Previous changes

June 2019 — reviewed. A literature search was conducted in May 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic.

• The information on specialist treatment for eating disorders has been updated based on recommendations in the National Institute for Health and Care Excellence (NICE) guideline Eating disorders: recognition and treatment [NICE, 2017].

September 2014 to October 2014 — reviewed. A literature search was conducted in September 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No significant changes have been made to the recommendations in this topic.

• Following two literature reviews in 2008 and 2011, NICE decided not to update their 2004 guidance on eating disorders [NICE, 2004]. Although new evidence for psychological and pharmacological treatments was identified for eating disorders, this was insufficient to warrant an update or any changes to the recommendations in the NICE guidance [NICE, 2013]. CKS have therefore used the NICE guidelines on eating disorders that were published in 2004 to support the recommendations made in this topic.

July to October 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There have been no major changes to the recommendations.

November 2005 — minor technical update. 

June 2004 — written. Validated in September 2004 and issued in November 2004.

New evidence

Evidence-based guidelines

• BSG (2025) BAPEN Position Statement on Electrolyte and Vitamin Replacement in Adult patients with severe malnutrition, including people with Eating Disorders and other conditions who are undergoing refeeding. British Society of Gastroenterology. [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2024.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 June 2024.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2024.

New policies

No new national policies or guidelines since 1 June 2024.

New safety alerts

No new safety alerts since 1 June 2024.

Changes in product availability

No changes in product availability since 1 June 2024.

Anorexia nervosa

• Complications of anorexia nervosa include:
  • Psychological and emotional disturbances such as anxiety, social withdrawal, poor quality of life, low mood, and suicidal ideation.
  • Social difficulties such as disrupted relationships, isolation, limitations on employment prospects, and economic disadvantage.
  • Family/carer stress — the burden of caring for a person with anorexia nervosa is comparable to that of caring for a person with depression or schizophrenia.
  • Physical abnormalities — usually secondary to compromised nutritional state and can affect many systems, including:
    • Cardiovascular — arrhythmias, hypotension, valve prolapse, peripheral oedema, sudden death.
    • Musculoskeletal — loss of muscle strength, loss of bone density (may be irreversible), fractures, impairment of growth in children and teenagers.
    • Endocrine — thyroid abnormalities, incomplete development of secondary sexual characteristics, impaired temperature regulation.
    • Gastrointestinal (GI) — slowed GI motility, constipation, upper GI bleeding, abnormal liver function tests, and enlargement of the parotid glands.
    • Haematological — low white blood cell count (particularly neutrophils), anaemia (rarely), thrombocytopenia.
    • Metabolic — dehydration, electrolyte disturbance in those who misuse laxatives or diuretics or induce vomiting, re-feeding syndrome (a complication of rapid re-feeding treatment).
    • Neurological — cognitive impairment, seizures (rarely).
    • Renal — kidney stones and acute or chronic kidney disease (chronic volume depletion can lead to the development of kidney disease).
    • Dental — erosion of tooth enamel from vomiting.
    • Dermatological — dry skin, alopecia, lanugo hair (fine, white hairs), and chilblains.
    • Obstetric and gynaecological — infertility (may be irreversible), sexual dysfunction, risk of polycystic ovaries, miscarriage, hyperemesis, anaemia, intrauterine growth restriction, preterm birth, postpartum depression, and anxiety.
  • Mortality — most deaths due to anorexia nervosa are a result of the medical consequences of starvation (especially cardiac and severe infection). However, around 20% are due to suicide.

[Mehler, 2015; Zipfel, 2015; Kimmel, 2016; Norris, 2016; Sachs, 2016; Westmoreland, 2016; Bould, 2017a; Wassenaar, 2018; RCP, 2019; NICE, 2020; Treasure, 2020; CoSRH, 2021; BMJ Best Practice, 2023a; RCP, 2023]

Bulimia nervosa

• Complications of bulimia nervosa include:
  • Emotional disturbances — mood and anxiety symptoms are very common.
  • Social difficulties — low self-esteem and body image disturbance can affect relationships and lead to social isolation.
  • Physical abnormalities — can affect many systems, including:
    • Cardiovascular — arrhythmias (due to hypokalaemia), diet pill toxicity (for example, palpitations, hypertension), valve prolapse, peripheral oedema.
    • Dermatological —knuckle calluses from inducing vomiting (Russell's sign).
    • Dental — erosion of tooth enamel from vomiting.
    • Endocrine — amenorrhoea, irregular menses, hypoglycaemia, osteopenia.
    • Gastrointestinal — acute gastric dilation, oesophageal rupture, Mallory–Weiss tears, parotid gland swelling.
    • Metabolic — dehydration, electrolyte imbalance (for example, hypokalaemia), obesity-related complications (around one in three people with bulimia nervosa or binge eating disorder are obese or will become obese).
    • Neurological — cognitive impairment (usually related to periods of extreme dieting), peripheral neuropathy.
    • Pulmonary — aspiration pneumonitis.
    • Renal — renal calculi.
    • Obstetric and gynaecological — risk of polycystic ovaries.
  • Mortality — the mortality rate associated with bulimia nervosa is lower than that of anorexia nervosa but higher than in people without an eating disorder (due to severe electrolyte imbalance associated with purging behaviours).

[Hay, 2014; Harrington, 2015; Lock, 2015; Kimmel, 2016; Westmoreland, 2016; RCP, 2019; NICE, 2020; Treasure, 2020; BMJ Best Practice, 2023b; RCP, 2023]

Binge eating disorder

• People with binge eating disorder have similar complications to people with bulimia nervosa, although purging carries a greater physical risk than binge eating alone.
  • For more information, see the section on Bulimia nervosa.

Atypical eating disorders

• Atypical eating disorders are characterized by symptoms of an eating disorder but do not meet the precise diagnostic criteria for them.
  • For example, all of the criteria for anorexia nervosa are met, there is significant weight loss, but the person's weight is within or above normal range.
• If an atypical eating disorder has similar features to the full syndrome of anorexia nervosa, bulimia nervosa or binge eating disorder, the physical and psychosocial complications will be similar.
  • For more information, see the sections on Anorexia nervosa, Bulimia nervosa and Binge eating disorder.

Clinical features of anorexia nervosa

• Restriction of energy intake resulting in low body weight.
  • Low weight is defined as less than normal in adults (typically BMI less than 18.5) or minimally expected in children and young people (typically BMI-for-age less than the 5th percentile on an appropriate growth chart).
• Intense fear of gaining weight.
  • Preoccupation with food and weight is often related to a pursuit of thinness or, later in the course of illness, a fear of gaining weight.
  • Changes in behaviour may be noticed, for example, becoming increasingly selective about food, avoiding eating with others, saying they aren't hungry, that they have already eaten, or refusing food they used to enjoy.
  • Other behaviours may include repeated weighing, measuring and checking in the mirror.
• Behaviour that interferes with weight gain.
  • Compensatory behaviours such as self-induced purging (by vomiting or misuse of laxatives), excessive exercise, and use of appetite suppressant medication or diuretics may be present.
• Psychological disturbance, which may include:
  • Distortion of body image, with a dread of being overweight.
  • Low self-esteem and a drive for perfection.
  • Over-evaluation of self-worth in terms of body weight and shape.
• Denial of the seriousness of malnutrition and its impact on physical health.
  • Many people with anorexia nervosa have difficulty acknowledging there is a problem, do not consider themselves to be ill and may be ambivalent about change.
  • In others, there may be secrecy about the symptoms, such as hiding weight loss.
• Hormonal disturbance.
  • Females with anorexia nervosa may present with amenorrhoea or other menstrual irregularities.
  • Hormonal disturbance is a common feature of anorexia nervosa. Amenorrhea is no longer in the criteria for diagnosis in females and is only one of several markers of hormonal insufficiency due to low weight.
  • Males with anorexia nervosa may present with loss of libido and potency.
  • In children, the onset of puberty, growth and physical development can be affected.
• Many physical signs are associated with anorexia nervosa, including dry skin, hair loss, bradycardia, orthostatic hypotension, hypothermia, loss of muscle strength, oedema, constipation, fainting, dizziness, and fatigue.
  • For more information, see the section on Complications.

Clinical features of bulimia nervosa

• Recurrent episodes of binge eating occurring on average at least once a week for 3 months.
  • A binge is defined as consuming excessive food in a discrete time, accompanied by a sense of loss of control over eating at that time.
  • In between binges, there are also typically continuing attempts to restrict eating.
• Recurrent inappropriate compensatory behaviour to prevent weight gain (occurring on average at least once a week for 3 months).
  • Compensatory behaviours include vomiting, purging, fasting, excessive exercise, laxatives, diuretics or diet pill use.
• Weight is often within normal limits or above the weight range for age.
  • Bulimia nervosa may be kept secret for many years, as the person’s appearance is typically unremarkable, and they can often eat normally in public.
  • Many people delay seeking help because of the shame associated with binge eating or because they do not know that treatment is available.
• Psychological features, which may include:
  • Over-evaluation of self-worth in terms of body weight and shape.
  • Fear of gaining weight, with a sharply defined weight threshold set by the person.
  • Mood disturbance and symptoms of anxiety and tension.
  • Persistent preoccupation and craving for food and feelings of guilt and shame about binge eating.
  • Self-harm, often by scratching or cutting.
• Physical symptoms, such as bloating, fullness, lethargy, gastro-oesophageal reflux, abdominal pain, and sore throat (from vomiting).
  • In severe cases, physical signs may include Russell's sign (knuckle calluses from inducing vomiting), dental enamel erosion, and salivary gland enlargement.
  • For more information, see the section on Complications.

Clinical features of binge eating disorder

• Recurrent episodes of binge eating (at least once per week for 3 months) in the absence of compensatory behaviours.
  • A binge is defined as consuming an excessive amount of food in a discrete time period accompanied by a feeling of loss of control where the person cannot stop eating or control the amount of food they eat at that time.
  • During a binge, the person may eat more rapidly than normal, eat until uncomfortably full or when not hungry and experience significant distress and feelings of guilt and shame.
• Body weight may be maintained at normal, overweight or obese.
  • Many people with binge eating disorder are overweight or obese.

Clinical features of atypical eating disorders

• Atypical eating disorders have features that closely resemble but do not meet the strict criteria for other diagnostic categories. For example, the person's weight may be just above the diagnostic threshold for anorexia nervosa, or binge eating/purging may occur infrequently.
  • The majority of eating disorders are atypical.
• Over-concern with body weight and shape is generally present.
• Many people with atypical eating disorders have had anorexia or bulimia nervosa previously or may go on to develop the full diagnostic criteria for anorexia or bulimia nervosa.

Basis for recommendation

The information on the clinical features of eating disorders is derived from the Diagnostic and Statistical Manual of mental disorders: DSM-5-TR [APA, 2022], the Royal College of Psychiatrists clinical guideline Medical emergencies in eating disorders: guidance on recognition and management [RCP, 2023] and Position statement on early intervention for eating disorders [RCP, 2019], the National Institute of Health and Care Excellence (NICE) guideline Eating disorders: recognition and treatment [NICE, 2020], the BMJ Best Practice guidelines Anorexia nervosa [BMJ Best Practice, 2023a] and Bulimia nervosa [BMJ Best Practice, 2023b], the Royal Australian and New Zealand College of Psychiatrists Clinical practice guidelines for the treatment of eating disorders [Hay, 2014], the American Academy of Child and Adolescent Psychiatry (AACAP) Practice parameter for the assessment and treatment of children and adolescents with eating disorders [Lock, 2015], and expert opinion in review articles [Campbell, 2014; Zipfel, 2015; Montano, 2016; Allison, 2017; Rowe, 2017; Wassenaar, 2018; Hay, 2020; Giel, 2022].

Basis for recommendation

The recommendations on how to assess a person with a suspected eating disorder are based on the Royal College of Psychiatrists clinical guideline Medical emergencies in eating disorders: guidance on recognition and management [RCP, 2023], the National Institute of Health and Care Excellence (NICE) guideline Eating disorders: recognition and treatment [NICE, 2020], the BMJ Best Practice guidelines Anorexia nervosa [BMJ Best Practice, 2023a] and Bulimia nervosa [BMJ Best Practice, 2023b], the Royal Australian and New Zealand College of Psychiatrists Clinical practice guidelines for the treatment of eating disorders [Hay, 2014], the American Academy of Child and Adolescent Psychiatry (AACAP) Practice parameter for the assessment and treatment of children and adolescents with eating disorders [Lock, 2015], and expert opinion in review articles [Campbell, 2014; Zipfel, 2015; Montano, 2016; Allison, 2017; Bould, 2017b; Bould, 2017a; Rowe, 2017; Wassenaar, 2018; Hay, 2020; Giel, 2022].

Assessment may be normal even in acutely unwell people

• Clinical guidance from the Royal College of Psychiatrists [RCP, 2023], and NICE [NICE, 2020], highlight the fact that medically unstable people with anorexia nervosa and bulimia nervosa can appear deceptively well:
  • No one parameter is a good indicator of overall level of risk or illness.
• Primary care clinicians should carry out a thorough clinical assessment and have low threshold for seeking specialist advice (for example on the need for admission) [Bould, 2017a; RCP, 2023].
• The Royal College of Psychiatrists has provided a detailed list of parameters to help ascertain level of risk (low, moderate and high risk) in eating disorders [RCP, 2023].
  • Be aware that normal and cut-off physiological parameters, such as blood pressure, vary with age, and danger thresholds differ significantly for children and adults.

Collateral history

• Guidance from the American Psychiatric Association [APA, 2022], Royal Australian and New Zealand College of Psychiatrists [Hay, 2014] and NICE [NICE, 2020] and expert opinion in a review article [Bould, 2017b] recommend where possible (if not contraindicated or refused by the person) getting a collateral history from sources such as family members and other clinicians involved in the person’s care.
  • Input from others is especially helpful as people with eating disorders may be reluctant to disclose information, minimise symptoms and/or have poor insight into their condition.
  • Respect Gillick competence if a young person under 16 does not want family members or carers involved [NICE, 2020].

Screening tools

• NICE recommend that screening tools (such as SCOFF) should not be used as the sole method of identifying an eating disorder [NICE, 2020].

Ask about co-morbidities

• Other mental health disorders
  • Expert opinion in guidelines [Hay, 2014; RCP, 2019; NICE, 2020; RCP, 2023] and review articles [Harrington, 2015; Zipfel, 2015; Bould, 2017a] is that people with suspected eating disorders must be assessed for mood disorders, substance misuse, and risk of self-harm or suicide.
  • Up to 75% of people with anorexia nervosa are reported to have an associated mood disorder (most commonly depression), 5–75% have a history of at least one anxiety disorder and obsessive-compulsive disorder occurs in 15–29% [Zipfel, 2015].
  • Approximately 20% of deaths in people with anorexia nervosa are due to suicide [NICE, 2020].
• Diabetes
  • People with diabetes who have an eating disorder are at increased risk of serious complications. Guidance from NICE recommends risk management as the first consideration [NICE, 2020].

Investigations

• The recommendations on which investigations to consider in primary care are based on clinical guidelines [RCP, 2023; NICE, 2020; Hay, 2014], and expert opinion in review articles [Zipfel, 2015; Bould, 2017a; Rowe, 2017; Wassenaar, 2018].
  • As many test results remain normal even with extreme weight loss and when the person is acutely unwell a low threshold for seeking advice on further assessment or the need for admission to hospital is required.

Basis for recommendation

The information on the differential diagnoses of eating disorders is based on the Royal College of Psychiatrists clinical guideline Medical emergencies in eating disorders: guidance on recognition and management [RCP, 2023], the BMJ Best Practice guidelines Anorexia nervosa [BMJ Best Practice, 2023a] and Bulimia nervosa [BMJ Best Practice, 2023b], the American Academy of Child and Adolescent Psychiatry (AACAP) Practice parameter for the assessment and treatment of children and adolescents with eating disorders [Lock, 2015], and expert opinion in review articles [Campbell, 2014; Bould, 2017b; Bould, 2017a; Treasure, 2020; Giel, 2022].

How should I manage a suspected eating disorder in primary care?

• Consider the need for emergency medical or psychiatric admission for anyone at risk of serious physical complications, suicide or serious self-harm.
• For all other people with a suspected eating disorder:
  • Refer immediately to an age-appropriate eating disorder service for specialist assessment and management – do not use a watchful waiting strategy for managing eating disorders.
    • Depending on locally agreed care pathways and service provision referral may be to a community mental health team (CMHT), child and adolescent services (CAMHS), or a specialist eating disorder unit.
    • Consider simultaneous paediatric referral for children and young people with eating disorders.
    • Urgency of referral depends on the specific clinical situation and on clinical judgement — if unsure seek advice from the nearest specialist eating disorders service, eating disorders or liaison psychiatry clinician, the local CAMHS service, or a paediatrician/physician (as appropriate).
  • While awaiting specialist assessment:
    • Arrange regular review (with frequency dependant on the clinical situation [for example, weekly in children]) to monitor levels of physical and mental health risk and consider the need for urgent admission, further investigations, or increasing the urgency of referral.
    • Consider the possibility of complications and monitor/manage appropriately, seeking specialist advice when indicated.
    • Ensure that people with co-morbidities (such as diabetes) or pregnant women have specialist input — increased monitoring and alterations to treatment may be required.
    • When prescribing medication for people with a suspected eating disorder, take into account the impact of malnutrition and compensatory behaviour on medication effectiveness (for example, the oral contraceptive pill) and the risk of side effects (in particular, cardiac side effects).

When should I admit a person with a suspected or confirmed eating disorder?

• Be aware that some medically unstable people with eating disorders can appear deceptively well – a low threshold for concern is essential. If there is uncertainty, seek specialist advice from an eating disorders or liaison psychiatry clinician, the local CAMHS service, or a paediatrician/physician (as appropriate).
• Clinicians are strongly encouraged to review the detailed information on parameters that indicate level of risk from the Royal College of Psychiatrists.
• Consider emergency admission for anyone at risk of serious physical or psychological complications such as:
  • Severely compromised physical health, including:
    • BMI or body weight below a safe range—the degree of dietary restriction and rate of weight loss are important; for example, more than 1kg per week indicates high risk.
    • Cardiovascular instability, for example, bradycardia of 40 beats or less per minute), tachycardia on standing, prolonged QT interval on ECG, or hypotension (including postural).
    • Hypothermia.
    • Reduced muscle power on the Sit up–Squat–Stand (SUSS) test.
    • Concurrent infection.
    • Overall ill health or rapid deterioration.
    • Abnormal blood tests such as electrolyte imbalance or hypoglycaemia.
  • Risk of refeeding syndrome:
    • Risk is increased by rapid weight loss, fasting for over five days, BMI less than 16kg/m2, compensatory behaviours (such as laxative misuse or vomiting), dehydration, use of diet pills or diuretics, water loading or excessive exercise.
  • Acute mental health risk (such as risk of suicide attempt or serious self-harm):
    • Consider psychiatric crisis care or psychiatric inpatient care – discuss with a specialist if unsure whether admission to medical/paediatric ward is more appropriate.
  • Lack of support at home:
    • Consider admission if the person may not be kept from significant harm at home or where the home environment impedes recovery.
• If unsure where to admit (for example acute psychiatric ward, specialist eating disorders unit or acute medical/paediatric ward) discuss with a specialist.
  • The most appropriate place to admit a person with a life-threatening eating disorder is not always obvious and depends on local services and practice.
  • Children and adolescents should be admitted to age-appropriate facilities.
• If a person's physical health is at serious risk due to their eating disorder and they can only be treated safely as an inpatient but they do not consent to admission:
  • Consider the need for compulsory admission and seek specialist advice.

Mental Health Act 1983 (amended 2007)

• The Mental Health Act allows compulsory admission and treatment of people who:
  • Have a mental disorder of a nature and degree that warrants treatment in hospital, and
  • Need to be admitted in the interests of their own health or safety, or for the protection of other people.
• Compulsory admission is arranged using the appropriate section of the Mental Health Act:
  • Section 2 allows compulsory admission for up to 28 days for assessment.
  • Section 3 allows compulsory admission for up to 6 months for treatment (in people with an established diagnosis).
    • Sections 2 and 3 require an application from an Approved Mental Health Professional (AMHP, formerly an Approved Social Worker) or, rarely, the person's nearest relative, and recommendations from two doctors, one of whom is section 12-approved (usually a psychiatrist) and one who has previous acquaintance with the person (usually the person's GP if at all practicable).
    • Ideally, the person should be examined jointly by the two doctors with the AMHP also present. Where this is not possible, each doctor may carry out a separate examination. If the AMHP is not present, at least one of the doctors must discuss the person with the AMHP.
  • Section 4 is used in exceptional cases to permit compulsory admission for up to 72 hours if there is an urgent necessity and an undesirable delay occurs while trying to arrange admission under section 2.
    
    • It requires an application from an AMHP (or, rarely, the person's nearest relative) and just one medical recommendation, preferably from a doctor with previous acquaintance (usually the person's GP).
  • Section 136 is used by police to take people from a public place to a place of safety to enable examination by a registered medical practitioner and interview by an AMHP. The person's GP, where known, may be informed.
• Details of guidance and forms for the most common sections of the Mental Health Act can be accessed from the Department of Health website, as well as details of amendments made in the Mental Health Act 2007.

How should I manage someone with a confirmed eating disorder in primary care?

• Ensure there is a clear agreement between primary and secondary or tertiary care about the responsibility for monitoring a person with an eating disorder.
  • Monitoring of general medical problems usually occurs in primary care.
  • Good coordination of care is essential when young people move from child to adult services if more than one service is involved in care or care is needed in different places at different times (for example, university students).
• For people who are being treated in secondary care — monitor the level of risk to the person's mental and physical health as treatment progresses.
  • Be aware that medically unstable people with eating disorders (such as anorexia nervosa and bulimia nervosa) can appear deceptively well.
  • Risk may increase, for example following weight change or at times of transition between services — consider the need for admission or increased specialist input.
  • Monitor growth and development closely in children and young people with anorexia nervosa who have not completed puberty — discuss with a specialist if unsure.
• If the person has chronic anorexia nervosa and is not receiving ongoing treatment in secondary care, review their physical and mental health at least annually in primary care.
  • A baseline assessment tool is available on the NICE website.
  • Review should include discussion of treatment options and:
    • Weight or BMI (using centile charts where appropriate).
    • Blood pressure.
    • Relevant blood tests.
    • Discussion of problems with daily function.
    • ECG for people with purging behaviours and/or significant weight changes.
    • Assessment of risk (both physical and mental health).
• If the person exhibits compensatory behaviours such as:
  • Vomiting — give advice on the importance of regular dental and medical review. They should:
    • Avoid brushing their teeth immediately after vomiting. This can brush acid onto the teeth, causing further damage.
    • Rinse with water or a non-acidic mouthwash after vomiting.
    • Reduce the acidity of the oral environment (for example, by avoiding acidic foods and drinks).
  • Misuse of laxatives or diuretics — advise them that:
    • Laxatives and diuretics do not reduce calorie absorption and do not help with weight loss — laxative or diuretic use should be gradually reduced and stopped.
  • Excessive exercise — advise them to stop.
• Put an alert in the person’s prescribing record to highlight the potential risk of adverse drug effects.
  • Adverse drug effects, such as prolonged QT interval and cardiac dysrhythmias, are more likely in malnourished people and those with electrolyte abnormalities — review all drugs prescribed to people with an eating disorder.
  • Offer ECG monitoring to people with an eating disorder who are taking medication that can compromise cardiac functioning, for example, drugs that may cause electrolyte imbalance, bradycardia, hypokalaemia, or a prolonged QT interval.
  • Be aware that paracetamol toxicity can be caused by a low body weight. For example, ingestion of 7.5 g of paracetamol over 24 hours in a person weighing 30 kg can lead to severe toxicity. For more information, consult Toxbase. 
• Manage complications (considering other causes) depending on their type and severity.
  • Some people will require inpatient or specialist outpatient care while others can be managed in primary care— seek advice if unsure.
  • For suspected developmental delay or faltering growth in children and young people with an eating disorder, seek specialist paediatric advice.
  • If low bone mineral density is suspected — discuss bone density scanning and treatment with the eating disorder team. Advise people with anorexia nervosa and osteoporosis/related bone disorders to avoid activities that are high-impact or significantly increase the chance of falls or fractures.
  • For information on identifying, assessing and managing obesity, see the CKS topic on Obesity.
• Manage comorbidities with input from specialists where appropriate, for example:
  • Diabetes — insulin may be misused in people with eating disorders. Close monitoring and collaboration between the eating disorder and diabetes teams is required — have a low threshold for checking blood glucose and ketones and seeking specialist advice.
  • Associated mental health problems and substance abuse – seek specialist advice.
• Be aware that women with an eating disorder:
  • Who are sexually active should be advised of the risk of unplanned pregnancy and the need for effective contraception even if they have amenorrhoea.
    • Long-acting reversible contraception (LARC) methods (such as implant and intra-uterine contraceptives) are most effective in this group.
    • Implants should only be fitted by experienced clinicians as some women with eating disorders may have little subcutaneous tissue.
    • Consideration of the UK Medical Eligibility Criteria for contraceptive use (UKMEC) is required – for more information, see the CKS topic on Contraception - assessment.
    • Anorexia nervosa is a significant risk factor for osteoporosis — use of progesterone-only injectables in anorexia requires careful, informed discussion and consideration by the woman.
  • Who are planning a pregnancy and are underweight:
    • Should be informed that the risk of adverse pregnancy outcomes is increased when underweight and advised to delay conception until in remission. Give advice on the importance of maintaining good mental health, adequate nutrition, a healthy body weight and stopping behaviours such as binge eating, vomiting, laxatives, and excessive exercise.
  • Who are pregnant need increased monitoring and support during pregnancy and postpartum.
    • Eating disorders increase possible health risks to mother and child and are associated with a high risk of mental health problems in the perinatal period – seek urgent specialist advice.
• For information on what treatments may be offered in secondary care:
  • See Specialist treatments for eating disorders.
• Ensure the person and their family/carers have access to information and support. Be aware that:
  • The family/carers of a person with an eating disorder may experience severe distress.
  • The need for support (including practical support and emergency plans if the person with the eating disorder is at high medical or psychiatric risk) should be assessed.
  • Some people with eating disorders may not want family/carers involved in their care, and in some cases, involvement may not be appropriate — Gillick competence should be respected in children or young people under 16 who do not want family/carers involved.
• Patient information is available from:
  • Beat Eating Disorders
    • "Types of eating disorder."
    • "Eating disorders: a guide for friends and family."
  • NHS
    • "Eating disorders."
  • The Royal College of Psychiatrists
    • "Anorexia and bulimia."

What specialist psychological treatments are recommended for eating disorders?

Anorexia nervosa

• For adults with anorexia nervosa, one of the following may be considered:
  • Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) — typically up to 40 sessions over 40 weeks, with twice-weekly sessions in the first 2 or 3 weeks.
  • Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) — typically 20 sessions, with weekly sessions for the first 10 weeks and a flexible schedule after this. Up to 10 extra sessions may be added for people with complex problems.
  • Specialist supportive clinical management (SSCM) — typically 20 or more weekly sessions (depending on severity).
  • If individual CBT-ED, MANTRA, or SSCM is unacceptable, contraindicated or ineffective eating-disorder-focused focal psychodynamic therapy (FPT) may be considered — typically 40 sessions over 40 weeks.
• For anorexia nervosa in children and young people:
  • 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 will be considered — typically 18–20 sessions over 1 year.
  • If FT-AN is unacceptable, contraindicated or ineffective for children or young people with anorexia nervosa, individual CBT-ED or adolescent-focused psychotherapy for anorexia nervosa (AFP-AN) will be considered.
    • Individual CBT-ED for children and young people with anorexia nervosa typically consists of up to 40 sessions over 40 weeks, with individual and family sessions.
    • AFP-AN for children and young people typically consists of 32–40 individual sessions over 12–18 months, with 8–12 additional family sessions.

Bulimia nervosa

• Psychological treatments in adults:
  • Bulimia-nervosa-focused guided self-help programmes may be considered, for example, 4 to 9 sessions lasting 20 minutes each over 16 weeks, running weekly initially.
  • If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, individual eating-disorder focused cognitive behavioural therapy (CBT-ED) may be considered. This typically consists of up to 20 sessions over 20 weeks.
• Psychological treatments in children and young people:
  • Bulimia-nervosa-focused family therapy (FT-BN) may be considered in children and young people with bulimia nervosa — typically 18–20 sessions over 6 months.
  • If FT-BN is unacceptable, contraindicated or ineffective, individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) for children and young people with bulimia nervosa may be considered — typically 18 sessions over 6 months, with more frequent sessions early in treatment and up to 4 additional sessions with parents or carers.

Binge eating disorder

• Psychological interventions that may be offered to adults, children and young people with binge eating disorder include:
  • Evidence-based self-help programmes with brief supportive sessions (for example, 9 sessions over 16 weeks).
  • If guided self-help is unacceptable, contraindicated or ineffective after 4 weeks, group eating-disorder-focused cognitive behavioural therapy (CBT-ED) may be offered — typically 16 weekly 90 minute group sessions over 4 months.
  • If group CBT-ED is refused or unavailable, individual CBT-ED may be considered — typically 16–20 sessions.
• Psychological treatments aimed at binge eating have a limited effect on body weight, and weight loss is not in itself a goal of therapy.

Other specified feeding and eating disorders (OSFED)

• For people with OSFED, treatments for the eating disorder it most closely resembles will be considered.