Natalie is a 32-year-old woman with a history of generalized anxiety disorder. She presents to your primary care appointment with ongoing constipation and hair loss, and more recently, the loss of her menstrual cycle. She wants to start a family with her husband but she has not had her period in 6 months.
You notice her heart rate is 50 (within her typical range) and her BMI has decreased from 26 to 22 in the last year. She is a long-distance runner who follows a pescatarian diet, rarely drinks alcohol, and never uses cigarettes or drugs.
How do you talk with patients about restrictive eating?
The estimated lifetime prevalence for anorexia nervosa in women is 1.4% (vs 0.1% in adult men) (Feltner 2022). The premature death rate from anorexia nervosa is higher than that of every other psychiatric illness, except opioid use disorder (Phillipou 2025).
Patients with restrictive eating behaviors rarely present to their PCP with a chief concern of “eating disorder.” They usually present with signs or symptoms of restrictive eating, like fatigue, cold intolerance, menstrual irregularity, abdominal pain, or constipation (Klein 2021). Patients may be reluctant to discuss these issues due to shame, embarrassment, or a sense that the medical establishment will not help. Restrictive eating behaviors may also be ego-syntonic, with patients viewing them as helpful coping strategies that provide structure, self-worth, and safety (Sangvai 2016).
Broad screening for eating disorders is not a part of routine primary care practice, and no studies have directly assessed the benefits and harms of screening (Feltner 2022).
When clinicians have concern for disordered eating behavior, they should bring up the topic.
Structuring a primary care visit with a person with restrictive eating
Your aim in taking a history is to understand the patient and their eating habits. If their eating behaviors are concerning, your goal is to express concern about the negative impact of the eating disorder on the patient’s physical and mental health and refer to local specialty treatment settings.
Forcing a person to have a conversation that they’re not ready to have is more likely to erode the therapeutic relationship than change a patient’s behaviors. Start by evaluating if the patient is ready to discuss their eating behaviors. Be open to accepting “not now” as long as there is no serious risk for medical compromise.
The ask, offer, ask model is a structured way to have a conversation about disordered eating, learn more, and probe motivation for change. Commonly, clinicians take a history by interrogating a patient with question after question, and then sharing their own point of view on what is wrong. The ask, offer, ask model from motivational interviewing provides a framework for how to have a conversation in which the patient’s voice is at the forefront and your thoughts as a clinician are situated around the patient’s specific concerns.
Below are some short examples of ask, offer, ask. The “ask” can be a request for the patient’s permission to discuss a topic, a history question, or a probing question for clarity. The “offer” is an expression of your thoughts: these are commonly reflections of what the patient has just said, a statement of affirmation, or a new concern that you want to bring into the conversation.
Ask: “Is it OK if we discuss exercise and its relation to your weight today?”
Offer: “I’ve noticed that your weight has decreased over the last year, and I worry that this may be contributing to the symptoms you are noticing, like your periods stopping, constipation, and hair loss.”
Ask: “What do you think about that?”
Ask: “Some people notice that when they are eating less, they feel more fatigued and less focused. What impact does eating less have on you?”
Offer: You are struggling to focus on anything but your size right now, and these thoughts about your body feel intrusive to you.
Ask: “What do you do when you find yourself thinking about food a lot?”
If the patient you are meeting with is open to it, you can move the conversation forward by asking more specifics about disordered eating patterns and patient coping strategies. The RIP-TEAR framework, often used to structure history-taking with a patient with substance use disorder, can also help clinicians take a focused history with a patient with restricted eating.
| Risk | Evaluate for imminent risk. | Check vital signs for low weight, bradycardia, hypotension. Check labs for electrolyte disturbances. Ask about suicidal thoughts and behaviors. |
| Initiation | When and how did these eating behaviors begin? | “Some of my patients tell me that their weight or body shape causes stress. What, if any, struggles have you had around this?” “When did you first [restrict your calories]?” “When did you ramp up your exercise regimen?” “What was going on in your life at that time?” |
| Pattern | Pattern of current behaviors. | “Sometimes people think about how they are eating all day to the point that it is difficult to concentrate on anything else. Does that happen to you?” “What percentage of the day do you spend thinking about food/weight/body shape?” “What do you do when you find yourself thinking about food a lot?” “How do you track your food intake or exercise?” “Do you use laxatives?” “Tell me more.” “Do you ever make yourself throw up after eating?” “Tell me about that experience.” “Do you ever eat an unusually large amount of food in a short period of time? “ |
| Treatment | Treatment episodes and effectiveness. | “Have you ever been treated for an eating disorder before?” “What was your experience like with [that treatment]?” |
| Effects | Positive and negative perceived effects. | “Are there times in the past when you did not spend so much time thinking about food and what you ate? What was going on then?” “What would be the benefits of changing how you eat and exercise? What would be the downsides?” “How does eating / exercise impact your… …ability to function during the day?” …energy levels?” |
| Abstinence | In this case, episodes when the patient did not participate in restrictive eating or excessive exercising. | “Are there times in the past when you did not spend so much time thinking about food and what you ate?” “What was going on then?” |
| Return to use | In this case, triggers for restrictive eating or excessive exercise. | “What has contributed to increased food restriction in the past?” “What might cause you to increase your exercise regimen?” |
Questions adapted from Klein 2021 and RIP-TEAR.
Additional history questions that may be helpful:
“Have you ever weighed much less than people thought you should weigh?”
“Have you ever been diagnosed with an eating disorder?”
“Does anyone in your family have an eating disorder?”
Be intentional about asking for and reflecting on the patient’s experience. You can use “some people” statements to probe for more history. Bring the patient into the conversation by asking for their opinion on your comments, providing affirmative statements and recognizing the patient’s experience.
“Some of my patients tell me that their weight or body shape causes stress. What, if any, struggles have you had around this?”
“Given your experiences with treatment in the past, I can understand your skepticism.”
“I’m curious whatyou already know about this topic.”
(Klein 2021)
As patients describe their history, pay attention to statements or described behaviors that suggest disordered eating patterns.
| Statements | Behaviors |
| “I am just not hungry and don’t feel comfortable forcing myself to eat.” “I am too busy and sometimes forget to eat.” “I cannot find foods that I like to eat.” “Whenever I eat something, I feel sick.” | Preoccupation with weight loss, food, calories, and dieting Refuses to eat certain foods and often eliminates whole food groups (carbohydrates, fats, etc.) Makes excuses to avoid mealtimes or situations involving food Develops food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate) Withdraws from friends and previously pleasurable activities and becomes more isolated and secretive Extreme concern with body size and shape Frequent checking in the mirror for perceived flaws in appearance Extreme mood swings |
Adapted from NEDA – National Eating Disorders Association, Sangvai 2016.
Returning to Natalie
Natalie says that she is open to having this conversation. She hears your concerns and recognizes she has lost weight. She likes being thin and feels most comfortable in a slim body. This has been the case since she was in college, when she realized she had full control over her diet and exercise, now that she didn’t live at home. Recently, she notes that she has been feeling increased anxiety and stress around trying to get pregnant and this has led her to feel out of control. One way she manages this “out of control” feeling is by exercising and restricting her diet to 2 small, non-carbohydrate-containing meals per day. She has never purged or used laxatives. She sees that this is probably causing the change in her menstrual cycle, but is frustrated that many of her friends who exercise just as much as she does still have their periods. She feels that exercise has been very stabilizing for her mood and is an important part of her life. However, she is open to referrals to speak with a psychotherapist and nutritionist.
Key Points
- Patients may be reluctant to bring up restrictive eating or excessive exercise habits; it is up to the clinician to begin this conversation and share concerns.
- Use the ask, offer, ask framework to guide the conversation.
- The RIP-TEAR framework, adapted from discussions of substance use disorders, can scaffold a focused initial conversation about restrictive eating.
Special thank you to Dr. Jessica Keyser (Clinical Professor, Eating Disorder Program Fellowship Training Director, Eating Disorders Program, Department of Psychiatry and Behavioral Sciences at University of California, San Francisco) for her guidance and feedback on this PsychSnap.
Related PsychSnaps:
“How do you talk to patients about their substance use?” Era Kryzhanovskaya, September 2023.
“How do you diagnose binge eating disorder in primary care?” Zoë Kopp, July 2024.
References:
Attia, E., & Walsh, B. T. (2025). Eating Disorders: A Review. JAMA, 333(14), 1242.
Feltner, C., et al. (2022). Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 327(11), 1068.
Klein, D. A., Sylvester, J. E., & Schvey, N. A. (2021). Eating Disorders in Primary Care: Diagnosis and Management. EATING DISORDERS, 103(1).
National Eating Disorders Association: https://www.nationaleatingdisorders.org/
Phillipou, Andrea, et al. (2025). Anorexia nervosa—facts, frustrations, and the future. JAMA Psychiatry 82(8), 844-847.
Sangvai, D. (2016). Eating Disorders in the Primary Care Setting. Primary Care: Clinics in Office Practice, 43(2), 301–312.