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Eating disorders: recognition and treatment

  • This Guidelines for Nurses summary includes recommendations that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations.

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, 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

  • 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

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 (OSFED)

  • For people with OSFED, 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

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

Terms used in this guideline

Children

  • Aged 0–12 years

Young people

  • Aged 13–17 years

Adults

  • Aged 18 years and over

© NICE 2017. Eating disorders: recognition and treatment. Available from: www.nice.org.uk/guidance/NG69. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: October 2016, updated July 2017.