If anorexia nervosa is suspected:

• Enquire about symptoms, for example menstruation patterns, muscle weakness, cold sensitivity, sleep disturbance, fainting or dizzy spells, dental problems, and digestive problems.
• Physical assessment should include (as a minimum):
• Height and weight:
• Ideally the person should be weighed before referral. This can usually be achieved with explanation of why it is necessary (to assess physical risk), but it is also important to maintain the therapeutic relationship. If weighing is not possible, the person should be referred with as much information as possible about their physical appearance and psychological state to enable a physical risk assessment to be made.
• Some people are so concerned by unwanted interventions by healthcare professionals that they will falsify their weight by drinking copious amounts of water beforehand or by hiding heavy objects in their clothes.
• In children and adolescents, comparison with previous growth parameters may be revealing. It is important to make an early diagnosis in children because they are at risk of irreversible growth impairment.
• Calculation of body mass index (BMI). Use centile charts if the person is younger than 18 years of age.
• Pulse and blood pressure.
• Findings on examination may be normal, especially if it is early in the course of the illness, but the following may be helpful to assess the risk of physical complications:
• Core temperature (this is easily done using an ear thermometer).
• Examination of peripheries (circulation and oedema).
• Cardiovascular examination, including postural hypotension.
• Test of muscle power, for example:
• The sit up test — the person lies flat on a firm surface such as the floor and has to sit up without, if possible, using their hands.
• The squat test — the person is asked to rise from a squatting position without, if possible, using their hands.

If bulimia nervosa is suspected, physical assessment is often unremarkable and is of less help in assessing physical risk. However, physical signs suggestive of complications may be present.

• Assess the person's motivation to change their eating habits.
• Ask about:
• Their views on how important it is for them to change their eating patterns.
• What they like and dislike about their current eating habits.
• The perceived benefits and disadvantages of changing their current habits.
• Explore and highlight any problems that their eating or weight loss may be causing them.
• Determine the person's views on the causes of their current eating habits — for example coexisting stress, anxiety, or feelings of loss of control.
• Determine the person's views on the consequences of their current eating habits — for example feelings after bingeing or purging, effects on functioning during the day, and concentration.
• Assess if there is a risk of suicide or self harm.
• Enquire about the person's level of social support.

• If the person has suspected anorexia nervosa, extensive laboratory investigation is not usually required in a primary care setting. Many test results remain normal even with extreme weight loss and are a poor guide to physical risk. However, tests may be useful to rule out complications.
• Depending on the results of the history and physical examination, consider the following investigations in primary care (seeking specialist advice or admitting to hospital may be more appropriate):
• Full blood count (may show anaemia), erythrocyte sedimentation rate (ESR), urea and electrolytes (potassium level < 3.5 mmol/L is suggestive of vomiting or laxative abuse), creatinine, liver function tests, random blood glucose, urinalysis.
• Electrocardiography (ECG). This should be considered for all people with anorexia nervosa, and is strongly advised if there are symptoms or signs of cardiac compromise, bradycardia, electrolyte abnormality, or when the person has a body mass index less than 15 kg/m² (or equivalent on centile chart).
• Further tests may be required in more severe cases or to assess complications: calcium, magnesium, phosphate, serum proteins, creatine kinase (or creatine phosphokinase).
• If the person has suspected bulimia nervosa with frequent vomiting, or is taking large quantities of laxatives (especially if they are also underweight), check fluid balance and urea and electrolytes. Common abnormalities include dehydration, hypokalaemia, hypochloraemia, and alkalosis.

The National Institute for Health and Clinical Excellence recommends that GPs should take the responsibility for initial assessment and the initial coordination of care.

• Make a physical and psychosocial assessment of all people with a suspected eating disorder.
• Refer all people with a suspected eating disorder to secondary care.
• This is particularly important for people with diabetes and pregnant women, as these groups require increased monitoring.
• The urgency of referral depends on the person's circumstances and on clinical judgement.
• People who are particularly at risk of physical or psychological complications may require admission to hospital.
• People with eating disorders should receive treatment at the earliest opportunity.
• It is recognized, however, that at the current time there are wide variations in the provision of eating disorder services throughout the UK.
• Services range from outpatient treatment provided by community mental health teams and psychological therapy units to specialist eating disorder units.
• Most areas have agreed pathways of care for people with eating disorders that allow the matching of the severity of the illness with the intensity of treatment required.
• Ensure there is a clear agreement between primary and secondary or tertiary care about the responsibility for monitoring people with eating disorders.
• This agreement should be in writing and should be shared with the person and, where appropriate, his or her family and carers.
• Manage complications depending on their type and severity. Some people will need admission to hospital, whereas others can be managed in primary care.
• For more information on managing the osteoporosis risk associated with amenorrhoea in primary care, see the CKS topic on Amenorrhoea.

• Consider admission to hospital if any of the following are present (discussion with a specialist may be necessary):
• Risk of suicide or severe self harm — this will require admission to an acute psychiatric ward, not a specialist eating disorders unit.
• Home environment impedes recovery.
• Severe deterioration — this may require admission to an acute medical ward.
• Very low body weight or rapid weight loss — admission to an eating disorders unit may be most appropriate.
• Medical complications (for example pronounced oedema, severe electrolyte disturbance, hypoglycaemia, or severe intercurrent infection) — admission to an acute medical ward may be most appropriate.
• If considering compulsory admission (regardless of the person's age), consider seeking advice from an appropriate specialist.
• If a young person refuses treatment that is deemed essential, consideration should be given to the use of the Mental Health Act 1983 or the right of those with parental responsibility to override the young person's refusal.
• Discuss with a local specialist the most appropriate place to admit a person with life-threatening anorexia, as it is not always obvious and depends on local services and practice.
• An acute medical ward that specializes in endocrinology, gastroenterology, or diabetes may be preferable to an eating disorders unit or general psychiatric ward in certain circumstances.
• Admit children and adolescents to age-appropriate facilities (with the potential for separate child and adolescent services), which have the capacity to provide appropriate educational and related activities.