Page options

Eating Disorders Care Pathway Overview

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.

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

                                            

Red Flags
Indications for urgent discussion with the Eating Disorders Service:

Are there significant risk factors?

  • BMI <13 (adults) or <70% median BMI for age (under 18)?
  • Recent loss of ≥1 kg for two consecutive weeks?
  • Little or no nutrition for >5 days?
  • Acute food refusal or <500 kcal/day for >2 days in under 18s?
  • Pulse <40?
  • BP low with postural dizziness?
  • Core temperature <35°C?
  • Na <130 mmol/L?
  • K <3.0 mmol/L?
  • Raised transaminase?
  • Glucose <3 mmol/L?
  • Raised urea or creatinine?
  • ECG: e.g. bradycardia? QTc >450 ms?
Contact the Eating Disorders Service for urgent discussion on: 01242 634 242 
Presentation and Screening

Presentation to Primary Care at any age:

  • Patient or relative expresses concerns (even in a child, male or older woman)
  • Significant unexplained weight loss or gain or failure to grow and develop in children
  • 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, diet pills or Ipecac

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.

Sensitively ask the 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?

Administer SCOFF Screening

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?

Measure and record the following: 

  • body mass index (BMI), blood pressure and pulse, temperature
  • 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 BMI below 15
  • consider a bone density scan if amenorrhoeic for 1 year <18 or 2 years in adults or if there is 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 

Referral form avaialble here

The vast majority of people with an eating disorder are not underweight. The patient can be severely ill without being significantly underweight. Please refer as early as possible as watching and waiting rarely results in progress and early intervention is more likely to be effective.

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 and especially in children).

In assessing whether a person has anorexia nervosa, pay attention to the overall clinical assessment (repeated over time), including rate of weight loss, growth rates in children, 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 (see below section Ongoing Care).

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.

Where laxative abuse is present, 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).

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.

Pregnancy

Pregnant women with eating disorders require careful monitoring throughout the pregnancy and in the postpartum period.

Diabetes

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

Ongoing Primary 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 and who remian or appear to be underweight.
  • For patients with chronic Anorexia Nervosa measure and record (as above);
    • Body mass index (BMI), blood pressure and pulse, temperature, muscle strength (Sit Up, 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 for 1 year <18 or 2 years in adults or if there is bone pain or recurrent fractures
  • 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
Notification of Serious Untoward Incidents (SUIs)

Recent reviews of serious incidents have identified potential system and process changes which could improve the quality and responsiveness of care for people who require secondary care mental health services.

It would be helpful if GPs could please share any information in relation to substance misuse with GHC, particularly when a patient is injecting, as this aids clinical risk assessment and management. It is also really helpful if referrals into mental health services contain an appropriate risk assessment.

In all instances when a patient dies unexpectedly, especially if the cause of death is suspected suicide, GPs should inform GHC as soon as possible. This will allow GHC to quickly put in place support for those bereaved and minimise the risk of appointment letters etc. being sent to the deceased.

Contact: gordonbenson@nhs.net (Assistant Director of Governance & Compliance, GHC)

Expand all