for acute onset of weakness and paresthesia, admitted
to the youth crisis stabilization unit for suicidal ideation. The patient was recently diagnosed with anorexia
nervosa and has lost 25 kg in the last 4 months. The intern who admitted the patient the first night started
the patient on a diet of 3000 kcal/day. She is currently on day 3 of hospitalization.
Physical exam:
Cachectic, bilateral lower extremity edema noted
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Vitals: Temp 98.2F (36.8C); HR 45; BP 92/54; RR 22; O2 sat 98% on RA
Labs:
Sodium 137 meq/L (normal 135 - 145 meq/L)
Potassium 2.9 mmol/L (normal 3.7 - 5.6 mmol/L)
Chloride 102 meq/L (normal 95 - 106 mmol/L)
BUN 14 mg/dL (normal 5-18 mg/dL)
Cr 0.74 mg/dL (normal 0.40 - 1.10 mg/dL)
Glucose 122 mg/dL (normal 60-115 mg/dL)
Ca 9.4 mg/dL (normal 8 - 10.5 mg/dL)
Mg 1.2 mg/dL (normal 1.5 - 2.4 mg/dL)
Phos 2.4 mg/dL (normal 3.3 - 5.4 mg/dL)
What is the most appropriate next step in management of this patient?
A. Immediate EKG, make patient NPO, initiate maintenance IV fluids with D5 0.45NS 20K.
B. Immediate EKG, reduce nutritional support, aggressively correct electrolyte imbalances.
C. Immediate EKG, reduce nutritional support, initiate maintenance IV fluids with D5 0.45NS 20K, stat
repeat chem 7 panel.
D. Immediate EKG, make patient NPO, start maintenance IV fluids with 0.9 normal saline, aggressively
correct electrolyte imbalances.
9B. You are called to consult on a 15-year-old female admitted to the youth crisis stabilization unit for
suicidal ideation. She is complaining of acute onset of chest pain. The patient was recently diagnosed with
anorexia nervosa and has lost 45 kg in the last 7 months. The intern who admitted the patient the first night
started the patient on a diet of 3000 kcal/day. She is currently on day 3 of hospitalization.
Physical exam:
Cachectic, bilateral lower extremity edema noted, increased work of breathing
Vitals: Temp 98.2F (36.8C); HR 45; BP 92/54; RR 22; O2 sat 91% on RA
Labs:
Sodium 137 meq/L (normal 136 - 145 meq/L)
Potassium 2.4 meq/L (normal 3.5 - 5 meq/L)
Chloride 102 meq/L (normal 98 - 107 meq/L)
BUN 14 mg/dL (normal 6-22 mg/dL)
Cr 0.74 mg/dL (normal 0.72 - 1.25 mg/dL)
Glucose 122 mg/dL (normal 70-105 mg/dL)
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Mg 1.2 mg/dL (normal 1.6 - 2.9 mg/dL)
Phos 1.0 mg/dL (normal 2.3 - 4.7 mg/dL)
Your most immediate concern in this patient is for which of the following?
A. Esophageal tear secondary to persistent, purposeful purging.
B. Myocardial infarction secondary to decreased blood flow to the heart.
C. Superior Mesenteric Artery Syndrome causing the duodenum to be compressed between the aorta and
the superior mesenteric artery secondary to malnutrition.
D. Heart Failure secondary to Refeeding syndrome.
9C. You are called to consult a 14-year-old female in a psychiatric unit for electrolyte abnormalities. The
patient was recently diagnosed with anorexia nervosa and lost 30 kg in the last 5 months. The intern taking
care of the patient started the patient on a diet of 2700 kcal/day.
Physical exam: thin appearing, no acute distress, lanugo, dry vaginal mucosa
Vitals: Temp 98.2F (36.8C); HR - 45; BP - 92/54; RR - 22; O2 sat - 98% on RA, LMP 4 months prior to
presentation
Labs:
Sodium 137 meq/L (normal 135 - 145 meq/L)
Potassium 2.9 mmol/L (normal 3.7 - 5.6 mmol/L)
Chloride 102 meq/L (normal 95 - 106 mmol/L)
BUN 14 mg/dL (normal 5-18 mg/dL)
Cr 0.74 mg/dL (normal 0.40 - 1.10 mg/dL)
Glucose 122 mg/dL (normal 60-115 mg/dL)
Ca 9.4 mg/dL (normal 8 - 10.5 mg/dL)
Mg 1.2 mg/dL (normal 1.5 - 2.4 mg/dL)
Phos 2.4 mg/dL (normal 3.3 - 5.4 mg/dL)
The EKG shows ST segment depression, inverted T waves, and U waves with bradycardia.
The patient’s clinical condition is secondary to?
A. Anorexia Nervosa, binge eating-purging subtype.
B. Refeeding syndrome.
C. Bulimia nervosa.
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D. Diuretic and laxative use prior to hospitalization.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Maria D. Ash, Cynthia Holland-Hall, Andrea E. Bonny
Acquisition, analysis, or interpretation of data: Maria D. Ash, Andrea E. Bonny, Guy N. Brock, Kenneth
Jackson
Drafting of the manuscript: Maria D. Ash
Critical review of the manuscript for important intellectual content: Maria D. Ash, Cynthia Holland-
Hall, Andrea E. Bonny, Guy N. Brock, Kenneth Jackson
Supervision: Cynthia Holland-Hall, Andrea E. Bonny
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All
authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: Guy N. Brock, PhD declare(s) a grant from National Institutes of
Health, National Center for Advancing Translational Sciences. GNB was supported in part by the National
Institutes of Health, National Center for Advancing Translational Sciences grant UL1TR002733. Maria Ash,
MD, MA(Ed) declare(s) a grant from Nationwide Children's Hospital. Maria was awarded with an Intramural
Grant for trainees, award AWD00000731. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.
Acknowledgements
Many thanks and deepest gratitude to Isaac Kistler, MS (the Ohio State University Biostatistics Resource at
NCH (BRANCH); Department of Adolescent Medicine, Nationwide Children’s Hospital). This publication
would not have been possible without the addition of his guidance, time, input, and effort. I am indebted.
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