By Jean Wu, M.D., first-year APA Foundation Child and Adolescent Psychiatry Fellow
Eating disorders are serious medical conditions characterized by disturbances in eating patterns that result in significant psychosocial impairment. They are among the most lethal psychiatric conditions due to high rates of medical complications and suicide. Eating disorders impact people of all genders, ages, body sizes, socioeconomic statuses, and racial/ethnic backgrounds. Since the COVID pandemic, rates of eating disorders have been rapidly escalating; however, medical education in eating disorders for psychiatry trainees continues to be underdeveloped.
While quick screening tools such as the SCOFF questionnaire and detailed research tools such as the EDE-Q exist, we lack a clinical framework to assess eating disorder symptoms in a diagnostic interview. This gap inspired me to create the “WEBB M.D.” or simply “WEBBMD” memory aid. Similar to the SIGECAPS tool for screening depression and DIGEFAST for mania symptoms, WEBBMD offers a framework for an eating disorder evaluation.
W = Weight
Objective body weight and subjective concerns about weight should be assessed. The “weight” criterion encompasses not only current weight, but patterns of weight changes. In practice, weight history may be more easily obtained via objective records or collateral, and the interview should focus more on a psychological assessment of weight, understanding the individual’s relationship with their weight, and the degree to which it influences self-image.
Sample questions include: “How important is your weight to you? Do you often think about your weight? Do you desire to change your weight? How often do you weigh yourself?”
E = Exercise
The amount of exercise should be quantified in terms of frequency and duration, and the type of exercise should be assessed. However, an increased quantity of exercise is not always pathological and can be seen in athletes. Thus, the clinician should attempt to understand the individual’s relationship with exercise.
Sample questions include: “Do you feel guilty when you miss a workout? Do you feel like you have to exercise everyday even when you don’t want to?
B = Body image
Body image encompasses the thoughts, feelings, and behaviors surrounding an individual's physical appearance. Disturbances in body image are key diagnostic criteria for anorexia nervosa and bulimia nervosa.
Sample questions include: “Do you feel like you need to control your appearance or body? How comfortable do you feel in your body - do you wish to change it? How so? How would you feel if you gained weight? Do you fear gaining weight? How often do you examine your body or appearance? How often do you look in the mirror or weigh yourself?”
B = Behaviors (binging and compensatory)
Behaviors should focus on assessing both compensatory and binging behaviors, paying attention to frequency and duration. Purging, self-induced vomiting or misuse of laxatives, enemas, or other bowel stimulants, to remove food from the body, is the most known compensatory behavior; however, it is only one of various compensatory behaviors. Binge eating is defined by consumption of an unusually large amount of food in a discrete period of time, accompanied by feelings of loss of control.
Sample questions include: “Do you do anything to control your weight, such as making yourself vomit after eating? Using medications to control weight (laxatives, enemas, GLP-1 agonists, etc.)? Eating only at certain times? Exercising after eating? Do you ever eat a large amount of food in a discrete period (i.e. two hours, and excluding holidays and events)? Would other people find that the amount of food you consumed is unusually large?” During these episodes, do you feel a loss of control?”
M = Menses
Among females, assessing changes in menses can be useful for understanding the degree of malnutrition. Amenorrhea is associated with other complications, including decreased bone mineral density, which increases risk for osteoporosis and fractures and may lead to stunted growth. A menstrual history should be obtained, including menarche, last menstrual period, and cycle regularity.
D = Diet history
The goal is to establish an understanding of the individual’s diet pattern, as well as the behaviors and attitudes towards eating. A thorough diet history includes assessing the type, quantity, and frequency of food consumed on an average day and week. It is important to inquire about any recent changes in dietary patterns, skipped meals, or prolonged fasting.
Sample questions include: “What does a typical day of eating look like for you? Have there been any changes to your diet recently? Do you follow a particular diet? Are there any foods you won’t eat? Why? Do you have any specific rules about food or eating?” Attitudes towards food should also be explored by asking “Do you view certain foods as good or bad?” A detailed 24-hour diet recall can also be a useful starting point.
If you are struggling or believe that you may be struggling with an eating disorder, help is available via the APA Foundation’s Mental Health Care Works campaign. Visit mentalhealthcareworks.org to learn how to access health care, how to support a loved one recovering from an eating disorder, or how to cope with symptoms of anxiety and depression in the lead-up to consulting with a mental health professional. Recovering from an eating disorder is challenging, but possible with support from loved ones and qualified care providers.