“I thought you’d tell me to get a grip”

On recognising eating disorders in primary care

Imagine Anna sitting in a consulting room. She nearly cancelled the appointment this morning. Her heart has been fluttering, and she feels tired, but there’s work to finish and dinner to organise. “It’s probably just stress,” she says. Then she hesitates. There’s something else she hasn’t told anyone.

For months, Anna has been caught in a cycle of binge eating and making herself vomit. She’s ashamed, frightened, and convinced she should be able to stop on her own. Her weight hasn’t changed much. Nobody suspects she’s unwell. Even she has struggled to believe that what’s happening deserves medical attention.

Following a fuller assessment, her clinician diagnoses bulimia nervosa. Her blood tests reveal a potassium level low enough to need urgent treatment, because it could put her at risk of a dangerous heart rhythm. The sensitivity in her teeth also needs attention; repeated exposure to stomach acid can wear away enamel. Her clinician arranges urgent medical care and treatment for the eating disorder, alongside dental support.

Anna’s first response is quiet. “I thought you’d tell me to get a grip.” She’s still frightened, but she now knows that help is available. She doesn’t have to keep pretending that everything is fine.

That’s why I care about identifying eating disorders in primary care. A routine appointment may be the first opportunity to help someone whose illness might otherwise continue for months or years. Patients don’t always arrive knowing what is wrong, or feeling able to say it. Sometimes they come because they’re dizzy, exhausted, or struggling with their stomach.

Those symptoms deserve attention in their own right. They can also be a reason to ask sensitively about eating and how someone is coping. A person who has spent months hiding their difficulties may find it hard to introduce the subject themselves. Making room for that conversation can help a clinician understand what else needs assessment.

Purging can disturb the balance of electrolytes, including potassium, that helps the heart function normally. Undernutrition can affect the heart and weaken bones. In children and adolescents, it can interfere with growth and puberty. Earlier care offers a chance to limit these harms. Normal blood tests don’t rule out an eating disorder or mean someone doesn’t need care.

Anna’s blood test shows one urgent problem in her particular story. Another person’s assessment may look different. The need to listen and investigate should never depend on having the same symptoms as Anna.

Waiting until someone looks visibly ill can delay that care. Eating disorders occur across body sizes, and serious illness can be missed when appearance reassures us. Someone in a larger body may be praised for weight loss that reflects dangerous restriction. Someone with bulimia may have no obvious change in weight at all. I worry about the message patients receive when the suffering they describe seems to matter less than the number on the scale.

The same problem arises when we expect eating disorders to belong to a particular age, gender, or background. A man may already feel nobody will take his symptoms seriously. An older adult may assume the diagnosis cannot apply to them. Those assumptions can postpone care that is needed now.

When I return to Anna’s story, I think about how easily that appointment might have ended with her eating disorder still unrecognised. Her palpitations might have been addressed while the illness behind them continued. Instead, she has a chance to receive care before further harm occurs. I can’t promise every complication will be prevented or every recovery will be straightforward. But Anna’s concerns have been taken seriously, and she knows she deserves help.

Anna is a composite of patients; names and identifying details have been changed.

Stock photos are for illustration and do not depict the people described in this article. Photos: Klaus Nielsen and Thirdman / Pexels.