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1 Eating disorders: recognition and
2 treatment
4 NICE guideline: short version
5 Draft for consultation, December 2016
This guideline covers assessment, treatment, monitoring and inpatient care for people with eating disorders. In addition to general recommendations for all eating disorders, specific recommendations are made on the treatment of anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding and eating disorders (OSFED). Who is it for? Healthcare professionals responsible for assessing and treating eating disorders. Commissioners of eating disorder services. Other professionals who may provide public services to people with eating disorders (including in criminal justice and education settings). People with suspected or diagnosed eating disorders and their families and carers. This guideline will update and replace NICE guideline CG9 (published January 2004). New recommendations have been made on assessment, treatment, monitoring and inpatient care for people with eating disorders. This version of the guideline contains the draft recommendations, context and recommendations for research. Information about how the guideline was developed is on the guideline’s page on the NICE website. This includes the guideline committee’s discussion and the evidence reviews (in
the full guideline), the scope, and details of the committee and any declarations of interest. 1 2
1 Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity) and safeguarding. 2
3 1.1 General principles of care
4 Improving access to services 5 1.1.1 Be aware that people with an eating disorder may: 6 avoid contact with and find it difficult or distressing to interact 7 with healthcare professionals, staff and other service users 8 be vulnerable to stigma and shame. 9 1.1.2 Ensure that people with an eating disorder and their parents or 10 carers (as appropriate) get equal access to treatments for eating 11 disorders, regardless of: 12 gender or gender identity (including people who are 13 transgender) 14 sexual orientation 15 religion, belief, culture or family origin 16 where they live and who they live with 17 any mental or physical health problems or disabilities. 18 Communication and information 19 1.1.3 When assessing a person with a suspected eating disorder, find 20 out what they and their family members or carers (as appropriate) 21 know about eating disorders and address any misconceptions.
1 1.1.4 Offer people with eating disorders and their family members or 2 carers (as appropriate) education and information on: 3 the nature and risks of their eating disorder and how it is likely to 4 affect them 5 the treatments available and their likely benefits and limitations. 6 1.1.5 When communicating with people with an eating disorder and their 7 family members or carers (as appropriate): 8 check that they understand what is being said 9 be sensitive when discussing a person’s weight and appearance 10 be aware that family members or carers may feel guilty and 11 responsible for the eating disorder 12 show empathy, compassion and respect. 13 1.1.6 Ensure that people with an eating disorder and their parents or 14 carers (as appropriate) understand the purpose of any meetings 15 and the reasons for sharing information about their care with 16 others. 17 Support for children and young people with an eating disorder 18 1.1.7 For children and young people, assess the impact of their home, 19 education, work and wider social environment on their eating 20 disorder. Ensure that their emotional, education and social needs 21 are met throughout treatment. 22 1.1.8 If appropriate, encourage family members, carers, teachers, and 23 peers of children and young people to support them during their 24 treatment. 25 Working with family members and carers 26 1.1.9 Be aware that the family members or carers of a person with an 27 eating disorder may experience severe distress. Offer them an 28 assessment of their own needs, including:
1 1.1.15 Base the content, structure and duration of psychological 2 treatments on relevant manuals that focus on eating disorders. 3 1.1.16 Professionals who provide treatments for eating disorders should: 4 receive appropriate supervision 5 use standardised outcome measures, for example the Eating 6 Disorder Examination Questionnaire (EDE-Q), bulimic 7 behaviours or weight 8 monitor their competence (for example, by using recordings and 9 external audit and scrutiny) 10 monitor treatment adherence in people who use their service.
11 1.2 Identification and assessment
12 Initial assessments in primary and secondary mental health care 13 1.2.1 Be aware that eating disorders present in a range of settings, 14 including: 15 primary and secondary health care 16 social care 17 education. 18 1.2.2 Think about the possibility of an eating disorder in people with one 19 or more of the following: 20 an unusually low or high BMI or body weight for their age 21 dieting or restrictive eating practices (such as dieting when they 22 are underweight) that are worrying them, their family members 23 or carers, or professionals 24 family members or carers report a change in eating behaviour 25 other mental health problems 26 a disproportionate concern about their weight (for example, 27 concerns about weight gain as a side effect of contraceptive 28 medication)
1 problems managing a chronic illness that affects diet, such as 2 diabetes 3 menstrual or other endocrine disturbances, or unexplained 4 gastrointestinal symptoms 5 physical signs of: 6 starvation, such as poor circulation, dizziness, palpitations, 7 fainting or pallor 8 compensatory behaviours, such as laxative misuse, vomiting 9 or excessive exercise 10 dental erosion 11 taking part in activities associated with a high risk of eating 12 disorders (for example, professional sport, fashion, dance, or 13 modelling). 14 1.2.3 When assessing for an eating disorder, think about all of the points 15 in recommendation 1.2.2 regardless of the person's gender, 16 ethnicity or socio-economic background. 17 1.2.4 Think about the possibility of an eating disorder in children and 18 young people with poor growth (for example a low weight or height 19 for their age). 20 1.2.5 Be aware that the risk of eating disorders is highest in young 21 women (13–17 years), and that young men are also at greater risk 22 between 13 and 17 years than at other ages. 23 1.2.6 Do not use screening tools (for example SCOFF) as the sole 24 method to determine whether or not people have an eating 25 disorder. 26 1.2.7 Do not use single measures such as BMI or duration of illness to 27 determine whether to offer treatment for an eating disorder. 28 1.2.8 Professionals in primary and secondary mental health settings 29 should assess the following in people with a suspected eating 30 disorder:
1 and sexual) and neglect. For guidance on when to suspect child 2 maltreatment, see the NICE guideline on child maltreatment. 3 Treating anorexia nervosa 4 1.2.12 Be aware that a key goal of treatment for anorexia nervosa is to 5 help people reach a healthy body weight or BMI for their age. 6 1.2.13 When weighing people with anorexia, consider sharing the results 7 with them and (if appropriate) their family members or carers. 8 Psychological treatment for adults with anorexia nervosa 9 1.2.14 Consider either individual eating-disorder-focused cognitive 10 behavioural therapy (CBT-ED) or eating-disorder-focused focal 11 psychodynamic therapy for adults with anorexia nervosa. 12 1.2.15 Individual CBT-ED programmes for adults with anorexia nervosa 13 should: 14 use a CBT-ED manual 15 consist of up to 40 sessions over 40 weeks 16 aim to reduce the risk to physical health and any other 17 symptoms of the eating disorder 18 encourage reaching a healthy body weight and healthy eating 19 cover nutrition, relapse prevention, cognitive restructuring, mood 20 regulation, social skills, body image concern and self-esteem 21 create a personalised treatment plan based on the processes 22 that appear to be maintaining the eating problem 23 explain the risks of starvation and being underweight 24 enhance self-efficacy 25 include self-monitoring 26 include homework, to help the person practice what they have 27 learned in their daily life. 28 1.2.16 Eating-disorder-focused focal psychodynamic therapy programmes 29 for adults with anorexia nervosa should:
1 use a focal psychodynamic manual specific to eating disorders 2 consist of up to 40 sessions over 40 weeks 3 include psychoeducation about nutrition and the effects of 4 starvation 5 make a patient-centred focal hypothesis that is specific to the 6 individual and addresses: 7 what the symptoms mean to the person 8 how the symptoms affect the person 9 how the symptoms influence the person's relationships with 10 others and with the therapist 11 in the first phase, focus on developing the therapeutic alliance 12 between the therapist and person with anorexia nervosa, 13 addressing pro-anorexic behaviour and ego-syntonic beliefs 14 (beliefs, values and feelings consistent with the person's sense 15 of self) and building self-esteem 16 in the second phase, focus on relevant relationships with other 17 people and how these affect eating behaviour 18 in the final phase, focus on transferring the therapy experience 19 to situations in everyday life and address any concern the 20 person has about what will happen when treatment ends. 21 1.2.17 If individual CBT-ED or focal psychodynamic-ED is ineffective, not 22 available or not acceptable for adults with anorexia nervosa, 23 consider specialist supportive clinical management (SSCM) or the 24 Maudsley Anorexia Treatment for Adults (MANTRA). 25 Psychological treatment for young people with anorexia nervosa 26 1.2.18 Consider anorexia-nervosa-focused family therapy for young 27 people with anorexia nervosa, delivered as single- or multi-family 28 therapy and with sessions provided either: 29 separately for the young person and for their family members 30 and carers or 31 for the young person and their family together.
1 1.2.22 If family therapy is unacceptable, contraindicated or ineffective for 2 young people with anorexia nervosa, consider individual CBT-ED 3 or adolescent focused eating disorder therapy. 4 1.2.23 Assess whether family members or carers (as appropriate) need 5 support if the young person with anorexia nervosa is having 6 therapy on their own. 7 Dietary advice for those with anorexia nervosa 8 1.2.24 Only offer dietary counselling as part of a multidisciplinary 9 approach. 10 1.2.25 Encourage people with anorexia nervosa to take an age- 11 appropriate oral multi-vitamin and multi-mineral supplement until 12 their diet includes enough to meet their dietary reference values. 13 1.2.26 Include family members or carers (as appropriate) in any dietary 14 education or meal planning for children and young people with 15 anorexia nervosa who are having therapy on their own. 16 1.2.27 Offer individualised supplementary dietary advice to children and 17 young people with anorexia nervosa and their parents or carers (as 18 appropriate) to help them meet their nutritional needs for growth 19 and development (particularly during puberty). 20 Medication 21 1.2.28 Do not offer medication as the sole treatment for anorexia nervosa. 22 Low bone mineral density in women with anorexia nervosa 23 1.2.29 Explain to women with anorexia nervosa that the primary aim of 24 prevention and treatment of a low bone mineral density is to 25 achieve and maintain a healthy body weight or BMI for their age. 26 1.2.30 Do not routinely offer oral or transdermal oestrogen therapy to treat 27 low bone mineral density in children or young people with anorexia 28 nervosa.
1 1.2.31 Seek specialist paediatric or endocrinological advice before starting 2 any hormonal treatment for a low bone mineral density. Coordinate 3 any treatment with the eating disorders team. 4 1.2.32 Consider transdermal 17-β-estradiol (with cyclic progesterone) for 5 young women (aged 13–17 years) with anorexia nervosa who have 6 long-term low body weight and low bone mineral density with a 7 bone age over 15. 8 1.2.33 Consider incremental physiological doses of oestrogen in young 9 women (aged 13–17 years) with anorexia nervosa who have 10 delayed puberty, long-term low body weight and low bone mineral 11 density with a bone age under 15. 12 1.2.34 Consider bisphosphonates for women (18 years and over) with 13 anorexia nervosa who have long-term low body weight and low 14 bone mineral density. Discuss the benefits and risks (including risk 15 of teratogenic effects) with women before starting treatment. 16 1.2.35 Advise people with anorexia nervosa and osteoporosis or related 17 bone disorders to avoid high-impact physical activities and activities 18 that significantly increase the chance of falls or fractures.
19 1.3 Treatment of bulimia nervosa
20 Psychological treatment for adults 21 1.3.1 Consider bulimia-nervosa-focused guided self-help for adults with 22 bulimia nervosa. 23 1.3.2 Bulimia-nervosa-focused guided self-help programmes for adults 24 with bulimia nervosa should: 25 use a cognitive behavioural self-help book for eating disorders 26 supplement the self-help programme with brief supportive 27 sessions (for example four to nine sessions lasting 20 minutes 28 each over 16 weeks running weekly at first)
1 use a bulimia-nervosa-focused family therapy manual 2 consist of 18–20 sessions over 6 months 3 support and encourage the family to help the young person 4 recover 5 not blame the young person or their family members or carers 6 include information about regulating body weight, dieting and the 7 adverse effects of controlling weight with self-induced vomiting 8 or laxatives 9 establish a good therapeutic relationship with the young person 10 and their family members or carers 11 use a collaborative approach between the parents and the 12 young person to establish regular eating patterns and minimise 13 compensatory behaviours 14 include regular meetings with the young person on their own 15 throughout the treatment 16 include self-monitoring of bulimic behaviours and discussions 17 with family members or carers 18 in later phases of treatment, support the young person and their 19 family members or carers to establish a level of independence 20 appropriate for their level of development 21 in the final phase of treatment, focus on plans for when 22 treatment ends (including any concerns the young person and 23 their family have) and on relapse prevention. 24 1.3.8 If family therapy is ineffective, or is not acceptable, consider 25 bulimia-nervosa-focused guided self-help for young people with 26 bulimia nervosa. 27 Medication 28 1.3.9 Do not offer medication as the sole treatment for bulimia nervosa.
1 1.4 Treating binge eating disorder
2 Psychological treatment for adults 3 1.4.1 Offer a binge-eating-focused guided self-help programme to adults 4 with binge eating disorder. 5 1.4.2 Binge-eating-focused guided self-help programmes for adults 6 should: 7 use a cognitive behavioural self-help book 8 focus on adherence to the self-help programme 9 supplement the self-help programme with brief supportive 10 sessions (for example four to nine sessions lasting 20 minutes 11 each over 16 weeks that are first run weekly): 12 delivered by a practitioner who is competent in delivering the 13 treatment 14 that focus exclusively on helping the person follow the 15 programme. 16 1.4.3 If guided self-help is ineffective after 4 weeks or is not acceptable, 17 offer group eating-disorder-focused cognitive behavioural therapy 18 (CBT-ED). 19 1.4.4 Group CBT-ED programmes for adults with binge eating disorder 20 should: 21 use a CBT-ED manual 22 consist of 16 weekly 90-minute group sessions over four months 23 focus on psychoeducation, self-monitoring of the eating 24 behaviour and helping the person analyse their problems and 25 goals 26 include making a daily food intake plan and identifying binge 27 eating cues 28 include body exposure training and helping the person to identify 29 and change negative beliefs about their body
1 1.8 Physical and mental health comorbidities
2 1.8.1 Eating disorder specialists and other care teams should collaborate 3 when caring for people with physical or mental health comorbidities 4 that may be affected by their eating disorder. 5 1.8.2 When collaborating, teams should use outcome measures for both 6 the eating disorder and the physical and mental health 7 comorbidities, to monitor the effectiveness of treatments for each 8 condition and the potential impact they have on each other. 9 Diabetes 10 1.8.3 Eating disorder teams and diabetes teams should collaborate to 11 explain the importance of physical health monitoring to people with 12 an eating disorder and diabetes. 13 1.8.4 Consider involving family members and carers (as appropriate) in 14 the treatment programme to help the person with blood glucose 15 control. 16 1.8.5 Agree between the eating disorder and diabetes teams who has 17 responsibility for monitoring the physical health of people with an 18 eating disorder and diabetes. 19 1.8.6 Explain to the person and their diabetes team that they may need 20 to monitor their blood glucose control more closely during the 21 treatment for the eating disorder. 22 1.8.7 Address insulin misuse as part of any psychological treatments for 23 eating disorders in people with diabetes. 24 1.8.8 Offer people with an eating disorder who are misusing insulin the 25 following treatment plan: 26 a low carbohydrate diet, so that insulin can be started at a low 27 level 28 gradually increasing insulin doses to reduce blood glucose levels
1 adjusted total glycaemic load and carbohydrate distribution to 2 meet their individual needs and prevent rapid weight gain 3 carbohydrate counting when adjusting their insulin dose 4 (including via pumps) 5 a diabetic educational intervention such as DAFNE 6 education about the problems caused by misuse of diabetes 7 medication. 8 1.8.9 For more guidance on managing diabetes, refer to the NICE 9 guidelines on type 1 and type 2 diabetes in children and young 10 people, type 1 diabetes in adults, and type 2 diabetes in adults. 11 Comorbid mental health problems 12 1.8.10 When deciding which order to treat an eating disorder and a 13 comorbid mental health condition (in parallel, as part of the 14 treatment or one after the other), take the following into account: 15 the severity and complexity of the eating disorder and 16 comorbidity 17 the person's level of functioning 18 the patient's preference. 19 1.8.11 Refer to the NICE guidelines on specific mental health problems for 20 further guidance on treatment. 21 Medication risk management 22 1.8.12 When prescribing medication for people with an eating disorder and 23 comorbid mental or physical health conditions, take into account 24 the impact malnutrition and compensatory behaviours can have on 25 the effectiveness and the risk of side effects. 26 1.8.13 When prescribing for people with an eating disorder and a 27 comorbidity, assess how the eating disorder will affect medication 28 adherence (for example, for medication that can affect body 29 weight).
