Eating Disorders: Recognition and Treatment

NICE

This summary covers assessment, treatment, monitoring and care for children, young people and adults with eating disorders. It aims to improve the care people receive by detailing the most effective treatments for anorexia nervosa, binge eating disorder and bulimia nervosa.

General Principles of Care

Improving Access to Services

Be aware that people with an eating disorder may:
- find it difficult or distressing to discuss it with healthcare professionals, staff and other service users
- be vulnerable to stigma and shame
- need information and interventions tailored to their age and level of development
Ensure that all people with an eating disorder and their parents or carers (as appropriate) have equal access to treatments (including through self-referral) for eating disorders, regardless of:
- age
- gender or gender identity (including people who are transgender)
- sexual orientation
- socioeconomic status
- religion, belief, culture, family origin or ethnicity
- where they live and who they live with
- any physical or other mental health problems or disabilities
Healthcare professionals assessing people with an eating disorder (especially children and young people) should be alert throughout assessment and treatment to signs of bullying, teasing, abuse (emotional, physical and sexual) and neglect. For guidance on when to suspect child maltreatment, see the NICE guideline on child maltreatment

Communication and Information

When assessing a person with a suspected eating disorder, find out what they and their family members or carers (as appropriate) know about eating disorders and address any misconceptions
Offer people with an eating disorder and their family members or carers (as appropriate) education and information on:
- the nature and risks of the eating disorder and how it is likely to affect them
- the treatments available and their likely benefits and limitations
When communicating with people with an eating disorder and their family members or carers (as appropriate):
- be sensitive when discussing a person’s weight and appearance
- be aware that family members or carers may feel guilty and responsible for the eating disorder
- show empathy, compassion and respect
- provide information in a format suitable for them, and check they understand it
Ensure that people with an eating disorder and their parents or carers (as appropriate) understand the purpose of any meetings and the reasons for sharing information about their care with others

Support for People With an Eating Disorder

Assess the impact of the home, education, work and wider social environment (including the internet and social media) on each person’s eating disorder. Address their emotional, education, employment and social needs throughout treatment
If appropriate, encourage family members, carers, teachers, and peers of children and young people to support them during their treatment

Working With Family Members and Carers

Be aware that the family members or carers of a person with an eating disorder may experience severe distress. Offer family members or carers assessments of their own needs as treatment progresses (see NICE’s guideline on supporting adult carers), including:
- what impact the eating disorder has on them and their mental health
- what support they need, including practical support and emergency plans if the person with the eating disorder is at high medical or psychiatric risk
If appropriate, provide written information for family members or carers who do not attend assessment or treatment meetings with the person with an eating disorder

Consent and Confidentiality

When working with people with an eating disorder and their family members or carers (as appropriate):
- hold discussions in places where confidentiality, privacy and dignity can be respected
- explain the limits of confidentiality (that is, which professionals and services have access to information about their care and when this may be shared with others)
When seeking consent for assessments or treatments for children or young people under 16, respect Gillick competence if they consent and do not want their family members or carers involved

Training and Competencies

Professionals who assess and treat people with an eating disorder should be competent to do this for the age groups they care for
Health, social care and education professionals working with people with an eating disorder should be trained and skilled in:
- negotiating and working with family members and carers
- managing issues around information sharing and confidentiality
- safeguarding
- working with multidisciplinary teams
Base the content, structure and duration of psychological treatments on relevant manuals that focus on eating disorders
Professionals who provide treatments for eating disorders should:
- receive appropriate clinical supervision
- use standardised outcome measures, for example the Eating Disorder Examination Questionnaire (EDE-Q)
- monitor their competence (for example by using recordings of sessions, and external audit and scrutiny)
- monitor treatment adherence in people who use their service

Coordination of Care for People With an Eating Disorder

Take particular care to ensure services are well coordinated when:
- a young person moves from children’s to adult services (see the NICE guideline on transition from children’s to adults’ services)
- more than one service is involved (such as inpatient and outpatient services, child and family services, or when a comorbidity is being treated by a separate service)
- people need care in different places at different times of the year (for example, university students)

Identification and Assessment

People with eating disorders should be assessed and receive treatment at the earliest opportunity
Early treatment is particularly important for those with or at risk of severe emaciation and such patients should be prioritised for treatment

Initial Assessments in Primary and Secondary Mental Health Care

Be aware that eating disorders present in a range of settings, including:
- primary and secondary health care (including acute hospitals)
- social care
- education
- work
Although eating disorders can develop at any age, be aware that the risk is highest for young men and women between 13 and 17 years of age
Do not use screening tools (for example, SCOFF) as the sole method to determine whether or not people have an eating disorder
When assessing for an eating disorder or deciding whether to refer people for assessment, take into account any of the following that apply:
- an unusually low or high BMI or body weight for their age
- rapid weight loss
- dieting or restrictive eating practices (such as dieting when they are underweight) that are worrying them, their family members or carers, or professionals
- family members or carers report a change in eating behaviour
- social withdrawal, particularly from situations that involve food
- other mental health problems
- a disproportionate concern about their weight or shape (for example, concerns about weight gain as a side effect of contraceptive medication)
- problems managing a chronic illness that affects diet, such as diabetes or coeliac disease
- menstrual or other endocrine disturbances, or unexplained gastrointestinal symptoms
- physical signs of:
  - malnutrition, including poor circulation, dizziness, palpitations, fainting or pallor
  - compensatory behaviours, including laxative or diet pill misuse, vomiting or excessive exercise
- abdominal pain that is associated with vomiting or restrictions in diet, and that cannot be fully explained by a medical condition
- unexplained electrolyte imbalance or hypoglycaemia
- atypical dental wear (such as erosion)
- whether they take part in activities associated with a high risk of eating disorders (for example, professional sport, fashion, dance, or modelling)
Be aware that, in addition to the points above, children and young people with an eating disorder may also present with faltering growth (for example, a low weight or height for their age) or delayed puberty
Do not use single measures such as BMI or duration of illness to determine whether to offer treatment for an eating disorder
Professionals in primary and secondary mental health or acute settings should assess the following in people with a suspected eating disorder:
- their physical health, including checking for any physical effects of malnutrition or compensatory behaviours such as vomiting
- the presence of mental health problems commonly associated with eating disorders, including depression, anxiety, self-harm and obsessive compulsive disorder
- the possibility of alcohol or substance misuse
- the need for emergency care in people whose physical health is compromised or who have a suicide risk

Referral

If an eating disorder is suspected after an initial assessment, refer immediately to a community-based, age-appropriate eating disorder service for further assessment or treatment

Treating Anorexia Nervosa

Provide support and care for all people with anorexia nervosa in contact with specialist services, whether or not they are having a specific intervention. Support should:
- include psychoeducation about the disorder
- include monitoring of weight, mental and physical health, and any risk factors
- be multidisciplinary and coordinated between services
- involve the person’s family members or carers (as appropriate)
When treating anorexia nervosa, be aware that:
- helping people to reach a healthy body weight or BMI for their age is a key goal and
- weight gain is key in supporting other psychological, physical and quality of life changes that are needed for improvement or recovery
When weighing people with anorexia nervosa, consider sharing the results with them and (if appropriate) their family members or carers

Psychological Treatment for Anorexia Nervosa in Adults

For adults with anorexia nervosa, consider one of:
- individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- specialist supportive clinical management (SSCM)
Explain to the person what the treatments involve to help them choose which they would prefer

Psychological Treatment for Anorexia Nervosa in Children and Young People

Consider anorexia-nervosa-focused family therapy for children and young people (FT-AN), delivered as single-family therapy or a combination of single- and multi-family therapy. Give children and young people the option to have some single-family sessions:
- separately from their family members or carers and
- together with their family members or carers
FT-AN for children and young people with anorexia nervosa should:
- typically consist of 18–20 sessions over 1 year
- review the needs of the person 4 weeks after treatment begins and then every 3 months, to establish how regular sessions should be and how long treatment should last
- emphasise the role of the family in helping the person to recover
- not blame the person or their family members or carers
- include psychoeducation about nutrition and the effects of malnutrition
- early in treatment, support the parents or carers to take a central role in helping the person manage their eating, and emphasise that this is a temporary role
- in the first phase, aim to establish a good therapeutic alliance with the person, their parents or carers and other family members
- in the second phase, support the person (with help from their parents or carers) to establish a level of independence appropriate for their level of development
- in the final phase:
  - focus on plans for when treatment ends (including any concerns the person and their family have) and on relapse prevention
  - address how the person can get support if treatment is stopped
For further information on support for children, young people, family members or carers, see the guideline

People With Anorexia Nervosa who are Not Having Treatment

For people with anorexia who are not having treatment (for example because it has not helped or because they have declined it) and who do not have severe or complex problems:
- discharge them to primary care
- tell them they can ask their GP to refer them again for treatment at any time
For people with anorexia who have declined or do not want treatment and who have severe or complex problems, eating disorder services should provide support

Dietary Advice for People With Anorexia Nervosa

Only offer dietary counselling as part of a multidisciplinary approach
Encourage people with anorexia nervosa to take an age-appropriate oral multi-vitamin and multi-mineral supplement until their diet includes enough to meet their dietary reference values
Include family members or carers (as appropriate) in any dietary education or meal planning for children and young people with anorexia nervosa who are having therapy on their own
Offer supplementary dietary advice to children and young people with anorexia nervosa and their family or carers (as appropriate) to help them meet their dietary needs for growth and development (particularly during puberty)

Medication for Anorexia Nervosa

Do not offer medication as the sole treatment for anorexia nervosa

Treating Binge Eating Disorder

Psychological Treatment for Binge Eating Disorder in Adults

Explain to people with binge eating disorder that psychological treatments aimed at treating binge eating have a limited effect on body weight and that weight loss is not a therapy target in itself. Refer to the NICE guideline on obesity identification, assessment and management for guidance on weight loss and bariatric surgery
Offer a binge-eating-disorder-focused guided self-help programme to adults with binge eating disorder
Binge-eating-disorder-focused guided self-help programmes for adults should:
- use cognitive behavioural self-help materials
- focus on adherence to the self-help programme
- supplement the self-help programme with brief supportive sessions (for example, 4 to 9 sessions lasting 20 minutes each over 16 weeks, running weekly at first)
- focus exclusively on helping the person follow the programme
If guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks, offer group eating-disorder-focused cognitive behavioural therapy (CBT-ED)

Psychological Treatment for Binge Eating Disorder in Children and Young People

For children and young people with binge eating disorder, offer the same treatments recommended for adults with binge eating disorder

Medication for Binge Eating Disorder

Do not offer medication as the sole treatment for binge eating disorder

Treating Bulimia Nervosa

Explain to all people with bulimia nervosa that psychological treatments have a limited effect on body weight

Psychological Treatment for Bulimia Nervosa in Adults

Consider bulimia-nervosa-focused guided self-help for adults with bulimia nervosa
Bulimia-nervosa-focused guided self-help programmes for adults with bulimia nervosa should:
- use cognitive behavioural self-help materials for eating disorders
- supplement the self-help programme with brief supportive sessions (for example 4 to 9 sessions lasting 20 minutes each over 16 weeks, running weekly at first)
If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)

Psychological Treatment for Bulimia Nervosa in Children and Young People

Offer bulimia-nervosa-focused family therapy (FT-BN) to children and young people with bulimia nervosa
If FT-BN is unacceptable, contraindicated or ineffective, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) for children and young people with bulimia nervosa

Medication for Bulimia Nervosa

Do not offer medication as the sole treatment for bulimia nervosa

Treating Other Specified Feeding and Eating Disorders

For people with other specified feeding and eating disorders, consider using the treatments for the eating disorder it most closely resembles

Physical Therapy for Any Eating Disorder

Do not offer a physical therapy (such as transcranial magnetic stimulation, acupuncture, weight training, yoga or warming therapy) as part of the treatment for eating disorders

Physical and Mental Health Comorbidities

Eating disorder specialists and other healthcare teams should collaborate to support effective treatment of physical or mental health comorbidities in people with an eating disorder
When collaborating, teams should use outcome measures for both the eating disorder and the physical and mental health comorbidities, to monitor the effectiveness of treatments for each condition and the potential impact they have on each other

Diabetes

For people with an eating disorder and diabetes, the eating disorder and diabetes teams should:
- collaborate to explain the importance of physical health monitoring to the person
- agree who has responsibility for monitoring physical health
- collaborate on managing mental and physical health comorbidities
- use a low threshold for monitoring blood glucose and blood ketones
- use outcome measurements to monitor the effectiveness of treatments for each condition and the potential impact they have on each other
When treating eating disorders in people with diabetes:
- explain to the person (and if needed their diabetes team) that they may need to monitor their blood glucose and blood ketones more closely during treatment
- consider involving their family members and carers (as appropriate) in treatment to help them with blood glucose control
Address insulin misuse as part of any psychological treatment for eating disorders in people with diabetes
Offer people with an eating disorder who are misusing insulin the following treatment plan:
- a gradual increase in the amount of carbohydrates in their diet (if medically safe), so that insulin can be started at a lower dose
- a gradual increase in insulin doses to avoid a rapid drop in blood glucose levels, which can increase the risk of retinopathy and neuropathy
- adjusted total glycaemic load and carbohydrate distribution to meet their individual needs and prevent rapid weight gain
- psychoeducation about the problems caused by misuse of diabetes medication
- diabetes educational interventions, if the person has any gaps in their knowledge
For people with suspected hypoglycaemia, test blood glucose:
- before all supervised meals and snacks
- when using the hypoglycaemia treatment algorithm
- after correction doses
For people with suspected hyperglycaemia or hypoglycaemia, and people with normal blood glucose levels who are misusing insulin, healthcare professionals should test for blood ketones:
- when using the hypoglycaemia treatment algorithm
- after correction doses
For people with bulimia nervosa and diabetes, consider monitoring of:
- glucose toxicity
- insulin resistance
- ketoacidosis
- oedema
When diabetes control is challenging:
- do not attempt to rapidly treat hyperglycaemia (for example with increased insulin doses), because this increases the risk of retinopathy and neuropathy
- regularly monitor blood potassium levels
- do not stop insulin altogether, because this puts the person at high risk of diabetic ketoacidosis
See the NICE guidelines on type 1 and type 2 diabetes in children and young people, type 1 diabetes in adults and type 2 diabetes in adults for more guidance on:
- fluid replacement in children and young people with diabetic ketoacidosis
- insulin therapy, insulin delivery (including rotating injection sites within the same body region) and insulin dosage adjustment.

Comorbid Mental Health Problems

When deciding which order to treat an eating disorder and a comorbid mental health condition (in parallel, as part of the same treatment plan or one after the other), take the following into account:
- the severity and complexity of the eating disorder and comorbidity
- the person’s level of functioning
- the preferences of the person with the eating disorder and (if appropriate) those of their family members or carers
Refer to the NICE guidelines on specific mental health problems for further guidance on treatment

Medication Risk Management

When prescribing medication for people with an eating disorder and comorbid mental or physical health conditions, take into account the impact malnutrition and compensatory behaviours can have on medication effectiveness and the risk of side-effects
When prescribing for people with an eating disorder and a comorbidity, assess how the eating disorder will affect medication adherence (for example, for medication that can affect body weight)
When prescribing for people with an eating disorder, take into account the risks of medication that can compromise physical health due to pre-existing medical complications
Offer ECG monitoring for people with an eating disorder who are taking medication that could compromise cardiac functioning (including medication that could cause electrolyte imbalance, bradycardia below 40 beats per minute, hypokalaemia, or a prolonged QT interval)

Substance or Medication Misuse

For people with an eating disorder who are misusing substances, or over the counter or prescribed medication, provide treatment for the eating disorder unless the substance misuse is interfering with this treatment
If substance misuse or medication is interfering with treatment, consider a multidisciplinary approach with substance misuse services

Growth and Development

Seek specialist paediatric or endocrinology advice for delayed physical development or faltering growth in children and young people with an eating disorder

Conception and Pregnancy for Women With Eating Disorders

Provide advice and education to women with an eating disorder who plan to conceive, to increase the likelihood of conception and to reduce the risk of miscarriage. This may include information on the importance of:
- maintaining good mental health and wellbeing
- ensuring adequate nutrient intake and a healthy body weight
- stopping behaviours such as binge eating, vomiting, laxatives and excessive exercise
Nominate a dedicated professional (such as a GP or midwife) to monitor and support pregnant women with an eating disorder during pregnancy and in the post-natal period, because of:
- concerns they may have specifically about gaining weight
- possible health risks to the mother and child
- the high risk of mental health problems in the perinatal period
For women who are pregnant or in the perinatal period and have an eating disorder:
- offer treatment for their eating disorder as covered above
- provide monitoring and education as recommended in the NICE guideline on antenatal and postnatal mental health
For guidance on providing advice to pregnant women about healthy eating and feeding their baby, see the NICE guideline on maternal and child nutrition
Consider more intensive prenatal care for pregnant women with current or remitted anorexia nervosa, to ensure adequate prenatal nutrition and foetal development

Physical Health Assessment, Monitoring and Management for Eating Disorders

Physical Health Assessment and Monitoring for All Eating Disorders

Assess fluid and electrolyte balance in people with an eating disorder who are believed to be engaging in compensatory behaviours, such as vomiting, taking laxatives or diuretics, or water loading
Assess whether ECG monitoring is needed in people with an eating disorder, based on the following risk factors:
- rapid weight loss
- excessive exercise
- severe purging behaviours, such as laxative or diuretic use or vomiting
- bradycardia
- hypotension
- excessive caffeine (including from energy drinks)
- prescribed or non-prescribed medications
- muscular weakness
- electrolyte imbalance
- previous abnormal heart rhythm

Management for All Eating Disorders

Provide acute medical care (including emergency admission) for people with an eating disorder who have severe electrolyte imbalance, severe malnutrition, severe dehydration or signs of incipient organ failure
For people with an eating disorder who need supplements to restore electrolyte balance, offer these orally unless the person has problems with gastrointestinal absorption or the electrolyte disturbance is severe
For people with an eating disorder and continued unexplained electrolyte imbalance, assess whether it could be caused by another condition
Encourage people with an eating disorder who are vomiting to:
- have regular dental and medical reviews
- avoid brushing teeth immediately after vomiting
- rinse with non-acid mouthwash after vomiting
- avoid highly acidic foods and drinks
Advise people with an eating disorder who are misusing laxatives or diuretics:
- that laxatives and diuretics do not reduce calorie absorption and so do not help with weight loss
- to gradually reduce and stop laxative or diuretic use
Advise people with an eating disorder who are exercising excessively to stop doing so
For guidance on identifying, assessing and managing overweight and obesity, see the NICE guideline on obesity

Assessment and Monitoring of Physical Health in Anorexia Nervosa

GPs should offer a physical and mental health review at least annually to people with anorexia nervosa who are not receiving ongoing treatment for their eating disorder. The review should include:
- weight or BMI (adjusted for age if appropriate)
- blood pressure
- relevant blood tests
- any problems with daily functioning
- assessment of risk (related to both physical and mental health)
- an ECG, for people with purging behaviours and/or significant weight changes
- a discussion of treatment options
Monitor growth and development in children and young people with anorexia nervosa who have not completed puberty (for example, not reached menarche or final height)

Low Bone Mineral Density in People With Anorexia Nervosa

Bone mineral density results should be interpreted and explained to people with anorexia nervosa by a professional with the knowledge and competencies to do this
Before deciding whether to measure bone density, discuss with the person and their family members or carers why it could be useful
Explain to people with anorexia nervosa that the main way of preventing and treating low bone mineral density is reaching and maintaining a healthy body weight or BMI for their age
Consider a bone mineral density scan:
- after 1 year of underweight in children and young people, or earlier if they have bone pain or recurrent fractures
- after 2 years of underweight in adults, or earlier if they have bone pain or recurrent fractures
Use measures of bone density that correct for bone size (such as bone mineral apparent density [BMAD]) in children and young people with faltering growth
Consider repeat bone mineral density scans in people with ongoing persistent underweight, especially when using or deciding whether to use hormonal treatment

Using the Mental Health Act and Compulsory Treatment

If a person’s physical health is at serious risk due to their eating disorder, they do not consent to treatment, and they can only be treated safely in an inpatient setting, follow the legal framework for compulsory treatment in the Mental Health Act 1983
If a child or young person lacks capacity, their physical health is at serious risk and they do not consent to treatment, ask their parents or carers to consent on their behalf and if necessary, use an appropriate legal framework for compulsory treatment (such as the Mental Health Act 1983/2007 or the Children Act 1989)
Feeding people without their consent should only be done by multidisciplinary teams who are competent to do so.