People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about 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.
Health and care professionals should follow our general guidelines for people delivering care:
In this guideline, 'family members' includes the siblings, children and partners of people with an eating disorder.
Be aware that people with an eating disorder may:
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.
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.
When communicating with people with an eating disorder and their family members or carers (as appropriate), be aware that family members or carers may feel guilty and responsible for the eating disorder.
Assess the impact of the home, education, work and wider social environment (including the internet and social media) on each person's eating disorder. Address their emotional, education, employment and social needs throughout treatment.
If appropriate, encourage family members, carers, teachers and peers of children and young people to support them during their treatment.
Professionals who assess and treat people with an eating disorder should be competent to do this for the age groups they care for.
Health, social care and education professionals working with people with an eating disorder should be trained and skilled in working with multidisciplinary teams.
Base the content, structure and duration of psychological treatments on relevant manuals that focus on eating disorders.
Professionals who provide treatments for eating disorders should:
Take particular care to ensure services are well coordinated when:
People with eating disorders should be assessed and receive treatment at the earliest opportunity.
Early treatment is particularly important for those with or at risk of severe emaciation and such patients should be prioritised for treatment.
Be aware that eating disorders present in a range of settings, including:
Although eating disorders can develop at any age, be aware that the risk is highest for young men and women between 13 and 17 years of age.
Do not use screening tools (for example, SCOFF) as the sole method to determine whether or not people have an eating disorder.
When assessing for an eating disorder or deciding whether to refer people for assessment, take into account any of the following that apply:
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.
Do not use single measures such as BMI or duration of illness to determine whether to offer treatment for an eating disorder.
Professionals in primary and secondary mental health or acute settings should assess the following in people with a suspected eating disorder:
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.
Provide support and care for all people with anorexia nervosa in contact with specialist services, whether or not they are having a specific intervention. Support should:
When treating anorexia nervosa, be aware that:
When weighing people with anorexia nervosa, consider sharing the results with them and (if appropriate) their family members or carers.
For adults with anorexia nervosa, consider one of:
Individual CBT‑ED programmes for adults with anorexia nervosa should:
MANTRA for adults with anorexia nervosa should:
SSCM for adults with anorexia nervosa should:
If individual CBT‑ED, MANTRA or SSCM is unacceptable, contraindicated or ineffective for adults with anorexia nervosa, consider:
FPT for adults with anorexia nervosa should:
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:
FT‑AN for children and young people with anorexia nervosa should:
Consider support for family members who are not involved in the family therapy, to help them cope with distress caused by the condition.
Consider giving children and young people with anorexia nervosa additional appointments separate from their family members or carers.
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.
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).
Individual CBT‑ED for children and young people with anorexia nervosa should:
AFP‑AN for children and young people should:
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:
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 the recommendation on providing support and care in the section on treating anorexia nervosa.
Only offer dietary counselling as part of a multidisciplinary approach.
Encourage people with anorexia nervosa to take an age-appropriate oral multi-vitamin and multi-mineral supplement until their diet includes enough to meet their dietary reference values.
Include family members or carers (as appropriate) in any dietary education or meal planning for children and young people with anorexia nervosa who are having therapy on their own.
Offer supplementary dietary advice to children and young people with anorexia nervosa and their family or carers (as appropriate) to help them meet their dietary needs for growth and development (particularly during puberty).
Do not offer medication as the sole treatment for anorexia nervosa.
Explain to people with binge eating disorder that psychological treatments aimed at treating binge eating have a limited effect on body weight and that weight loss is not a therapy target in itself. Refer to the NICE guideline on obesity identification, assessment and management for guidance on weight loss and bariatric surgery.
Offer a binge-eating-disorder-focused guided self-help programme to adults with binge eating disorder.
Binge-eating-disorder-focused guided self-help programmes for adults should:
If guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks, offer group eating-disorder-focused cognitive behavioural therapy (CBT‑ED).
Group CBT‑ED programmes for adults with binge eating disorder should:
If group CBT‑ED is not available or the person declines it, consider individual CBT‑ED for adults with binge eating disorder.
Individual CBT‑ED for adults with binge eating disorder should:
For children and young people with binge eating disorder, offer the same treatments recommended for adults with binge eating disorder.
Do not offer medication as the sole treatment for binge eating disorder.
Explain to all people with bulimia nervosa that psychological treatments have a limited effect on body weight.
Consider bulimia-nervosa-focused guided self-help for adults with bulimia nervosa.
Bulimia-nervosa-focused guided self-help programmes for adults with bulimia nervosa should:
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).
Individual CBT‑ED for adults with bulimia nervosa should:
Offer bulimia-nervosa-focused family therapy (FT‑BN) to children and young people with bulimia nervosa.
FT-BN for children and young people with bulimia nervosa should:
Consider support for family members who are not involved in the family therapy, to help them to cope with distress caused by the condition.
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.
Individual CBT‑ED for children and young people with bulimia nervosa should:
Do not offer medication as the sole treatment for bulimia nervosa.
For people with OSFED, consider using the treatments for the eating disorder it most closely resembles.
Do not offer a physical therapy (such as transcranial magnetic stimulation, acupuncture, weight training, yoga or warming therapy) as part of the treatment for eating disorders.
Eating disorder specialists and other healthcare teams should collaborate to support effective treatment of physical or mental health comorbidities in people with an eating disorder.
When collaborating, teams should use outcome measures for both the eating disorder and the physical and mental health comorbidities, to monitor the effectiveness of treatments for each condition and the potential impact they have on each other.
For people with an eating disorder and diabetes, the eating disorder and diabetes teams should:
When treating eating disorders in people with diabetes:
Address insulin misuse as part of any psychological treatment for eating disorders in people with diabetes.
Offer people with an eating disorder who are misusing insulin the following treatment plan:
For people with suspected hypoglycaemia, test blood glucose:
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:
For people with bulimia nervosa and diabetes, consider monitoring of:
When diabetes control is challenging:
When 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:
Refer to the NICE guidelines on specific mental health problems for further guidance on treatment.
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.
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).
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.
Offer electrocardiogram (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).
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.
If substance misuse or medication is interfering with treatment, consider a multidisciplinary approach with substance misuse services.
Seek specialist paediatric or endocrinology advice for delayed physical development or faltering growth in children and young people with an eating disorder.
Provide advice and education to women with an eating disorder who plan to conceive, to increase the likelihood of conception and to reduce the risk of miscarriage. This may include information on the importance of:
Nominate a dedicated professional (such as a GP or midwife) to monitor and support pregnant women with an eating disorder during pregnancy and in the post-natal period, because of:
For women who are pregnant or in the perinatal period and have an eating disorder:
For guidance on providing advice to pregnant women about healthy eating and feeding their baby, see the NICE guideline on maternal and child nutrition.
Consider more intensive prenatal care for pregnant women with current or remitted anorexia nervosa, to ensure adequate prenatal nutrition and fetal development.
Assess fluid and electrolyte balance in people with an eating disorder who are believed to be engaging in compensatory behaviours, such as vomiting, taking laxatives or diuretics, or water loading.
Assess whether ECG monitoring is needed in people with an eating disorder, based on the following risk factors:
Provide acute medical care (including emergency admission) for people with an eating disorder who have severe electrolyte imbalance, severe malnutrition, severe dehydration or signs of incipient organ failure.
For people with an eating disorder who need supplements to restore electrolyte balance, offer these orally unless the person has problems with gastrointestinal absorption or the electrolyte disturbance is severe.
For people with an eating disorder and continued unexplained electrolyte imbalance, assess whether it could be caused by another condition.
Encourage people with an eating disorder who are vomiting to:
Advise people with an eating disorder who are misusing laxatives or diuretics:
Advise people with an eating disorder who are exercising excessively to stop doing so.
For guidance on identifying, assessing and managing overweight and obesity, see the NICE guideline on obesity.
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:
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).
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.
Before deciding whether to measure bone density, discuss with the person and their family members or carers why it could be useful.
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.
Consider a bone mineral density scan:
Use measures of bone density that correct for bone size (such as bone mineral apparent density [BMAD]) in children and young people with faltering growth.
Consider repeat bone mineral density scans in people with ongoing persistent underweight, especially when using or deciding whether to use hormonal treatment.
Do not repeat bone mineral density scans for people with anorexia nervosa more frequently than once per year, unless they develop bone pain or recurrent fractures.
Do not routinely offer oral or transdermal oestrogen therapy to treat low bone mineral density in children or young people with anorexia nervosa.
Seek specialist paediatric or endocrinological advice before starting any hormonal treatment for low bone mineral density. Coordinate any treatment with the eating disorders team.
Consider transdermal 17‑β‑estradiol (with cyclic progesterone) for young women (13 to 17 years) with anorexia nervosa who have long-term low body weight and low bone mineral density with a bone age over 15.
Consider incremental physiological doses of oestrogen in young women (13 to 17 years) with anorexia nervosa who have delayed puberty, long-term low body weight and low bone mineral density with a bone age under 15.
Consider bisphosphonates for women (18 years and over) with anorexia nervosa who have long-term low body weight and low bone mineral density. Discuss the benefits and risks (including risk of teratogenic effects) with women before starting treatment.
Advise people with anorexia nervosa and osteoporosis or related bone disorders to avoid high-impact physical activities and activities that significantly increase the chance of falls or fractures.
Admit people with an eating disorder whose physical health is severely compromised to a medical inpatient or day patient service for medical stabilisation and to initiate refeeding, if these cannot be done in an outpatient setting.
Do not use an absolute weight or BMI threshold when deciding whether to admit people with an eating disorder to day patient or inpatient care.
When deciding whether day patient or inpatient care is most appropriate, take the following into account:
When reviewing the need for inpatient care as part of an integrated treatment programme for a person with an eating disorder:
For people with an eating disorder and acute mental health risk (such as significant suicide risk), consider psychiatric crisis care or psychiatric inpatient care.
Children, young people and adults with an eating disorder who are admitted to day patient or inpatient care should be cared for in age-appropriate facilities (for example, paediatric wards or adolescent mental health services). These should be near to their home, and have the capacity to provide appropriate educational activities during extended admissions.
When a person is admitted to inpatient care for medical stabilisation, specialist eating disorder or liaison psychiatry services should:
Inpatient or day patient services should collaborate with other teams (including the community team) and the person's family members or carers (as appropriate), to help with treatment and transition.
Ensure that staff of day patient, inpatient, or acute services who treat eating disorders are trained to recognise the symptoms of refeeding syndrome and how to manage it.
Use a standard operating procedure for refeeding that emphasises the need to avoid under-nutrition and refeeding syndrome. Refer to existing national guidance, such as the Royal College of Psychiatrists' MARSIPAN resource and the junior MARSIPAN report.
Develop a care plan for each person with an eating disorder who is admitted to inpatient care. The care plan should:
Whether or not the person is medically stable, within 1 month of admission review with them, their parents or carers (as appropriate) and the referring team, whether inpatient care should be continued or stepped down to a less intensive setting.
As part of the review:
If a person's physical health is at serious risk due to their eating disorder, they do not consent to treatment, and they can only be treated safely in an inpatient setting, follow the legal framework for compulsory treatment in the Mental Health Act 1983.
If a child or young person lacks capacity, their physical health is at serious risk and they do not consent to treatment, ask their parents or carers to consent on their behalf and if necessary, use an appropriate legal framework for compulsory treatment (such as the Mental Health Act 1983/2007 or the Children Act 1989).
Feeding people without their consent should only be done by multidisciplinary teams who are competent to do so.