Assessment of Eating Disorders

Depending on your discipline and the service setting you may assess your patient in some or all of these categories:

Initial Assessments

Weight history

• Current weight and BMI

• Weight history through adolescence/adult years

• Premorbid weight

• Highest and lowest weight

• Current trend

• Body weight and shape within family

Nutrition

• Dieting history

• Current food intake, including portion size for all meals and snacks

• Food groups eaten/not currently eaten

• Food preferences (vegetarian/vegan, including timeline for these preferences, i.e. was this before/since onset of ED)

• Religious and cultural beliefs

• Fluid intake (including diet and energy drinks)

• Food allergies/intolerances (formal or self-diagnosed)

• When food/body concerns became problematic

• Weighing and measuring food/calorie counting

Biopsychosocial Assessment

Psychosocial

• Current living situation

• Vocational; study/employment

• Supports; family/carer 2

• Risk factors: family history of eating disorders/high risk subculture e.g. gymnasts, dancers

• Strengths/protective factors

Mental Health History

• Comorbid diagnosis, previous and current treatment

• Mental health risk factors (suicidal ideation/self harming behaviours, risk of violence to/from others)

• Family mental health history

• Previous eating disorder treatment

• Background of trauma; neglect, abuse, bullying

• Drug, smoking and alcohol use

Timeline and cognitions

• Can you identify starting point for eating difficulties?

• What maintainsthe eating difficulties?

• What needs to changein order for them to get better?

• Personality traits (perfectionist/obsessiveness)

• Motivation to change

Attitudes towards weight and shape

• Level of fear of weight gain

• Level of self-criticism

• Perception of shape

• Presence of body checking behaviours (weighing, mirror checking)

• Family attitudes towards food, weight and shape (including family history of dieting)

Eating Disorder Behaviours

It is important not to list these behaviours when assessing for them, also to be aware that often these behaviours carry shame and guilt and the individual will need to feel a sense of rapport with you before opening up.

Purging

• Self-induced vomiting (how often, method,precipitants)

• Use of laxatives, enemas, suppositories, diuretics, diet pills, misuse of insulin, steroids, self phlebotomy, self lavage (DO NOT LIST THESE).

Binge Eating

• Usual binge episode (type of food, quantity,frequency, duration)

• Subjective/objective

• Triggers

• Feeling of loss of control

• Feelings before and after

• Uncontrolled grazing outside of binges/night eating

• Behavioural consequences following binge eating (restricting, self harm)

• Stealing of food/money for a binge episode

Exercise

Current pattern of exercise (frequency/duration/type/intensity)

Incidental activity (walking, standing)

Recent changes to exercise patterns

Motivation to exercise

Effects of missing a day of exercise

Is weight and shape controlled with exercise?

Exercise despite illness or injury

Impact of Eating Disorder on Life

• Physically (energy levels, motivation, sleep)

• Psychologically (mood, irritability, agitation)

• Vocationally (study/employment affected)

• Cognitively (concentration/ability to think flexibly)

• Socially (are relationships affected/more conflict about food? Are you socialising or isolating?

• Amount of time spent thinking about eating,weight and shape

Cognitive Changes, Mood and Personality

Evidence of starvation syndrome:

• Cognitive impairment, personality changes, preoccupation with food

• Impaired concentration and alertness

• Increased/decreased need for sleep

• Impaired ability to make decisions, rigid andinflexible thinking

• Depressed mood, suicidal ideation

• Increased perfectionism, obsessiveness, impulsivity

Physiological Assessment

General Medical History

Menstrual History

Age of menarche or pubertal status

Absence and duration of menstrual periods

Date of last menstrual period

Cardiovascular/Respiratory

• Blood pressure (seated and standing)

• A fall or rise of 10-20 beats per minute onstanding indicates cardiac compromise

• Heart rate (seated and standing)

• Bradycardia/tachycardia on minimalexertion indicates deconditioning

• Core temperature

• Shortness of breath (orthopnoea, paroxysmalnocturnal dyspnoea, exercise tolerance)

• Palpitations (sudden onset, frequency, duration)

• Chest pain (onset, frequency, duration, associated symptoms, precipitating factors)

• Examination of peripheries (circulation, coldness in hands and feet, oedema)

• Fainting, collapse, light-headedness, dizziness

Gastro Intestinal & Renal

• Delayed gastric emptying (causes prolongedfullness)

• Post prandial symptoms (distension, abdominal pain, bloating and early satiety)

• Reflux

• Diarrhoea, constipation

• Urinalysis (may show high specific gravity and ketones)

Assess for Dehydration

• Sunken eyes

• Dry lips and tongue

• Poor skin turgor

• Slow capillary return

Assess for Signs of Vomiting

• Swollen parotid glands

• Recurrentsore throat

• Bouts of tonsillitis Halitosis

• Callused knuckles (repeated induced vomiting)

• Bloodshot eyes, broken capillaries in the cheeks and eyelids

Oral Examination

May occur with recurrent vomiting:

• Dental erosions

• Pharyngeal redness

• Parotid enlargement

Orthopaedic

• Stress fractures and overuse injuries

Skin Examination

• Acrocyanosis (blue discolouration)

• Jaundice

• Dry skin

• Hair loss/thinning

• Lanugo hair (soft downy hair on back, arms)

• Callused knuckles (repeated induced vomiting)

• Skin infections and lesions from self-harm

Medical Investigations

ECG

Useful in all patients as it provides a more accurate resting pulse and assesses for arrhythmias (especially prolonged QTc which is common with severe weight loss). A multidisciplinary approach is recommended (including a medical officer, therapist and dietitian). Early intervention and treatment will improve prognosis and outcomes.

Blood Tests

• Full blood count

• Electrolytes

• Liver function tests

• Glucose

• Calcium, magnesium and phosphate

• Thyroid stimulating hormone

• Triodothyronine and Serum Thyroxine

• Follicle stimulating hormone

• Luteinising Hormone

• Oestradiol

Bone Densitometry

Test if underweight or food intake restricted for > 6months, with or without amenorrhoea.

Further Investigations

To exclude other diagnoses and assess nutritional status:

• Erythrocyte sedimentation rate (ESR)

• Ferritin

• B12

• Folate

• Anti-transglutaminase Antibodies

• Stool microscopy