g logo nice orange

Eating disorders: recognition and treatment—information for the public

The following information has been taken from the information for the public section of NICE guideline 69 on Eating disorders: recognition and treatment, covering the key points around what eating disorders are, how they are identified, and the methods available to manage them. Please see the information for patients section of the full guideline if you would like to know more about:

Contents

The care you should expect
What is an eating disorder?
Signs that you may have an eating disorder
What should happen next?
Information and support
Anorexia nervosa: treatment for adults
Anorexia nervosa: treatment for children and young people
Binge-eating disorder
Bulimia nervosa: treatment for adults
Bulimia nervosa: treatment for children and young people
Other eating disorders
Looking after your physical health
Managing other conditions
Supporting parents, family members, and carers
Where can I find out more?

Eating disorders: the care you should expect

  • This information explains the care NICE says works best for people who have, or may have, an eating disorder. It is written for children, young people, and adults and it will help you and your family and carers know what to expect from health and care services
  • If you are a parent or carer of a child with an eating disorder you may want to read this information together as a family. Children and young people may also want to read it for themselves
  • There is a section about supporting parents, family members, and carers

Why is this important for you?

  • NICE aims to help people get the best care no matter who they are or where they live. This NICE advice aims to:
    • help healthcare professionals spot the signs and symptoms of an eating disorder
    • make sure you get specialist treatment that meets your needs
    • explain the support and information you and your family should get
  • Your doctor and other professionals should know what NICE has said. Talk to them if you don’t think you are getting the care NICE has said you should have

What is an eating disorder?

  • An eating disorder is when you have an unhealthy relationship with food which can take over your life and make you ill. It might involve eating too much or too little, or becoming obsessed with controlling your weight. The most common types of eating disorder are:
    • anorexia nervosa: keeping your weight down by not eating enough food or exercising too much; you could start to starve, which can make you very ill
    • bulimia nervosa: going through periods of eating a lot of food quickly (‘bingeing’) and thentrying to get rid of calories in unhealthy ways, for example by making yourself sick, using laxatives (‘purging’), exercising too much, taking medication, or using diet supplements
    • binge-eating disorder: regularly eating large portions of food all at once (often in secret) until you feel uncomfortably full, and then often upset or guilty
    • OSFED: this means ‘other specified feeding or eating disorder’ and means you don’t have all the typical symptoms of one of the types above—it does not mean it is a less serious illness
  • An eating disorder can happen to anyone, male or female and at any age, although they most commonly start in young people aged 13 to 17 years. They can happen to people from any cultural, religious, or social background
  • Eating disorders are serious medical conditions, and when they get really bad they can put your life at risk. However, there are treatments that can help, and you can recover from an eating disorder
  • You can find out more about eating disorders from NHS Choices

Getting help for an eating disorder

  • It can be difficult to talk to someone about your eating problems, but your GP or practice nurse can give you advice and support and tell you about the next steps towards getting treatment. Sometimes, a healthcare professional you see might ask you some questions if they think you are having eating problems
  • Your GP will ask you some questions about your eating habits. They should find out how much you already know about eating disorders and explain anything you’re not sure about. They will check your overall health, including your weight. They may look for some of the signs below to see if you could have an eating disorder

Signs that you may have an eating disorder

Eating and behaviour

  • You are very worried or spend a lot of time worrying about your weight and shape
  • You have made sudden major changes to your diet (such as cutting out particular kinds of food altogether)
  • You are dieting or limiting your food in a way that worries you or those around you
  • Your friends or family have noticed changes in your eating habits
  • You are avoiding social situations that involve food (such as eating meals with your family or going to a restaurant)
  • You have very strict habits or routines around food (such as recording everything you eat or weighing yourself every day)
  • You have been making yourself vomit after meals
  • You are exercising too much
  • There has been a change in your mood (for example, you feel more irritable or anxious than normal)

Physical signs

  • You have symptoms of starvation, like feeling cold or dizzy, fainting or having problems with your circulation
  • You have stomach or digestive problems with no obvious cause
  • You have problems with your teeth—some people with an eating disorder make themselves vomit regularly to get rid of the food they eat, and this can damage the teeth
  • Your weight may be very high or very low—for adults, your BMI (body mass index) is used to check if you are a healthy weight
  • If you’re under 18: your weight and height are lower than expected for your age
  • If you’re a girl or woman: your periods aren’t regular or they stop altogether

What should happen next?

Being referred for specialist treatment

  • If your GP thinks you may have an eating disorder they should arrange an appointment for you to see a professional who specialises in eating disorders. This will usually be at an eating disorder clinic or centre in your area. If you are under 18 you should be seen at a clinic for children and young people
  • There are lots of different signs that can point to an eating disorder. Your GP should think about everything that is affecting you when deciding whether to refer you for treatment, and not make a decision based on one particular problem (such as a low BMI)

Planning your support and treatment

  • It is common for eating disorders to go together with conditions like depression, anxiety, self-harm, alcohol or substance misuse, or obsessive-compulsive disorder. Sometimes an eating disorder is picked up when people are having care for one of these other conditions. The healthcare professionals you are seeing should explore if you need any other support, so that all your needs can be included in your treatment plan. You can find out more about treating other conditions alongside an eating disorder in managing other conditions

What treatments are there?

  • Treatment usually involves psychological therapy, also known as talking therapy. There is more information about the different types of therapy recommended in the separate treatment sections. You should also have tests and regular checks of your physical health (see looking after your physical health)
  • You shouldn’t be offered medicine on its own for your eating disorder

Information and support

  • Eating disorders can happen to anyone, and if you have one you should get the support and treatment you need. Healthcare professionals should explain to you, and your family or carers, what eating disorders are, how they can affect you, and about different treatments. They should help you understand all the treatment options, including pros and cons, so that you can decide what is best for you. When they talk to you and your family they should:
    • talk in a way that you can understand
    • be sensitive and supportive when discussing how you feel about your body shape and weight
    • explain any medical terms
    • check that you understand the information
    • encourage you to ask questions

Sharing information with other professionals

  • Anything you say to a professional is confidential, but sometimes information needs to be shared with other professionals involved in your care so that they know what you need. Your doctor should explain who needs to see information about you, and why

Support for children and young people

  • When you talk to a healthcare professional about your eating problems they might ask if there is anything else worrying you. They should also ask how things are going at home, and at school, college, or work. This will help them understand more about your life and what other support you need

Involving your family and friends

  • It can make a huge difference to have support and encouragement from your family, friends, and teachers during your recovery. Your doctor and other professionals should encourage them to support you if you would find it helpful
  • If you prefer, you can choose not to have your family or carers involved in your care. They should still be given their own support while you are having care and treatment, and there is more about the help they can expect in supporting parents, family members, and carers

If you are under 16

  • If you are under 16, a parent or carer usually needs to agree (‘give consent’) to treatment on your behalf. If you are worried about this, talk to your doctor. They may be happy for you to give your own consent if it is clear that you can understand and make decisions about your own care

Anorexia nervosa: treatment for adults

  • If you have anorexia you should usually be offered a talking therapy. This kind of therapy helps you to understand the causes of your eating problems and learn new ways of thinking and behaving. You may be offered cognitive behavioural therapy (CBT), the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) or specialist supportive clinical management (SSCM). Treatment aims to help you feel comfortable around food, so you can eat enough to stay healthy. It is also likely to involve helping you reach a healthy weight

Changing to a different therapy

  • If you are offered a therapy and you don’t think it is right for you, or you try one and it doesn’t help, you should be able to have a different therapy. Talk to your practitioner if you think you would like to try something different. It could be another of the therapies above, or a treatment called focal psychodynamic therapy

Diet advice

  • During your treatment you may be given some advice about healthy eating by a dietitian. Although a healthy diet is important and will help you get to a healthy weight, dietary advice on its own does not work as a treatment for anorexia so you should be offered other therapies too
  • While you are recovering you should take a multivitamin and mineral supplement, to make sure you get the vitamins and minerals you need

Bone health

  • If you have anorexia your bones can become weaker, especially if your weight has been very low for a long time. Losing bone strength makes you more likely to develop osteoporosis, a condition where your bones become fragile and break (fracture) easily, even from a minor knock or fall
  • If you have osteoporosis or another bone disorder you will need to be careful about what types of exercise you do. To avoid broken bones you should avoid high-impact physical activities like running, and other activities that might increase your chance of falling. The best way to protect your bones is to work towards reaching a healthy weight or BMI

Tests and treatment for low bone strength

  • Your doctor may offer you a special type of X-ray called a bone density scan to check the health of your bones. This is normally for adults who have been underweight for 2 years, but it may be offered earlier if you have pain in your bones or have had a lot of fractures. Your doctor should talk to you about bone scans and whether having one might be useful
  • Women with anorexia are at particular risk of low bone strength. Because of this, if your bone strength is very low you might be offered a medicine called a bisphosphonate, which is used to treat osteoporosis. Before you start taking this medicine it’s important to discuss with your doctor the pros and cons (including side effects), so you can decide if it’s right for you

Anorexia nervosa: treatment for children and young people

Family therapy

  • Many children and young people with anorexia find it helpful to have a talking therapy that family members or carers can take part in too. This is known as family therapy. It involves working with a practitioner (for example a therapist), and allows you to explore how anorexia has affected you and how your family can support you to get better
  • You should be able to choose whether to have therapy sessions together with your family or separately (you can also have a mixture of both). Sometimes family therapy is offered together with other families
  • Family therapy usually involves between 18 and 20 sessions over a year. After the first 4 weeks, your practitioner should check if you are happy with how often you have sessions and how long they last. You can make changes if you want to. Your practitioner should ask you about this every 3 months after that, to make sure the therapy suits you

Other talking therapies

  • If family therapy is not right for you, your practitioner might suggest cognitive behavioural therapy (CBT) or adolescent-focused psychotherapy. Ask your practitioner if you would like to know more about these

Eating a healthy diet

  • Food gives you the energy and vitamins you need to grow and develop properly. This is important as you reach your teenage years when your body is changing quickly. If you have anorexia, you might not be getting everything you need from your diet, so your doctor should encourage you to take vitamins and minerals. They should also give you advice about the best foods to eat to stay healthy and grow
  • If you are having therapy separately from your parents or carers, your practitioner will need to tell them about any eating plans you have agreed so that they can support you at home

Growth and development

  • Anorexia has physical effects on your body and your growth. If your body weight is low for a long time it can delay your puberty (the time when your body becomes more adult-like, when you are about 13). For girls and women, it can also make your periods stop If your doctor thinks anorexia might be causing problems with your growth and development they might make an appointment for you to see a specialist to help with this

Bone health

  • Anorexia can also interfere with building strong bones. Because of this, you may be offered a special type of X-ray called a bone density scan to check if your bones are healthy. You might be offered this if you have been underweight for a year or more, but it might be offered sooner if you have pain in your bones or have had lots of fractures (broken bones). Your doctor should talk to you about bone scans and whether having one might be useful
  • Bone problems can be worse in girls and women. Because of this, you may be offered medicine to help with your body’s growth if you are underweight or have bone problems

Check-ups for people for anorexia

  • Ongoing support is important for people with anorexia. You should be offered information about anorexia, and checks of your weight and physical and mental health. This will normally be done by your GP. However, if anorexia is causing you severe problems you may see an eating disorder specialist
  • If you are not currently having treatment, you should have check-ups with your GP at least once a year. Your GP should check your overall health by taking some blood and measuring your weight, BMI and blood pressure. They might offer you an electrocardiograph (called ‘ECG’ for short) to check that your heart is healthy
  • They should ask about your day-to-day life, your mood and how you are managing. They will also be happy to talk about treatment options with you if you feel you need some help and support

Binge-eating disorder

Guided self-help

  • Children, young people, and adults who have binge-eating disorder should be offered guided self-help. This means working through a book about binge eating, and having short sessions with a practitioner (such as a therapist) to check how you are doing. People generally have between 4 and 9 sessions that last about 20 minutes each. However, you and your practitioner should agree how many sessions to have and how long they will last, depending on what works for you

Cognitive behavioural therapy

  • Guided self-help may not be right for everyone, and if you don’t feel it has helped after 4 weeks, you may be offered group sessions of cognitive behavioural therapy (CBT). This should take place in 16 weekly sessions over 4 months, each one lasting about 90 minutes. It should cover:
    • showing you how to plan your food intake every day
    • working out the triggers that make you binge
    • helping you to change negative beliefs about your body
    • helping you stick to your new eating habits (this is called relapse prevention)
  • You may be offered individual CBT rather than group CBT. The treatments are similar but individual CBT involves having one-to-one sessions with your practitioner rather than group sessions

Reaching a healthy weight

  • Your body weight is unlikely to change during your therapy because it is not designed to help you gain or lose weight. If you need to reach a healthy weight, this should be a longer-term part of your recovery. Your practitioner can give you more advice about this
  • NICE has written separate advice about treatments for obesity

Bulimia nervosa: treatment for adults

Guided self-help

  • If you have bulimia you may be offered a guided self-help programme. This means working through a book about bulimia, and having short sessions with a practitioner (such as a therapist) to check how you are doing. People generally have between 4 and 9 sessions that last about 20 minutes each. However, you and your practitioner should agree how many sessions to have and how long they will last, depending on what works for you
  • Guided self-help is often helpful but it isn’t right for everyone. If you feel it hasn’t helped after 4 weeks, you may be offered cognitive behavioural therapy (CBT)

Cognitive behavioural therapy

  • If you’re offered CBT you should expect to have up to 20 sessions over 20 weeks (4 to 5 months). To start with you should see your practitioner twice a week. You can also choose to involve people close to you in your therapy

Reaching a healthy weight

  • Your body weight is unlikely to change much during your therapy because it is not designed to help you lose or gain weight. If you need to reach a healthy weight, you should expect this to be a longer-term part of your recovery. Your practitioner can give you more advice about this

Bulimia nervosa: treatment for children and young people

Family therapy

  • Many children and young people with bulimia find it helpful to have a talking therapy that family members or carers can take part in too. This is known as family therapy. It involves working with a practitioner (for example a therapist), and allows you to explore how bulimia has affected you and how your family can support you to get better
  • Your family therapy should usually last for 6 months and you should expect to have between 18 and 20 sessions. You should also have regular meetings with your practitioner on your own

Cognitive behavioural therapy

  • Another treatment you might be offered is cognitive behavioural therapy (CBT). If you’re offered this you will normally have 18 sessions with a practitioner over 6 months. You will also usually have some sessions with your parents or carers

Other eating disorders

  • If you have been diagnosed with an ‘other specified feeding and eating disorder’ (called ‘OSFED’ for short) it means you don’t have all the typical symptoms of any of the main types of eating disorder. It could be because you have a mixture of signs or symptoms of different eating disorders. It does not mean your condition is less serious
  • If you have OSFED, you should be offered the treatments recommended here for the type of eating disorder your symptoms are most similar to. Have a look at the separate treatment sections and ask your doctor for more information

Looking after your physical health

  • If you are diagnosed with an eating disorder you should be offered tests to see how it has affected your body

Tests you might be offered

  • You might be offered blood tests and a physical examination to see if you are dehydrated. Your doctor will also check the minerals in your blood (like calcium, sodium and potassium). These minerals are called ‘electrolytes’ and you need to have a healthy balance of these for your body to work normally. An electrolyte imbalance can lead to organ damage if left untreated. You may be prescribed electrolyte supplements to correct this imbalance. If it becomes severe, or if you are very dehydrated, you will need medical care straight away
  • You may also be offered an electrocardiograph (called ‘ECG’ for short) to check how well your heart is working, because an eating disorder can put a strain on the heart. An ECG is a simple test that involves attaching sensors to your body with stickers, to look at the activity of your heart

Looking after your teeth

  • Eating disorders, especially bulimia, can damage your teeth over time. If you make yourself sick regularly, the stomach acid in your vomit gradually wears away the enamel (the top layer) that protects your teeth. To look after your teeth:
    • make sure you see your dentist regularly
    • don’t brush your teeth straight after vomiting because this can help to rub away the enamel—instead rinse your mouth with a non-acidic mouthwash
    • avoid highly acidic foods and drinks, such as fruit juices, fizzy drinks, and coffee
    • avoid smoking

Advice about laxatives

  • People with eating disorders sometimes use laxatives to try and get rid of unwanted calories. Laxatives do not help with weight loss. The calories from your food have already been absorbed before the food reaches your colon (large bowel), where laxatives have their effect. Regularly overusing laxatives can cause symptoms like stomach pain, bloating, diarrhoea, and dehydration. Your doctor or other professionals can help you to gradually cut down and stop using them

Advice about exercise

  • If exercising too much is making your eating disorder worse, you may be advised to exercise less

Children and young people

  • If you have an eating disorder you might not be getting everything you need from your diet to help you grow and develop properly. If your doctor thinks your eating disorder might be causing problems with your growth and development they might refer you to a specialist for advice

Managing other conditions

  • People with eating disorders often have other conditions too. You might have been diagnosed with anxiety or depression or have a long-term condition like diabetes. If you see different healthcare professionals for treatment, it is important that they stay in touch with each other so that they all know what is happening with your care. This is because the eating disorder could affect other treatments you are having. You might need to be checked more often for side effects caused by medicines you are taking, or a change might be needed to your treatment plan

Deciding your treatment plan

  • If you have anxiety or depression or another mental health condition, your doctor should help you decide whether you need treatment for this before your eating disorder. You might be able to have treatment for both at the same time, either combined or separately. This depends on how you feel and how quickly you need help. Your doctor can help you decide what would be best for you. You might also want to talk to your family to help you decide
  • If you are misusing substances (this can include alcohol, drugs or medicines) you should still be able to have treatment for your eating disorder. If the substance misuse makes it difficult to follow your treatment, your doctor may recommend that you see a professional who specialises in helping people with substance misuse. This could be before you have treatment for your eating disorder, or while you are having the treatment

Diabetes and an eating disorder

  • If you have diabetes, your diabetes care team should be told that you are having treatment for an eating disorder so they can give you extra help to monitor your blood glucose. It can also be useful to involve a family member or carer in your therapy to help you. Your physical health also needs to be monitored closely. The different professionals looking after you should decide who will be responsible for this and make sure everyone involved in your care knows who this is
  • For some people, the way they use their insulin becomes part of their eating disorder (this is called ‘insulin misuse’). If you are misusing your insulin, your treatment should help you to address this by:
    • slowly increasing the amount of carbohydrates in your diet, so that you don’t need to take much insulin at first
    • gradually increasing your insulin so that your blood glucose level falls slowly
    • teaching you how to adjust insulin to match the carbohydrates in your meals
    • teaching you about managing your diabetes and about what happens in your body when you misuse insulin
  • If you have diabetes, you may be used to checking your blood glucose. However, if your specialist thinks you might have hypoglycaemia or hyperglycaemia, they may want to check your blood glucose themselves. They may also want to check your blood ketones, particularly if you are misusing your insulin. Your doctor will explain what checks you need and how often, the results of the checks, and what you should do next
  • If you have bulimia and diabetes, you may need to have extra tests to make sure you are not at risk of any serious problems (such as diabetic ketoacidosis). Your doctor will explain what tests you need and how often
  • NICE has written separate advice about managing diabetes. See where can I find out more?

Supporting parents, family members and carers

  • It is difficult and distressing for parents, partners and other family members of someone with an eating disorder. If you care for someone with an eating disorder you may feel guilty or responsible and unsure of how to help them get better. You should be asked what help and support you need while the person you care for has treatment. This should include:
    • emotional and social support
    • practical support, including discussing care plans and what to do if emergency care is needed

Being involved

  • Your child or partner might find it comforting to have family members involved in their care while they recover. But if they decide they prefer not to have family involved then professionals will need to respect their wishes

Advice for parents

  • If you have a child with an eating disorder who is under 16, you may need to consent to treatment on their behalf. They may have an assessment of whether they can understand and make decisions on their own. If they can, professionals should respect their wishes about how much information they can give you
  • If you are not involved in family therapy with your child or in meetings about your child’s care, you should still be kept informed as much as possible with what’s happening and offered your own support
  • You should also be told about any dietary planning and information that your child agrees with their doctor or other professionals, so that you can support them at home

Where can I find out more?

  • Anorexia and Bulimia Care, 0300 011 1213
    www.anorexiabulimiacare.org.uk
  • Beat
    Adult helpline: 0808 801 0677
    Under 18s helpline: 0808 801 0711
    www.b-eat.co.uk
  • Men Get Eating Disorders Too
    www.mengetedstoo.co.uk
  • You can also go to NHS Choices for more information on eating disorders
  • Colleges and universities often have services that can help their students with eating disorders and provide support with their studies if needed
  • NICE is not responsible for the quality or accuracy of any information or advice provided by these organisations

© NICE 2017. Eating disorders: recognition and treatment—information for the public. 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: September 2018.