Medical Assessment of Eating Disorders

This information sheet can be used to help guide you in conducting a comprehensive medical assessment with an individual that has an eating disorder, or that you suspect may have an eating disorder.

Confidentiality

Permission to contact other members of treating team, family/carers

Explain confidentiality boundaries

Past Medical & Psychiatric History

General past medical history

Previous eating disorder treatment including inpatient admissions

Psychiatric history (neglect, trauma, depression, self-harm, suicidal thoughts, bullying)

Personality traits (perfectionism, obsessiveness)

Current medications and allergies

Social & Family History

Living situation, family/carer support, school, work

Family history of mental health

Assessment of Eating Disorder

It is important to assess the presence of eatingdisorder behaviours using a non-judgemental, person centred approach. Many of these behaviours carry significant shame and guilt, and the individual will need to feel a sense of rapport with you before opening up.

Nutrition Intake

• Current food intake, including portion size (breakfast, snack, lunch, snack, dinner, snack)

• Foods eaten and foods not currently eaten

• Fluid intake (overall intake, specific types of drinks including diet and energy drinks)

• Dieting history

• Food allergies/intolerances (what food, what happens, formal or self-diagnosed)

• Food preferences (vegetarian, vegan, organic, no preservatives)

• Time course of beliefs around food (timed with onset of eating disorder)

• Religious and cultural beliefs

• Rituals around eating (eating alone, in secret, heavy use of spices and condiments, time taken to eat, hoarding)

• When food/body concerns became problematic

• Weighing and measuring food

• Calorie counting (how often, daily goal)

Purging

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

• Blood vomited (how often, how much)

• Use of laxatives, enemas, suppositories, diuretics, diet pills, misuse of insulin, steroids, self phlebotomy, self lavage (what, how much, when)

Binge Eating

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

• Feelings before, during and after

• Feeling of loss of control

• Binge environment (where, when)

• Perceived triggers

• Uncontrolled grazing outside of binges

• Behavioural consequences following binge eating (restrict/fasting, self harm, isolation)

• Stealing of food/money for a binge episode

Other Behaviours

Establish a baseline level of frequency and intensity of the following behaviours:

• Chewing and spitting

• Rumination (regurgitation of food, then re-chewed, re-swallowed or spat out)

• Night eating

• Medications

• Illicit drug taking

• Cigarette smoking/Vaping

• Alcohol intake

• Chewing gum

Exercise

• Current pattern of exercise

• Types of exercising (aerobic/anaerobic, gym, class, social based)

• Most extreme exercise

• Incidental activity (walking, standing)

• Duration of exercise per 24 hours

• Calorie goals per session

• Changes to exercise patterns

• Motivation to exercise

• Compulsive exercise

• Effects of missing a day of exercise

• Is weight and shape controlled with exercise?

• Exercise despite illness or injury

Assessment of Weight

For someone with an eating disorder, being weighed can be very distressing. This needs to be done with sensitivity and empathy. Try to refrain from making comments about the number on the scales.

Weight History

• Weight history through adolescence/adult years

• Premorbid weight

• Highest and lowest weight

• Current weight

• Current trend

• Desired vs healthiest weight

• Current height and BMI

• Healthy BMI range or BMI percentile for children and adolescents

• Body weight and shape within family

Attitudes Towards Weight & Shape

• Level of self-criticism (whole body and specific regions)

• Perception of shape

• Perceptions of others’ attitudes about their weight and shape

• Fear of weight gain

• Presence of body checking behaviours (weighing, mirror checking, feeling/touching specific areas, using a piece of clothing as a ‘ruler’, mirror checking pre/post intake)

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

Menstrual History

• Age of menarche or pubertal status (using Tanner Stages)

• Regularity, length

• Absence of menstrual periods

• Date of last menstrual period

• Use of contraception (pill, IUD)

Physiological Assessment

Skin Examination

• Acrocyanosis (blue discolouration)

• Jaundice

• Carotenaemia (orange skin)

• 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

Assess for Dehydration

• Sunken eyes

• Dry lips and tongue

• Poor skin turgor

• Slow capillary return

Oral Examination

May occur with recurrent vomiting:

• Dental erosions

• Pharyngeal redness

• Parotid enlargement

Assess for Signs of Vomiting

• Swollen parotid glands

• Recurrent sore throat

• Bouts of tonsillitis

• Halitosis

• Callused knuckles (repeated induced vomiting)

• Bloodshot eyes, broken capillaries in the cheeks and eyelids

Cardiovascular/Respiratory

• Blood pressure (lying and standing)

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

• Heart rate (lying and standing)

• • Bradycardia/tachycardia on minimal exertion indicates deconditioning

• Core temperature

• Shortness of breath (orthopnoea, paroxysmal nocturnal 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 prolonged fullness)

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

• Reflux

• Diarrhoea, constipation

• Urinalysis (may show high specific gravity and ketones)

Musculoskeletal

• Stress fractures and overuse injuries

Psychological Assessment

Risk Assessment

• Suicidal ideation

• Deliberate self-harm

• Past suicidal behaviours and self-harm events

• Agitation

• Risk of harm to others

• Previous violent behaviour towards others

• Is the person the sole shared caregiver of a child <18 years? If yes, first name, age, do they live with the client full or part time?

Presence of Comorbid Psychiatric Illnesses

• Mood disorders

• Anxiety disorders

• Obsessive compulsive disorders

• Psychotic disorders

• Drug and alcohol use

• Neurodivergence

Effect of Eating Disorder on Life

• Effects of eating disorder (physically, emotionally, occupationally, socially, cognitively)

• Impact of eating disorder on family or significant other

• Amount of time spent thinking about eating, weight and shape (per hour or per day)

• Broken sleep, wake up thinking about the eating disorder

• Individual’s view on what maintains the eating difficulties

• Client’s beliefs about what needs to change in order for them to get better

• Denial or acknowledgment of illness severity

• Insight into illness

• Motivation to change (importance of change and confidence to execute change)

Cognitive Changes, Mood & Personality

• Changes in mood (irritably and rigid, low mood)

• Evidence of starvation syndrome (cognitive impairment, personality changes, preoccupation with food)

• Impaired concentration and alertness

• Agitation

• Increased/decreased need for sleep

• Impaired ability to make decisions, rigid and inflexible thinking

• Personality traits (perfectionism, obsessiveness, impulsivity)

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).

Blood Tests

• Full blood count

• Electrolytes

• Liver function tests

• Glucose

• Calcium, magnesium and phosphate

• Thyroid stimulating hormone

• Tri-iodothyronine and Serum Thyroxine

• Follicle stimulating hormone

• Luteinising Hormone

• Oestradiol

Bone Densitometry

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

Further Investigations

To exclude other diagnoses and assess nutritional status:

• Erythrocyte sedimentation rate (ESR)

• Ferritin

• B12

• Folate

• Anti-transglutaminase Antibodies ("Coeliac Serology")

• Stool microscopy