Eating Disorders

SIGN

Latest Guidance Updates

December 2022: the Guidelines team added a previously excluded recommendation on training and education for healthcare professionals working with pregnant and postnatal women

August 2022: SIGN replaced its reference to Management of really sick patients with anorexia nervosa (MARSIPAN) guidelines with a reference to revised Medical emergencies in eating disorders (MEED) Royal College of Psychiatrists' guidance

Overview

This Guidelines summary provides recommendations on the management of people with eating disorders of all ages and gender groups. Eating disorders covered are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Eating problems relating to type 1 diabetes are also covered.

Recommendations are marked [R] and good-practice points are marked [✓].

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Framing the Journey of Care

Early Intervention

[R] A pilot of an additional First episode and Rapid Early intervention for Eating Disorders (FREED) service to complement existing eating disorders services may be considered. This would offer early intervention to young adults aged 16–25 years with eating disorders of less than 3 years’ duration.

Support for Family and Carers

[R] Formal carer support should be offered to all carers. This could draw on materials from Experienced Carers Helping Others (ECHO) self-help or Collaborative Carer Workshops
[✓] Family and carer support can be provided without breaching patient confidentiality and should always be offered if carers are not involved in formal family work, and signposted to families even if their loved one is not accessing services. Manuals are available for both clinicians and lay readers teaching the cognitive interpersonal skills used in ECHO and related models
[✓] Clinical judgement on the applicability of ECHO self-help materials within child and adolescent mental health services should be made on an individual basis. There may be some conflict between advice given to parents or carers using this model and advice provided by family-based therapies (see the subsection Psychological therapies in the section, Children and adolescents with anorexia nervosa)
Encourage the patient to build a supportive network, which may involve family, carers, and/or friends, while respecting the individual’s right to confidentiality.

Acute Refeeding, Renutrition, and Maintaining a Healthy Weight

[R] Refeeding to an optimised healthy weight (taking the patient’s ethnicity and biological sex into consideration) should be offered routinely to all patients with AN, both as a life-saving measure and also as an adjunct to achieving an optimised weight and to reduce relapse
[R] In acutely ill patients, refer to the Medical emergencies in eating disorders (MEED) guideline to safely manage refeeding
[✓] Nutritional goals should be set on a patient-by-patient basis after a holistic assessment of the patient’s general physical and psychological condition, taking into account the patient’s ethnicity, biological sex, genetics, personal dietary requirements, sensory sensitivities, and cultural beliefs. This should be guided by an experienced specialist eating disorder dietitian or suitably qualified alternative healthcare professional.

Physical Activity and Exercise

[R] Specialist-supervised exercise programmes should be offered to patients with AN as part of a comprehensive management programme, which includes a psychoeducation component
[R] Where appropriate (depending on cognitive function and patient’s motivational status), the inclusion and integration of the treatment of dysfunctional exercise/activity should be considered as part of a multidisciplinary treatment programme
[R] Patients with AN participating in an exercise programme should be managed within a multidisciplinary team. Ideally, assessment and supervision should be carried out by a suitably qualified clinician, such as a specialist physiotherapist in eating disorders
[✓] Healthcare professionals should refer to the Safe Exercise at Every Stage (SEES) guideline to support adults with AN participating in an exercise programme
[✓] In the treatment of eating disorders in athletes and dancers, a return to high levels of physical exercise carries risks, which should be acknowledged and carefully addressed and monitored. There is specific guidance from SEES.

Severe Comorbid and Complex Eating Disorders

[✓] Alternative choices should be offered when first-line treatments are ineffective or unsuitable for those with moderate-to-severe comorbid psychiatric disorders. Choice of treatments should take into account therapeutic models that have an established evidence base in the treatment of comorbidities that have been shown to interfere with treatment outcomes in eating disorders (for example, post-traumatic stress disorder, personality disorder, substance misuse). Assertive outreach that includes other input from psychiatric specialties and the community mental health team should be considered for those with an eating disorder and severe comorbid conditions
[✓] Where a patient has an eating disorder and a personality disorder, different specialist services need to work closely together to prevent either gaps or conflicting goals in the work of each service. Transitions may also need to be sensitively managed (see the section, Transition).

Follow-up Interventions

[✓] Patients may relapse after functional recovery if the recovery was dependent on one main support, such as therapy or medication. Care plans therefore need to take an individualised and holistic approach to ensure patients are equipped to maintain recovery
- engage in discussions about returning to activities stopped during treatment, for example, exercise. Life after treatment, and life after an eating disorder, should be considered
- ensure the patient knows how to access support programmes, when needed, as they continue through their recovery journey (see the section on sources of further information in the full guideline).

Using the Mental Health Act to Support Care

[R] Clinicians should consider whether the Mental Health (Care and Treatment) (Scotland) Act 2003 needs to be invoked when a patient (of any age) declines treatment. There may be a responsibility to provide compulsory treatment if there is a risk to the person’s life or to prevent significant deterioration to health and wellbeing.

Transition

[R] When a patient’s age or geographical location necessitates a change of clinical team, the transition should be prepared, managed, and followed up by clinicians in both services
[R] A clinician should be identified as transition coordinator to supervise the process for several months before and after the move, and to communicate with all parties
[R] A written transition plan should be drawn up in collaboration with patient, clinicians, and carers, and copied to each party
[✓] Healthcare professionals should remember that serious illness in childhood and adolescence often causes people to miss out on the psychosocial, and even physical, progress experienced by their healthy peers, and can delay their ability to function independently from the support of family and other carers. Family involvement may be beneficial beyond the usual age where this seems appropriate.

Therapeutic Interventions

Treatment Fidelity

[✓] It is recommended that clinicians providing treatment for eating disorders should maximise treatment fidelity through regular ongoing training and clinical supervision, and should use standardised outcome measures to monitor outcomes
- discuss treatment plans with patients and allow them to share their ideas and concerns. Explain how a therapy works and why it may be appropriate for that individual
- engage in discussions about returning to activities stopped during treatment, for example, exercise. Life after treatment, and life after an eating disorder, should be considered.

Delivering Therapies Remotely

[✓] The delivery of psychological assessments and treatment via video conferencing could be offered as an adjunct or alternative to in-person sessions when there are barriers to accessing in-person sessions.

Children and Adolescents With Anorexia Nervosa

Psychological Therapies

[R] Children and adolescents with AN should be offered family-based treatment (FBT)
[R] Systemic family therapy and augmented FBT approaches could be considered for children and adolescents with AN where there are additional features, such as severe obsessive compulsive disorder or high levels of expressed emotion
[R] Adolescents with AN could be offered enhanced cognitive behavioural therapy (CBT-E as per Fairburn’s model), at a dosage of 20–40 weekly sessions, or other forms of transdiagnostic cognitive behavioural therapy (CBT) for eating disorders.

Pharmacological Therapies

Evidence on the use of antidepressants (including fluoxetine) in adolescents with AN was of poor quality. Antidepressants had no impact on weight gain, and the impact on eating symptoms or psychopathology is unclear
However, psychotropic medication, most often olanzapine or fluoxetine, can be prescribed for children and adolescents with eating disorders.

Children and Adolescents With Bulimia Nervosa

Psychological Therapies

[R] Adolescents with BN should be offered CBT or FBT adapted for BN
[R] If CBT or FBT are not acceptable, psychodynamic therapy could be considered for adolescents with BN.

Pharmacological Therapies

Fluoxetine is licensed in 8–18-year-olds for the treatment of major depression only, so use in young patients with BN is ‘off label’
[R] Fluoxetine (60 mg/day) may be considered in the treatment of patients with BN aged 16–18 years for short-term use, along with the offer of psychological therapy and with monitoring for suicidal, self-harming, or aggressive behaviours, particularly at initiation.

Children and Adolescents With Binge Eating Disorder

Psychological Therapies

[R] Adolescents with BED could be offered CBT, interpersonal psychotherapy, or family-based interventions.

Pharmacological Therapies

[R] Pharmacological therapies should not be used in the management of children and adolescents with BED.

Children, Adolescents, and Adults With Type 1 Diabetes

Eating problems are twice as common in people with type 1 diabetes than people without diabetes, and are usually associated with bingeing and purging
Insulin omission may be used to induce hyperglycaemia to lose calories and avoid weight gain or facilitate weight loss. This is associated with an elevated glycated haemoglobin (HbA_1c) level
However, some patients may restrict carbohydrate to reduce insulin requirements, resulting in weight loss, which can present with hypoglycaemia
There are screening tools specifically for patients with diabetes and possible eating disorder, for example the Diabetes Eating Problems Survey revised questionnaire
[✓] Assessment for the presence of eating disorders should be considered as part of the routine review of patients with type 1 diabetes
[✓] Healthcare professionals caring for people with diabetes and/or eating disorders should be aware of the common practice of insulin reduction to avoid weight gain. A high HbA_1c level, recurrent diabetic ketoacidosis (DKA), poor engagement with healthcare, infrequent/absent self-blood glucose monitoring, and omission of quick-acting insulin are frequently observed in people with type 1 diabetes and eating disorders. Hospital admissions with DKA and elevated HbA_1c are indicators of immediate and long-term risks to health
See the section, Using the Mental Health Act to Support Care, in the section Framing the journey of care, for advice on the use of the Mental Health Act to support the management of patients with type 1 diabetes with an eating disorder where there is a significant risk of life-threatening complications, such as DKA.

Psychological Therapies

[R] Integrated intensive specialist care, with the combined involvement of diabetes professionals and mental health professionals with experience in managing eating disorders, is recommended to support people with type 1 diabetes and an eating disorder or compulsive insulin omission for weight control. Some patients may benefit from a specialist inpatient eating disorders service
[R] Healthcare professionals should consider managing control of insulin administration alongside psychological interventions to address motivation, distress tolerance, and to build trusting relationships with professional and lay carers.

Pharmacological Therapies

No evidence was identified on pharmacological therapies for children or adults with type 1 diabetes and an eating disorder.

Adults With Anorexia Nervosa

Psychological Therapies

[R] CBT-E (enhanced cognitive behavioural therapy as per Fairburn’s model) for eating disorders, or other forms of CBT, should be used as first-line therapy for adults with AN
[R] If CBT is ineffective, unsuitable, or unacceptable for adults with AN, other therapeutic approaches could be considered, such as interpersonal psychotherapy, the Maudsley Model of Anorexia Treatment, Specialist Supportive Clinical Management, or focal psychodynamic therapy
[✓] Dialectical behaviour therapy is a transdiagnostic treatment regimen showing greater validity for people with eating disorders with comorbidities, including substance misuse disorder and borderline personality disorder (emotionally unstable personality disorder). This approach could, therefore, be considered instead of CBT for this complex group
[✓] Other therapies, such as cognitive analytical therapy, schema therapy, mentalisation-based therapy, or radically open dialectical behaviour therapy, could be considered for patients with AN, as part of a clinical trial.

Pharmacological Therapies

People with AN may need specific adjustments to medication prescribed for other conditions, both physical and psychiatric. It is assumed in most studies of psychotherapy for AN that patients will be taking psychotropic medications prescribed on a case-by-case basis by experienced specialists
[✓] All low-weight patients should be monitored particularly closely when psychotropic drugs are prescribed. A baseline electrocardiogram and further monitoring can alert clinicians to avoidable dangers
[R] Olanzapine may be offered to adults with AN to support recovery, but should not be offered as the sole treatment
[✓] Once the patient is weight restored, general guidelines on the management of obsessional symptomatology and treatment for depression, anxiety, and other conditions can be followed
[✓] Any other medication selected for the symptomatic treatment of AN and comorbid conditions should be carefully monitored and audited if possible. Patients should be entered into available research trials, if they consent
There is no available evidence on the safest medication for rapid tranquilisation. Older antipsychotics should be avoided, if possible, because of potentially dangerous side effects. Olanzapine is commonly used in this situation, as it is reasonably well tolerated in patients with AN.

Adults With Bulimia Nervosa

Evidence indicates that even the most effective treatments are limited for adults with BN. If first-line treatments are not effective, second-line or adjunctive treatment modalities may be offered.

Psychological Therapies

[R] CBT, preferably in the specially adapted format for eating disorders or BN, should be used as first-line therapy for adults with BN
[R] If CBT is ineffective, unsuitable, or unacceptable in adults with BN, other treatment options could be considered, such as interpersonal therapy, integrative cognitive-affective therapy, or schema therapy. Mentalisation-based therapy may be considered if the patient has comorbid borderline personality disorder
[✓] Adjunctive therapeutic approaches could be considered to enhance outcomes of established treatments.

Pharmacological Therapies

Fluoxetine is the only licensed medication for patients with BN in the UK
[R] Antidepressant medication should be considered as a short-term treatment for patients with BN or as an adjunct to psychological treatments
[R] When considering pharmacological treatment for patients with BN, fluoxetine, usually at a dose of 60 mg daily, should be the first choice. If selective serotonin reuptake inhibitors are contraindicated, other antidepressant medications could be considered.

Adults With Binge Eating Disorder

Evidence indicates that even the most effective treatments are limited for adults with BED. If first-line treatments are not effective, second-line or adjunctive treatment modalities may be offered.

Psychological Therapies

[R] CBT or interpersonal psychotherapy should be considered for first-line therapy for adults with BED
[R] If CBT or interpersonal psychotherapy are ineffective, unsuitable, or unacceptable in adults with BED, other treatment options could be considered, such as dialectical-based therapy, integrative cognitive-affective therapy, brief strategic therapy, or schema therapy
[✓] People with BED should be made aware that the focus of CBT is on eliminating dieting, due to its central role in increasing risk of binge eating. Therapies do not directly focus on weight loss, but on addressing the factors that result in a person having a difficult relationship with food, regardless of their size
Those who wish to lose weight (and this is deemed medically appropriate) need to be informed that it is a therapy which may not result in large reductions of body mass index (BMI), but that interventions with a primary focus on BMI reduction are generally ineffective in achieving this aim in the longer term
[✓] Adjunctive therapeutic approaches could be considered to enhance outcomes of established treatments.

Pharmacological Therapies

[R] Medication is not recommended either as an alternative or as an adjunct to psychological treatment for patients with BED
[✓] In patients with BED, medication should be considered in the treatment of comorbid conditions, with appropriate assessments of underlying risk factors, in particular cardiovascular and metabolic vulnerabilities.

Bone Mineral Density

[R] Weight restoration should be offered to patients with low-weight anorexia, regardless of gender identity and age, as part of a holistic programme of treatment, to improve bone mineral density
[R] Treatment with bisphosphonates or oestrogen to prevent loss of or restore bone mineral density and so reduce fracture risk should not be considered as treatment modalities on their own, but could be used as a supportive treatment. Benefits and risks should be discussed with the patient, and those who receive treatment should be closely monitored by experts in eating disorders and bone metabolism
[R] Bisphosphonate treatment is not recommended for younger patients due to its teratogenic side effects and long half-life
[✓] The restoration of healthy nutrition will be reflected in normal BMI. This is essential for optimal brain development and the health of other systems, such as the skeleton. Weight restoration is very difficult psychologically for patients. It is therefore essential that this is managed within a therapeutic setting, ensuring that the holistic needs of the patient are met
[✓] Before starting any hormonal treatment for low bone mineral density in a patient with AN, clinicians should seek advice from a paediatric, endocrinological, or bone specialist, and coordinate treatment with the eating disorders team
[✓] Men are also at risk of low bone mineral density, but there is a lack of evidence on treatments other than weight restoration. Those who have persistent low bone mineral density should be referred to a specialist in bone metabolism in consultation with an eating disorder specialist.

Severe and Enduring Eating Disorders

More severe eating disorder symptoms, poorer psychological function, and work and social wellbeing, alongside more lifetime hospitalisations, are associated with people with AN of longer than 7 years’ duration and a high level of reported distress, compared to those of a duration of under 3 years
The underlying neurological characteristics of people with enduring AN are similar to those of people with autism, so neurological traits need to be taken into account when considering appropriate treatment
Based on the limited evidence available, people with severe and enduring eating disorders may respond both to traditional treatment approaches and to those specifically modified, especially if they are targeted at enhancing patient engagement. However, there is a lack of evidence to guide clinical practice, particularly for eating disorders other than AN
[R] Where active symptom-focused treatments have been exhausted, either temporarily or in the medium-to-long term, healthcare professionals may consider offering either CBT adapted for AN or adapted specialist supportive clinical management while monitoring risk and quality-of-life outcomes
[✓] When it has been agreed that symptom-challenging treatment should stop, quality-of-life treatment should be continued and support offered to the patient’s family and other carers. This should be supported by robust ongoing clinical reviews
[✓] Patients who have disengaged from therapy should have the opportunity to change their mind, re-engage, and discuss the options with an appropriately trained healthcare professional
- individuals should be signposted to support from social services and to information about housing, education, and employment rights. Further information on peer support groups and support for family and carers is in the section on sources of further information in the full guideline.

Pregnancy and Postnatal Care