What's New? - November 2017

It is estimated that over 725,000 men and women in the UK are affected by eating disorders. People with eating disorders should be assessed and receive treatment at the earliest opportunity. This pathway has been published to help clinicians recognise the signs of eating disorders, how to assess them and how to manage patients once a diagnosis has been made.

Eating Disorders Care Pathway Overview

Please click the relevant flowchart box to be taken directly to textual information.


N.B Do not use screening tools (for example, SCOFF) as the sole method to determine whether or not people have an eating disorder

Red Flags
Potential indications for hospitalisation:
Physical Health
  • exhaustion
  • abnormal vital signs - hypotension, bradycardia, hypothermia
  • hypokalaemia
  • fasting for more than a few days
  • uncontrollable bingeing and purging
  • extreme ipecac abuse
  • dehydration
Mental Health
  • suicidality
Potential indications for urgent referral to Eating Disorder Service:
Are there significant risk factors?
  • is Body Mass Index (BMI) less than 13?
  • has there been a recent loss of 1kg or more for two consecutive weeks?
  • is pulse less than 40?
  • is blood pressure low with postural dizziness?
  • is core temeprature less then 35°C?
  • are sodium (Na) levels less than 130mmol/L?
  • are potassium (K) levels less than 3.0mmol/L?
  • are transaminase levels raised?
  • are glucose levels less than 3mmol/L?
  • raised urea or creatinine?
  • electrocardiogram (ECG): Bradycardia- QTc is more than 450ms.

2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here.


Presentation and Screening

Presentation to Primary Care:

  • patient or relative expresses concerns
  • significant unexplained weight loss or gain
  • over concern regarding weight or shape, fear of choking or vomiting
  • highly selective or restrictive diet with low weight, failure to grow or significant psychosocial impact
  • binge eating
  • patient engaging in unhealthy weight loss behaviours e.g. vomiting, fasting, excessive exercise, misuse of laxatives, diuretics or diet pills


Keep alert, if suspicious e.g. low weight, fatigue, dizziness, syncope, gastrointestinal (GI) symptoms, amenorrhoea, depression/anxiety.

Target groups for screening should include young women with low body mass index compared with age norms, patients consulting with weight concerns who are not overweight, women with menstrual disturbances or amenorrhoea, patients with gastrointestinal symptoms, patients with physical signs of starvation or repeated vomiting, and children with poor growth.

Screen and assess young people with Type 1 diabetes and poor treatment adherence for the presence of an eating disorder.

Differential Diagnosis

Other common medical causes of weight loss include:

Initial Primary Care Assessment

For people with eating disorders presenting in primary care, GPs should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment.


  • an unusually low or high body mass index (BMI) for their age
  • rapid weight loss
  • dieting or restrictive eating practices
  • family members/carers report a change in eating behaviours
  • other mental health problems
  • a disproportionate concern about their weight/shape
  • problems managing a chronic illness that affects diet i.e. diabetes or coeliac disease
  • menstrual or other endocrine disturbances or unexplained gastrointestinal symptoms
  • physical signs of:
    • malnutrition (poor circulation, dizziness, palpitations)
    • compensatory behaviours (laxative use, excessive vomiting/exercise)
  • abdominal pain linked to vomiting or diet restriction
  • unexplained electrolyte imbalance or hypoglycaemia
  • whether they are taking part in activities associated with high risk of eating disorders (ballet, modelling, professional sport etc.)


You may also consider sensitively asking the following questions:

  • Do you think you have an eating problem?
  • Do you have a problem controlling your eating?
  • Do you worry unduly about your weight? Do other people think you do?
The possibility of alcohol or substance misuse should also be assessed. For people with an eating disorder who are misusing substances, provide treatment for the eating disorder unless the substance misuse is interfering with this treatment. If the substance misuse is interfering with treatment, consider a multidisciplinary approach with misuse services such as Change, Grow, Live- Gloucestershire Community Drug & Alcohol Recovery Service.

If eating disorder NOT confirmed:

5 questions - 2 or more positive answers suggests eating disorder

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry you have lost Control over how much you eat?
  • Have you recently lost Over 10 lbs in a 3 month period (original description was One stone = 14 lbs = 6.3 kg)?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?

Do not use screening tools (e.g. SCOFF) as the sole method to determine whether or not a person has an eating disorder.

If eating disorder confirmed by patient OR 2 or more positive answers to SCOFF screening:

  • body mass index (BMI), blood pressure and pulse, temperature, muscle strength (‘the sit, squat, stand test’) if the patient is emaciated. For more guidance on the 'sit, squat, stand test' please click here.
  • co-existent psychopathology: depression, anxiety, self-harm and suicide risk
  • routine blood tests sufficient (full blood count (FBC), electrolytes, glucose)
  • check electrocardiogram (ECG) if low potassium (K) or BMIor body weight is unusually high or low for their age
  • consider a bone mineral density scan after 2 years of underweight in adults, or earlier if they have bone pain or recurrent fractures
Initial Primary Care Management

Provide advice/refer/signpost patients to any of the following self-management services;

Practice Point

The Eating Disorders Service may be contacted for advice at any stage:

Tel: 01242 634242

Email: 2gnft.EatingDisordersServiceReferrals@nhs.net 

Fax: 01242 634284

Address: The Eating Disorders Service, The Brownhill Centre, 121 Swindon Road, Cheltenham, GL51 9EZ 

Remember that most people with a clinically signfiicant eating disorder do not meet the strict diagnostic criteria for Anorexia Nervosa or Bulimia Nervosa. 


In anorexia nervosa, although weight and body mass index are important indicators they should not be considered the sole indicators of physical risk (as they are unreliable in adults)

In assessing whether a person has anorexia nervosa, pay attention to the overall clinical assessment (repeated over time), including rate of weight loss, objective physical signs and appropriate laboratory tests.

Offer patients with enduring anorexia nervosa who are not under the care of a secondary care service an annual physical and mental health review.

Do not provide dietary counselling as the sole treatment for anorexia nervosa.

Refer all cases of anorexia nervosa as early as possible to the Eating Disorders Service - 2gether

Assess the fluid and electrolyte balance of patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives (especially if they are also underweight).

When electrolyte disturbance is detected, it is usually sufficient to focus on eliminating the behaviour responsible. In the small proportion of cases where supplementation is required to restore electrolyte balance, oral rather than intravenous administration is recommended, unless there are problems with gastrointestinal absorption.

For patients with bulimia nervosa who are at risk of suicide or severe self-harm, consider admission as an inpatient or day patient, or the provision of more intensive outpatient care.

Be aware that patients with bulimia nervosa who have poor impulse control, notably substance misuse, may be less likely to respond to a standard programme of treatment. As a consequence treatment should be adapted to the problems presented.

Where laxative abuse is present (more than twenty per day), advise patients to gradually reduce laxative use and inform them that laxative use does not significantly reduce calorie absorption.

Patients with an eating disorder who are vomiting should have regular dental reviews.

Give patients with an eating disorder who are vomiting appropriate advice on dental hygiene, which should include: avoiding brushing after vomiting; rinsing with a non-acid mouthwash after vomiting; and reducing an acid oral environment (for example, limiting acidic foods).


Explain to people with binge eating disorder that psychological treatments aimed at treating binge eating have a limited effect on body weight and that weight loss is not a therapy target in itself. Refer to the NICE guideline on obesity identification, assessment and management for guidance on weight loss and bariatric surgery. Do not offer medication as the sole treatment for binge eating disorder.

Osteoporosis and bone disorders

Advise people with eating disorders and osteoporosis or related bone disorders to refrain from physical activities that significantly increase the likelihood of falls.


Pregnant women with eating disorders require careful monitoring throughout the pregnancy and in the postpartum period. Midwives should be encouraged to ask women if they have or have previously had an eating disorder. Measurement of weight should be undertaken as the baby can grow normally depsite the mother failing to gain weight, but this leads to significant weight loss for the mothr post-partum. Referral to the 2gether Eating Disorders Team should be offered to all women with a current or rpevious significant eating disorder.


Treatment of both subthreshold and clinical cases of an eating disorder in people with diabetes is essential because of the greatly increased physical risk in this group.

People with type 1 diabetes and an eating disorder should have intensive regular physical monitoring because they are at high risk of retinopathy and other complications

When to refer

If an eating disorder is suspected after an initial assessment, then please refer to 2gether Eating Disorder Service for further assessment and treatment.

Eating Disorders Service - 2gether

The Community Team is the first point of contact for anyone coming into the service.  The team complete initial assessments and offer advice and guidance to GP’s, practice nurses and carers.

Once an initial assessment has been completed the team work with the individual to decide the best course of action. The community team offer the following evidence based treatments: Family Based Treatment (FBT) for young people, Cognitive Behaviour Therapy-Enhanced (CBT-E), Interpersonal Psychotherapy (IPT) either individual or in group form for adults with Binge Eating Disorder and Clinical Management for patients who are severely ill, but not able to engage in a recovery focused treatment.

The team also work very closely with GP’s to ensure physical health is monitored for example asking for GP’s to undertake blood tests.

The Day Treatment Programme provides group therapy along with support during meal times to help people restore weight and gain control over dysfunctional eating disorder bahaviours. The programme runs at the Brownhill Centre, Cheltenham Monday-Friday, providing 2 meals and 2 snacks per day. 

Patients can refer themselves using the self-referral form here.

GPs and healthcare professionals can refer a patient using the GP referral form here.

Please complete referral form and email to 2gnft.EatingDisordersServiceReferrals@nhs.net or fax to 01242 634 284.

The Eating Disorders Service, Brownhill Centre, St Paul's Medical Complex, Swindon Road, Cheltenham, GL51 9EZ

Telephone: 01242 634242


Ongoing Care

Monitor physical health – Annual Health Check

  • monitor weight at GP appointments for patients who are no longer in contact with the Eating Disorders Service for aslong as their BMI is below 17.5.
  • for patients with chronic Anorexia Nervosa measure and record (as above);
    • body mass index (BMI), blood pressure and pulse, temperature, muscle strength (‘the sit, squat, stand test’)
    • co-existent psychopathology: depression, anxiety, self-harm and suicide risk
    • routine blood tests sufficient (full blood count (FBC), electrolytes, glucose)
    • check electrocardiogram (ECG0 if low potassium (K) or  BMI below 15
    • check bone density if amenorrhoeic
  • osteoporosis may develop quickly in anorexia nervosa. Restoration of weight and normal menstruation is key. Supplementation with calcium and vitamin D is recommended
  • encourage dental review in patients with frequent vomiting
Local Support Groups

The Cirencester Eating Disorders Self Help Group is part of a network of support groups all over the country co-ordinated by beat (a national self-help organisation). It is an open access drop-in group which means that people can refer themselves and do not have to commit themselves to coming on a regular basis. The aim of the group is to offer a confidential, approachable and understanding forum for help, support and information and to provide discussion and sharing of experiences in a relaxed and friendly environment.

The group meets every month on the first Wednesday of the month 7:30-8:45pm, and is open to anyone in Gloucestershire - sufferers, relatives and friends.

St Peter's Lounge, St Peter's Court, St Peter's Road, Cirencetser, GL7 1RZ

Group Facilitator: Pat Ayres   

Telephone: 01285 770385

Email: pat@ayrescares.orangehome.co.uk

Please follow the resource link below to the website.


Patient Resources

Please see the Patient & Carer Information & Leaflets and Community Resources section.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

There are no significant variations from the national standards in this pathway

Online Resources


Please see Clinican Education section

Pathway Leads




Pete Carter

Senior Commissioning Manager

Gloucestershire Clinical Commissioning Group

Dr Iain Jarvis


Gloucestershire Clinical Commissioning Group

Alex Burrage

IAPT Clinical Lead

Let’s Talk - MH ICT, 2gether NHS Foundation Trust

Sam Clark-Stone Lead Clinician, Eating Disorders Service 2gether NHS Foundation Trust
Ruth Turnball Lead Nurse 2gether, Children and Young People Service
Sarah Batten Service Director 2gether, Children and Young People Service

Reason for Pathway Selection

It is estimated that over 725,000 men and women in the UK are affected by eating disorders. People with eating disorders should be assessed and receive treatment at the earliest opportunity. This pathway has been published to help clinicians recognise the signs of eating disorders and how to assess them and how to manage patients once a diagnosis has been made.

Completion Date

November 2017

Review Date

October 2018