Black, Indigenous and People of Colour, Larger Bodies and Eating Disorder Recovery 6
The Diagnostic Tools
Let’s get back to the questionnaires for opening the gates to treatment.
“In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing.”
The EDE-QS (eating disorder examination questionnaire - short) is a screening tool and the other option is the SCOFF (an acronym I’ll get to later). The Telltale Dozen on this site acts as a screening tool as well.
The assessment tools are the eating attitudes test (EAT 26), the compulsive exercise test (CES), EDE-Q (full).
There are various scales and subscales as well: binge eating scale, eating disorder inventory and body dissatisfaction and drive for thinness subscales, the bulimia test, the multidimensional body—self relations questionnaire and the objectified body consciousness scale—a cornucopia of acronyms. These scales and inventories are more involved (psychologist-guided and/or self-administered then psychometrically measured) intellectual properties (i.e. for profit) where the answers to questions are plotted on various scales to determine the presence or absence of particular eating disorders described in the DSM. For a solid description of what comprises the Eating Disorder Inventory Scale you can read through it here.
To give you a sense of these various questionnaires here are some of the first statements or questions in each of these screenings and assessments:
Do you ever eat uncontrollably to the point of bloating (binge eating)? —BULIT-R
Have you been deliberately trying to limit the amount of food you eat to influence your weight or shape (whether or not you have succeeded)? —EDE-QS
I am terrified about being overweight. —EAT-26
During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)? —BEDS-7
SCOFF is an unfortunate acronym in my opinion. In predominantly British English it means to gobble down one’s food. In American/Canadian we would more likely use the term: scarfing down food. The questionnaire, right down to its acronym, fully embraces the distress of losing control over one’s eating rather than honing in on the difficulty of such distress and how it impinges upon quality of life.
S – Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry you have lost Control over how much you eat?
O – Have you recently lost more than One stone (6.35 kg) in a three-month period?
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life?
The first statement of the Compulsive Exercise Test is: “I feel happier and/or more positive after I exercise.” As I’ve pointed out in the Exercise Two article, the evidence doesn’t support the premise that those with eating disorders use exercise to feel happier. The research actually indicates these statements will identify using exercise as an eating disorder tool more accurately:
being annoyed if exercise interrupted
others feel you exercise a lot
feeling bad if unable to exercise a certain amount
feeling that you have/had problems with exercise. [2]
The problem with every one of these questionnaires is encapsulated in Dr. Rebeckah Peebles’ quote from a talk she gave in 2012:
“When treating those with eating disorders, the practitioners cannot be afraid of what the eating disorder is afraid of.”
Everything that falls within the range of trying to diagnose bulimia and/or binge eating disorder zeroes in on overeating and lost control. Everything that falls within the range of trying to diagnose anorexia focuses on weight loss and thinness. Nothing is getting at the crux of the matter: unending efforts to eat less than what the body needs to the point that your quality of life is being negatively impacted. Chances are that those close to you have already made some comments and observations around your issues even as you are perhaps still dealing with layers of denial and minimization.
The AUDIT (alcohol use disorders identification test) is one of the few questionnaires associated with the DSM as a whole that even has one question related to how others are interacting with you in the face of the set of symptoms you are experiencing:
“Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?”
Trusted others are an important piece of diagnosis.
Pick anyone you know who seems not to have any drive to restrict food intake (for any reason) and ask them how many times in a day they think about food. They predominantly don’t at all, and if the thought of food pops into their minds, then that’s just a basic signal they’ve gone way too long without food. If you think about the Snickers “Hangry” commercials the humour embedded in all of those ads is that these people have gone way too long without food and their personalities are negatively impacted.
For those with any type of eating disorder, the thoughts of food are constant. And part of having an eating disorder is thinking that these thoughts are the foundation of the disorder, rather than them being the biological expression of an energy deficit in the body. Eating avoidance disorder.
But putting aside the limitations of these questionnaires, are they valid for the identification of eating disorders in BIPoC and larger bodied people? The basic answer is yes. Most studies, and a systematic review from 2023, [3] confirm the validity of these questionnaires in the identification of eating disorders across ethnicities and genders.
For the purpose of accessing treatment, you can request from your primary care practitioner, psychologist, or psychiatrist that you be given the EAT-26, or EDDS (or other tests listed above) and be confident that the result is accurate (within the confines of what these tests are measuring).
Next installment July 11.
Image in Synopsis: Public Domain.
Kutz AM, Marsh AG, Gunderson CG, Maguen S, Masheb RM. Eating disorder screening: a systematic review and meta-analysis of diagnostic test characteristics of the SCOFF. Journal of general internal medicine. 2020 Mar;35:885-93.
Boyd, Catherine, Suzanne Abraham, and Georgina Luscombe. "Exercise behaviours and feelings in eating disorder and non‐eating disorder groups." European Eating Disorders Review 15, no. 2 (2007): 112-118.
Habashy J, Benning SD, Renn BN, Borgogna NC, Lawrence EM, Kraus SW. Psychometric properties of the eating disorder examination questionnaire: Factor analysis and measurement invariance by race/ethnicity and gender. Eating Behaviors. 2023 Jan 1;48:101696.
