What We Fail to See

Eating Disorders Through the Lens of Rural Family Medicine

My name is Dr. Raman Kumar, and I am very pleased to be joining the team at Body Brave as a guest blogger. I have worked as a family physician since 2017, including several years in Fort McMurray, Alberta. My interest in eating disorders is both personal and clinical. It began with my sister Sonia’s experience of a severe eating disorder and deepened through caring for patients in a remote, industrial community where eating disorders often appeared in forms that were easy to miss.

When Sonia revealed to our family that she was suffering from an eating disorder, she’d already been ill for over two years. Like so many people with eating disorders, she’d felt a sense of shame about the illness and had kept it hidden. Our family drew close to her, hoping that love and determination would be enough to pull her out of the illness. Instead, over the next seven years, we witnessed how relentlessly an eating disorder could take over a person’s life.

The illness affected her concentration, education, relationships and ability to function from day to day. At times, it seemed to obscure the person we knew. Watching her struggle dismantled any belief that an eating disorder is a choice, a failure of willpower or the result of poor values or upbringing. Bulimia was not something she could overcome through greater discipline; the illness had taken qualities such as perfectionism, self-criticism and determination and turned them against her.

That experience taught me that eating disorders are serious psychiatric and medical illnesses. They can be disabling, painful and life-threatening. Yet stigma often causes patients, families and even clinicians to minimize them as vanity, immaturity or attention-seeking. The problem becomes even harder to recognize when a patient does not fit the narrow stereotype of a young, visibly underweight woman.

These lessons followed me into family medicine. Patients rarely came into my office saying, “I think I have an eating disorder.” They came in with the consequences of the disorder.

A patient who was bingeing and purging might present with acid reflux, abdominal pain, chronic sore throat or difficulty swallowing. Stomach acid could cause enamel erosion, tooth sensitivity and dental decay. Some developed swollen salivary glands or calluses over the knuckles from inducing vomiting. Bloodwork might reveal dehydration, kidney dysfunction or disturbances in sodium, magnesium and potassium. Low potassium is particularly dangerous because it can disrupt the electrical activity of the heart and lead to weakness, palpitations or potentially fatal arrhythmias.

Patients who were restricting food might report exhaustion, headaches, poor concentration, irritability, feeling constantly cold, dizziness on standing or fainting. A family physician might notice low blood pressure, a slow heart rate, dry skin, hair loss or significant changes in weight. Menstrual periods could become irregular or stop altogether. Hormonal disruption could affect fertility, libido and bone health. Over time, inadequate nutrition could contribute to anemia, reduced bone density, stress fractures, impaired immunity and cognitive changes.

Because these complaints are common in primary care, the underlying eating disorder can remain hidden unless the physician asks directly and compassionately. General questions such as “Are you eating well?” are rarely enough. A useful opening question is: Do you have any issues with food, weight or body image? Follow-up questions include: Are you skipping meals or fasting? Do you ever feel out of control while eating? Do you vomit, use laxatives or exercise to compensate? Do you continue exercising when you are sick or injured? How anxious do you become when you cannot follow your usual eating or exercise routine? If you are reading this as a patient or a family member, these are the questions you would want your doctor to ask. They are also worth asking yourself.

It is so important for family physicians to learn about eating disorders, because these conditions are far more common than many people realize. I learned very little about them in my medical training. Sonia’s illness was what taught me how severe they can be, and it also taught me that recovery is possible. Her recovery took years of treatment, support and her own hard work, and it is why the task of recognizing these illnesses early matters so much to me. Today my sister is well. She is the CEO of Body Brave, the organization hosting this blog, and I am honoured to be writing here.