Executive summary
- Early recognition saves lives: eating disorders can present with “non-obvious” symptoms (fatigue, GI complaints, amenorrhoea, anxiety, dizziness, poor concentration).
- Risk is medical + psychological: do not rely on BMI alone — assess vitals, ECG where indicated, hydration and electrolyte risk, and suicidality/self-harm.
- Baseline physical screen is high yield in primary care: weight/BMI, postural vitals, and bloods targeted to malnutrition/purging risk.
- Refer early to specialist eating disorder services where available; use urgent pathways if high medical risk or safeguarding concerns.
- Ongoing monitoring (weight trajectory, vitals, electrolytes, ECG triggers) often sits partly in primary care—make this explicit in the shared plan.
Recognition (what should trigger suspicion)
- Behavioural clues: restrictive eating, rigid food rules, excessive exercise, purging, laxative/diuretic misuse, binge episodes, body-checking, distress about weight/shape.
- Physical clues: rapid weight loss, dizziness/syncope, cold intolerance, constipation, amenorrhoea/oligomenorrhoea, dental erosion, parotid swelling, lanugo, bruising.
- Psychological clues: anxiety, depression, irritability, perfectionism, social withdrawal, suicidality/self-harm.
- High-risk groups: adolescents/young adults, athletes, people with diabetes, neurodevelopmental conditions, and those with a history of trauma.
Primary care risk assessment (practical template)
- Vitals: HR, BP (including postural drop), temperature; consider dehydration assessment.
- Weight trajectory: current weight, recent % loss, BMI (interpret alongside clinical state and age).
- Purging risk: vomiting/laxatives/diuretics → check electrolytes and ECG threshold for concern.
- Bloods (typical baseline): FBC, U&E, LFTs, glucose, magnesium, phosphate; add thyroid/coeliac as indicated; consider pregnancy test where relevant.
- ECG: consider if bradycardia, syncope, electrolyte disturbance, or significant malnutrition/purging risk.
- Psych risk: suicidal ideation/self-harm, safeguarding issues, capacity and support at home/school.
Management + referral (what to do today)
- Urgent referral if medical instability, syncope, severe bradycardia/hypotension, dehydration, severe electrolyte derangement, or high suicide risk.
- Specialist referral early even when vitals are stable — earlier access improves outcomes.
- Safety: advise against sudden unsupervised “bulking up” in high-risk malnutrition (refeeding risk); escalate if rapid escalation in intake causes symptoms.
- Comorbidity: treat depression/anxiety cautiously; avoid using antidepressants as a substitute for eating disorder treatment.
- Shared monitoring plan: agree who does weights/vitals/bloods and at what frequency, and exactly what triggers escalation.
Frequently asked questions
Is BMI enough to judge risk?
No. BMI is one data point. Vitals, rapidity of weight loss, dehydration, electrolyte disturbance, purging behaviours, and psychological risk are crucial.
What tests matter most initially?
Weight trajectory + vitals, U&E (plus Mg/PO4), glucose, and ECG where indicated. Build a monitoring plan that is explicit about escalation thresholds.
When should I refer urgently?
Any medical instability (syncope, significant bradycardia/hypotension), severe dehydration, concerning ECG, electrolyte derangement, or high suicide risk/safeguarding concerns.
Can adults “look well” and still be high risk?
Yes. Rapid weight loss, purging-related electrolyte shifts, and hidden malnutrition can carry serious risk even when someone appears outwardly well.
What is the most useful thing I can do in primary care?
Recognise early, perform a robust risk screen, refer promptly, and run a shared monitoring plan with clear triggers for escalation.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.