Evaluation of Eating Disorders: Counselor Response to Weight Information in a National Eating Disorders Educational and Screening Program by Dr. David Herzog

1. Evaluation of Eating Disorders: Counselor Response to Weight Information in a National
Eating Disorders Educational and Screening Program! !
Eating disorders are frequently undetected and inadequately treated in clinical settings. To
understand better how clinical information is either utilized or disregarded by clinicians in the
assessment of eating disorders—and ultimately, to identify means of enhancing adherence to
best practices—Dr. Herzog and his team investigated how weight data were used by counselors
to make recommendations for need for further evaluation in the National Eating Disorders
Screening Program (NEDSP).! ! The first NEDSP was an educational, two-stage screening program for eating disorders held at
college campuses across the nation in 1996. The program included 9,069 individuals from 409
colleges and universities across the United States. The students filled out self-report, symptom-based
screening questionnaires and had the option of meeting with a counselor, who reviewed
responses and made a recommendation as to whether there was sufficient concern to warrant
further formal evaluation.! ! The current study investigated whether the counselors used weight data appropriately in making
recommendations for further care. Data comprised self-report questionnaires from 5,684
NEDSP participants who met with a counselor, as well as the associated flow sheets completed
by the counselors.! ! Training of the NEDSP counselors was standardized as much as possible through the advance
distribution of a two-volume procedure manual. The procedure manual recommended that
NEDSP staff undergo orientation one week before initiation of the program. Counselors were
provided with versions of the BWAT for women and men that were developed for the NEDSP on
which they were to plot the participants’ height and weight. A corresponding category describing
appropriateness of weight for height (e.g., normal weight or underweight) could then be read
from this tool. The categories were normal weight, underweight, very underweight and
extremely underweight (<75% of expected body weight).! !
Weight for height data were used in the NEDSP algorithm as follows: (1) Normal weight and
above: no recommendation for further evaluation based on weight; (2) underweight:
recommendation for further evaluation based on weight only if either amenorrhea or significantly
disordered eating attitudes were reported; (3) very underweight: recommendation for further
evaluation based on weight alone; and (4) extremely underweight: recommendation for urgent
further evaluation.! ! In 95% of cases, the counselors correctly used the algorithm developed for the NEDSP to
assign participants to weight categories ranging from normal to extremely underweight.
However, counselors were poorly adherent to the algorithm directing them to recommend urgent
evaluation to all extremely underweight participants—that is, those with a weight at or below
75% of expected weight. Of the extremely underweight participants (n = 32), only 25.0% (n = 8)
received an appropriate recommendation for urgent evaluation, whereas 59.4% (n = 19)
received a recommendation for further (but nonurgent) evaluation, and 15.6% (n = 5) did not
receive a recommendation to seek any evaluation.! ! These results suggested that further specific emphasis on the health risks of extreme
underweight may be helpful in training clinicians to manage patients with eating disorders.