Eating disorders: NICE Treatment Guidelines

Improving access to services

1.1.1 Be aware that people with an eating disorder may:

1.1.2 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:

1.1.3 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

1.1.4 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.

1.1.5 Offer people with an eating disorder and their family members or carers (as appropriate) education and information on:

1.1.6 When communicating with people with an eating disorder and their family members or carers (as appropriate):

1.1.7 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

1.1.8 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.

1.1.9 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

1.1.10 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:

1.1.11 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.

Consent and confidentiality

1.1.12 When working with people with an eating disorder and their family members or carers (as appropriate):

1.1.13 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

1.1.14 Professionals who assess and treat people with an eating disorder should be competent to do this for the age groups they care for.

1.1.15Health, social care and education professionals working with people with an eating disorder should be trained and skilled in:

1.1.16 Base the content, structure and duration of psychological treatments on relevant manuals that focus on eating disorders.

1.1.17 Professionals who provide treatments for eating disorders should:

Coordination of care for people with an eating disorder

1.1.18 Take particular care to ensure services are well coordinated when:

Initial assessments in primary and secondary mental health care

1.2.3 Be aware that eating disorders present in a range of settings, including:

1.2.4 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.

1.2.5 Do not use screening tools (for example, SCOFF) as the sole method to determine whether or not people have an eating disorder.

1.2.6 When assessing for an eating disorder or deciding whether to refer people for assessment, take into account any of the following that apply:

1.2.7 Be aware that, in addition to the points in recommendation 1.2.6, 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.

1.2.8 Do not use single measures such as BMI or duration of illness to determine whether to offer treatment for an eating disorder.

1.2.9 Professionals in primary and secondary mental health or acute settings should assess the following in people with a suspected eating disorder:

Referral

1.2.10 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.

Psychological treatment for anorexia nervosa in adults

1.3.4 For adults with anorexia nervosa, consider one of:

1.3.5 Individual CBT-ED programmes for adults with anorexia nervosa should:

1.3.6 MANTRA for adults with anorexia nervosa should:

1.3.7 SSCM for adults with anorexia nervosa should:

1.3.8 If individual CBT-ED, MANTRA, or SSCM is unacceptable, contraindicated or ineffective for adults with anorexia nervosa, consider:

1.3.9 FPT for adults with anorexia nervosa should:

Psychological treatment for anorexia nervosa in children and young people

1.3.10 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:

1.3.11 FT-AN for children and young people with anorexia nervosa should:

1.3.12 Consider support for family members who are not involved in the family therapy, to help them cope with distress caused by the condition.

1.3.13 Consider giving children and young people with anorexia nervosa additional appointments separate from their family members or carers.

1.3.14 Assess whether family members or carers (as appropriate) need support if the child or young person with anorexia nervosa is having therapy on their own.

1.3.15 If FT-AN is unacceptable, contraindicated or ineffective for children or young people with anorexia nervosa, consider individual CBT-ED or adolescent-focused psychotherapy for anorexia nervosa (AFP-AN).

1.3.16 Individual CBT-ED for children and young people with anorexia nervosa should:

1.3.17AFP-AN for children and young people should:

People with anorexia nervosa who are not having treatment

1.3.18 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:

1.3.19 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 as covered in recommendation 1.3.1.

Dietary advice for people with anorexia nervosa

1.3.20 Only offer dietary counselling as part of a multidisciplinary approach.

1.3.21 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.

1.3.22 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.

1.3.23 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

1.3.24Do not offer medication as the sole treatment for anorexia nervosa.

Psychological treatment for binge eating disorder in adults

1.4.1 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.

1.4.2Offer a binge-eating-disorder-focused guided self-help programme to adults with binge eating disorder.

1.4.3Binge-eating-disorder-focused guided self-help programmes for adults should:

1.4.4 If guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks, offer group eating-disorder-focused cognitive behavioural therapy (CBT-ED).

1.4.5 Group CBT-ED programmes for adults with binge eating disorder should:

1.4.6 If group CBT-ED is not available or the person declines it, consider individual CBT-ED for adults with binge eating disorder.

1.4.7 Individual CBT-ED for adults with binge eating disorder should:

Psychological treatment for binge eating disorder in children and young people

1.4.8 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

1.4.9 Do not offer medication as the sole treatment for binge eating disorder.

Psychological treatment for bulimia nervosa in adults

1.5.2 Consider bulimia-nervosa-focused guided self-help for adults with bulimia nervosa.

1.5.3 Bulimia-nervosa-focused guided self-help programmes for adults with bulimia nervosa should:

1.5.4 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).

1.5.5 Individual CBT-ED for adults with bulimia nervosa should:

Psychological treatment for bulimia nervosa in children and young people

1.5.6 Offer bulimia-nervosa-focused family therapy (FT-BN) to children and young people with bulimia nervosa.

1.5.7 FT-BN for children and young people with bulimia nervosa should:

1.5.8 Consider support for family members who are not involved in the family therapy, to help them to cope with distress caused by the condition.

1.5.9 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.

1.5.10 Individual CBT-ED for children and young people with bulimia nervosa should:

Medication for bulimia nervosa

1.5.11 Do not offer medication as the sole treatment for bulimia nervosa.

Diabetes

1.8.3 For people with an eating disorder and diabetes, the eating disorder and diabetes teams should:

1.8.4 When treating eating disorders in people with diabetes:

1.8.5 Address insulin misuse as part of any psychological treatment for eating disorders in people with diabetes.

1.8.6 Offer people with an eating disorder who are misusing insulin the following treatment plan:

1.8.7 For people with suspected hypoglycaemia, test blood glucose:

1.8.8 For people with suspected hyperglycaemia or hypoglycaemia, and people with normal blood glucose levels who are misusing insulin, healthcare professionals should test for blood ketones:

1.8.9 For people with bulimia nervosa and diabetes, consider monitoring of:

1.8.10 When diabetes control is challenging:

1.8.11 For more guidance on managing diabetes, including on fluid replacement in children and young people with diabetic ketoacidosis, refer to the NICE guidelines on type 1 and type 2 diabetes in children and young people, type 1 diabetes in adults, and type 2 diabetes in adults.

Comorbid mental health problems

1.8.12When deciding which order to treat an eating disorder and a comorbid mental health condition (in parallel, as part of the same treatment plan or one after the other), take the following into account:

1.8.13 Refer to the NICE guidelines on specific mental health problems for further guidance on treatment.

Medication risk management

1.8.14 When prescribing medication for people with an eating disorder and comorbid mental or physical health conditions, take into account the impact malnutrition and compensatory behaviours can have on medication effectiveness and the risk of side effects.

1.8.15 When prescribing for people with an eating disorder and a comorbidity, assess how the eating disorder will affect medication adherence (for example, for medication that can affect body weight).

1.8.16 When prescribing for people with an eating disorder, take into account the risks of medication that can compromise physical health due to pre-existing medical complications.

1.8.17 Offer ECG monitoring for people with an eating disorder who are taking medication that could compromise cardiac functioning (including medication that could cause electrolyte imbalance, bradycardia below 40 beats per minute, hypokalaemia, or a prolonged QT interval).

Substance or medication misuse

1.8.18 For people with an eating disorder who are misusing substances, or over the counter or prescribed medication, provide treatment for the eating disorder unless the substance misuse is interfering with this treatment.

1.8.19 If substance misuse or medication is interfering with treatment, consider a multidisciplinary approach with substance misuse services.

Growth and development

1.8.20 Seek specialist paediatric or endocrinology advice for delayed physical development or faltering growth in children and young people with an eating disorder.

Physical health assessment and monitoring for all eating disorders

1.10.1Assess 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.

1.10.2Assess whether ECG monitoring is needed in people with an eating disorder, based on the following risk factors:

Management for all eating disorders

1.10.3 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.

1.10.4 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.

1.10.5 For people with an eating disorder and continued unexplained electrolyte imbalance, assess whether it could be caused by another condition.

1.10.6 Encourage people with an eating disorder who are vomiting to:

1.10.7 Advise people with an eating disorder who are misusing laxatives or diuretics:

1.10.8 Advise people with an eating disorder who are exercising excessively to stop doing so.

1.10.9 For guidance on identifying, assessing and managing overweight and obesity, see the NICE guideline on obesity.

Assessment and monitoring of physical health in anorexia nervosa

1.10.10 GPs should offer a physical and mental health review at least annually to people with anorexia nervosa who are not receiving ongoing treatment for their eating disorder. The review should include:

1.10.11 Monitor growth and development in children and young people with anorexia nervosa who have not completed puberty (for example, not reached menarche or final height).

Low bone mineral density in people with anorexia nervosa

1.10.12 Bone mineral density results should be interpreted and explained to people with anorexia nervosa by a professional with the knowledge and competencies to do this.

1.10.13 Before deciding whether to measure bone density, discuss with the person and their family members or carers why it could be useful.

1.10.14 Explain to people with anorexia nervosa that the main way of preventing and treating low bone mineral density is reaching and maintaining a healthy body weight or BMI for their age.

1.10.15 Consider a bone mineral density scan: