Anorexia Nervosa: Care Staff Guide to Recognition, Treatment and Mealtime Support

Anorexia nervosa is a serious mental health condition, and it is one that care staff can notice early. A person may seem to be eating "normally" in front of others, wear loose clothes, avoid shared meals or become unusually preoccupied with food and exercise, while privately struggling with an overwhelming fear of gaining weight. This guide, based on NHS information, explains the signs of anorexia nervosa, how it is treated, when hospital care is needed and how to support someone with kindness and without making things worse.

What is anorexia nervosa?

The NHS describes anorexia nervosa as an eating disorder in which a person feels a need to keep their weight as low as possible. It is not a lifestyle choice or a diet that has gone too far, and it is not about vanity. It is a mental health condition with serious physical consequences, and the NHS recommends getting help early. Eating disorders in general can affect anyone, whatever their age, gender or background.

NICE guideline NG69 notes that anorexia nervosa is the most common cause of death from eating disorders, mainly through malnutrition, suicide and physical problems such as electrolyte imbalances. It is also more common in younger people, although it can occur at any age. Our guide to bulimia nervosa explains a related but different eating disorder.

Signs and symptoms

The NHS groups the symptoms of anorexia nervosa into emotional, behavioural and physical signs.

• Emotional and psychological: an overwhelming fear of gaining weight; believing you are fat when you are a healthy weight or underweight; not admitting that weight loss is serious; strict eating rituals and frequent thoughts about food; seeing weight loss as a success and weighing yourself often; and often having other mental health problems such as depression or anxiety.
• Behavioural: missing meals, eating very little or avoiding foods seen as fattening; lying about food intake or body weight; avoiding meals with others; wearing baggy clothing to hide body shape; using appetite suppressants, laxatives or diuretics; and exercising excessively or making oneself sick.
• Physical: in adults, an unusually low body mass index; in under-18s, weight and height below the expected minimum for age; periods stopping or not starting; bloating, constipation and abdominal pain; headaches and sleep problems; feeling cold, dizzy or very tired; poor circulation in the hands and feet; dry skin, hair loss and fine downy hair on the body; and reduced sex drive.

Warning signs in someone else

The NHS lists warning signs that others may notice, including dramatic weight loss, lying about eating or weight, avoiding meals with others, cutting food into small pieces or eating very slowly to hide how little is being eaten, and wearing loose clothes to hide how thin they are. In children and young people, puberty and growth spurts may be delayed and weight gain may be less than expected. Care staff should note changes in behaviour, mood, energy, mealtime patterns and appearance, record what they see factually and pass it on, rather than confronting the person.

Why early help matters

The NHS advises people to see a GP as soon as possible if they think they may have anorexia, even if they are not sure. If you are worried about someone else, encourage them to see a GP and offer to go with them. The eating disorders charity Beat offers confidential advice on 0808 801 0677, and urgent medical help is available through NHS 111. If a person collapses, has chest pain, faints repeatedly, is confused or has a seizure, call 999.

Treatment

According to the NHS, treatment for anorexia nervosa usually involves a combination of talking therapy and supervised weight gain. Early treatment reduces the risk of serious complications.

• Talking therapies for adults. The NHS lists cognitive behavioural therapy (CBT), the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), specialist supportive clinical management and focal psychodynamic therapy. CBT is typically weekly for up to 40 weeks, with two sessions a week at the start. MANTRA is 20 sessions, the first 10 of which are weekly. Adults can involve family or carers in MANTRA if they wish.
• Family involvement for under-18s. Family therapy is usually offered, typically 18 to 20 sessions over a year.
• Dietary support. Adults are offered specialist dietary advice and a meal plan with regular check-ups. Young people's doctors give advice on food and talk to parents or carers about supporting diet at home.
• Medicines. The NHS states that antidepressants are not used to treat anorexia itself. Fluoxetine may be offered alongside therapy for anxiety, depression or social phobia, and is very rarely prescribed for under-18s. Medicine may be prescribed to protect bones, and vitamin and mineral supplements are commonly advised.

Physical monitoring

Regular check-ups track progress. The NHS explains that anorexia can weaken bones, so doctors may suggest a bone density scan, and bone risk rises if weight has been low for a year or more in children and young people, or two years or more in adults. After treatment, weight and physical and mental health should be checked at least once a year. Our guide to MEED guidance on eating disorder physical health monitoring explains how physical risk is assessed in more detail.

When is hospital care needed?

The NHS says most people stay at home. Hospital admission or day care may be needed if the person is very underweight and still losing weight, is very ill with their life at risk, is under 18 without enough support at home, or is at risk of self-harm or suicide. Compulsory treatment under the Mental Health Act is a last resort. Staff should follow the person's care plan and take any expressions of hopelessness seriously, following our guide to suicide and self-harm awareness.

Supporting someone day to day

• Be calm and consistent at mealtimes. Follow the agreed meal plan, avoid commenting on portions, weight or appearance, and keep conversation light.
• Do not use force, bargaining or punishment. Pressure usually increases secrecy and distress. Raise difficulties with the clinical team.
• Avoid diet talk. Do not praise weight loss or label foods as good or bad, and keep it out of group settings.
• Watch for hiding food and over-exercising, and report patterns factually.
• Look for low mood and anxiety, which the NHS notes often accompany anorexia.
• Keep communication open. Show you care about the person, not just their eating. Listen without trying to fix.
• Support the whole team to be consistent, so the person does not receive mixed messages.

Supporting families and carers

Families often feel frightened, guilty and exhausted. Signpost them to Beat and the person's care team, and recognise their expertise about the person.

Frequently asked questions

Can people recover from anorexia?

Treatment can help, and early treatment reduces the risk of serious complications, according to the NHS. Recovery can take time and may include setbacks.

Is anorexia only about weight?

No. The NHS lists emotional, behavioural and physical symptoms. Fear of weight gain, rituals around food and distorted body image are core features, and other mental health problems are common.

Should I tell the person to eat more?

No. Encouragement to "just eat" rarely helps and can increase shame. Encourage them to see a GP, follow the care plan and tell the clinical team what you see.

Keep building your knowledge

Informed, compassionate staff help people take the first step towards recovery. Explore the health and social care learning available through Learnsignal CPD to keep your knowledge current.

This article is general information for care staff, based on NHS information, and does not replace the advice of a person's own clinicians. If you are worried about someone's health right now, contact their GP, NHS 111 or, in an emergency, call 999.