Clinical Practice Guideline for Eating Disorders.

  1. Introduction
  2. Scope and Objectives
  3. Methodology
  4. Definition and Classification of Eating Disorders
  5. Prevention of Eating Disorders
  6. Detection of Eating Disorders
  7. Diagnosis of Eating Disorders
  8. Interventions at the Different Levels of Care in the Management of Eating Disorders
  9. Treatment of Eating Disorders
  10. Assessment of Eating Disorders
  11. Prognosis of Eating Disorders
  12. Legal Aspects Concerning Individuals with Eating Disorders in Spain
  13. Detection, Diagnosis and Treatment Strategies for Eating Disorders
  14. Dissemination and Implementation
  15. Recommendations for Future Research
  16. Bibliography

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CPG Recommendations

In this section recommendations are presented following the guide’s structure. Chapters 1, 2 and 3 of the CPG include an introduction, scope and objectives, and methodology, respectively. Chapter 4 covers eating disorders and Chapter 11 addresses prognosis. All these chapters are descriptive and thus no recommendations have been formulated for clinical practice. Chapter 5, which covers prevention, is the first to provide recommendations. This section’s abbreviations can be found at the end.

Grade of recommendation: A, B, C o D, depending on whether evidence quality is very high, high, moderate or low.

√ Good clinical practice: recommendation based on the working group’s consensuses. (Please refer to Annex 1).

5. Primary Prevention of Eating Disorders (Question 5.1.)
5.1. Sample, format and design characteristics of eating disorder prevention programmes that have shown greater efficacy should be considered the model for future programmes.
5.2. In the design of universal eating disorder prevention strategies, it must be taken into account that expected behavioural changes in children and adolescents without these types of problems might differ from those of high-risk populations.
5.3. Messages on measures that indirectly protect individuals from eating disorders should be passed on to the family and adolescent: following a healthy diet and eating at least one meal at home with the family, facilitating communication and improving self-esteem, avoiding family conversations from compulsively turning to eating and image and avoiding jokes and disapproval regarding the body, weight or eating manner of children and adolescents.

6. Detection of Eating Disorders (Question 6.1.)
D 6.1. Target groups for screening should include young people with low body mass index (BMI) compared to age-based reference values, patients consulting with weight concerns without being overweight or people who are overweight, women with menstrual disorders or amenorrhoea, patients with gastrointestinal symptoms, patients with signs of starvation or repeated vomiting, and children with delayed or stunted growth, children, adolescents and young adults who perform sports that entail a risk of developing an eating disorder (athletics, dance, synchronised swimming, etc.).
D 6.2. In anorexia nervosa (AN), weight and BMI are not considered the only indicators of physical risk.
D 6.3. Early detection and intervention in individuals presenting weight loss are important to prevent severe emaciation.
D 6.4. In the case of suspected AN, attention should be paid to overall clinical assessment (repeated over time), including rate of weight loss, growth curve in children, objective physical signs and appropriate laboratory tests.
6.5. It is recommended to use questionnaires adapted and validated in the Spanish population for the detection of eating disorder cases (screening).

The use of the following tools is recommended:
Eating disorders in general: SCOFF (for individuals aged 11 years and over)
AN: EAT-40, EAT-26 and ChEAT (the latter for individuals aged between 8 and 12 years)
Bulimia nervosa (BN): BULIT, BULIT-R and BITE (the three for individuals aged 12-13 years and over)
6.6. Adequate training of PC physicians is considered essential for early detection and diagnosis of eating disorders to ensure prompt treatment or referral, when deemed necessary.
6.7. Due to the low frequency of visits during childhood and adolescence, it is recommended to take advantage of any opportunity to provide comprehensive management and to detect eating disorder risk habits and cases. Eating disorder risk behaviour, such as repeated vomiting, can be detected at dental check-ups.
6.8. When interviewing a patient with a suspected eating disorder, especially if the suspected disorder is AN, it is important to take into account the patient’s lack of awareness of the disease, the tendency to deny the disorder and the scarce motivation to change, these reactions being more pronounced in earlier stages of the disease.
6.9. It is recommended that different groups of professionals (teachers, school psychologists, chemists, nutritionists and dieticians, social workers, etc.) who may be in contact with at-risk population have adequate training and be able to act as eating disorder detection agents.

7. Diagnosis of Eating Disorders (Questions 7.1.-7.3.)
7.1. It is recommended to follow the WHO’s (ICD-10) and the APA’s (DSM-IV o DSM-IV-TR) diagnostic criteria.
D 7.2.1. Health care professionals should acknowledge that many patients with eating disorders are ambivalent regarding treatment due to the demands and challenges it entails.
D 7.2.2. Patients and, when deemed necessary, carers should be provided with information and education regarding the nature, course and treatment of eating disorders.
D 7.2.3. Families and carers may be informed of existing eating disorder associations and support groups.
7.2.4. It is recommended that the diagnosis of eating disorders include anamnesis, physical and psychopathological examinations and complementary explorations.
7.2.5. Diagnostic confirmation and therapeutic implications should be in the hands of psychiatrists and clinical psychologists.

8. Interventions at the Different Levels of Care (Questions 8.1.-8.4.)
D 8.1. Individuals with eating disorders should be treated in the appropriate care level based on clinical criteria: outpatient care, day care (day hospital) and inpatient care (general or psychiatric hospital).
D 8.2. Health care professionals without specialist experience in eating disorders or who are faced with uncertain situations should seek the advice of a trained specialist when emergency inpatient care is deemed the most appropriate option for a patient with an eating disorder.
D 8.3. The majority of patients with BN can be treated on an outpatient basis. Inpatient care is indicated when there is risk of suicide, self-inflicted injuries and serious physical complications.
D 8.4. Health care professionals should assess patients with eating disorders and osteoporosis and advise them to refrain from performing physical activities that may significantly increase the risk of fracture.
D 8.5. The paediatrician and the family physician must be in charge of the management of eating disorders in children and adolescents. Growth and development must be closely monitored.
D 8.6. Primary care centres should offer monitoring and management of physical complications to patients with chronic AN and repeated therapeutic failures who do not wish to be treated by mental health services.
D 8.7. Family members, especially siblings, should be included in the individualized treatment plan (ITP) of children and adolescents with eating disorders. The most common interventions involve sharing of information, advice on behavioural management of eating disorders and improving communication skills. The patient’s motivation to change should be promoted by means of family intervention.
D 8.8. Where inpatient care is required, it should be carried out within a reasonable distance to the patient’s home to enable the involvement of relatives and carers in treatment, to enable the patient to maintain social and occupational links and to prevent difficulties between care levels. This is particularly important in the treatment of children and adolescents
D 8.9. Patients with AN whose disorder has not improved with outpatient treatment must be referred to day patient treatment or inpatient treatment. For those who present a high risk of suicide or serious self-inflicted injuries, inpatient management is indicated.
D 8.10. Inpatient treatment should be considered for patients with AN whose disorder is associated with high or moderate risk due to common disease or physical complications of AN.
D 8.11. Patients with AN who require inpatient treatment should be admitted to a centre that ensures adequate re-nutrition, avoiding the re-feeding syndrome, with close physical monitoring (especially in the first few days), along with the appropriate psychological intervention.
D 8.12. The family physician and paediatrician should take charge of the assessment and initial intervention of patients with eating disorders who attend primary care.
D 8.13. When management is shared between primary and specialised care, there should be close collaboration between health care professionals, patients and relatives and carers.
8.14. Patients with confirmed diagnosis or clear suspicion of an eating disorder will be referred to different health care resources based on clinical and age criteria.
8.15. Referral to adult or children mental health centres (CSMA/CSMIJ) by the family physician or paediatrician should consist of integrated care with shared responsibilities.
8.16. Cases referred to adult or children mental health centres (CSMA/CSMIJ) still require different levels to work together and short- and mid-term monitoring of patients, to avoid complications, recurrences and the onset of emotional disorders, and to detect changes in the patient’s environment that could influence the disease.
8.17. The need to prescribe oestrogen treatment to prevent osteoporosis in girls and adolescents with AN should be carefully assessed, given that this medication can hide the presence of amenorrhoea.
8.18. In childhood, specific eating disorder treatment programmes designed for these ages will be required.
9. Treatment of Eating Disorders (Questions 9.1.-9.20.)
Medical Measures (Re-nutrition and Nutritional Counselling)
Re-nutrition (Question 9.1.)
Anorexia nervosa
D A physical exploration and in some cases oral multivitamin and/or mineral supplements are recommended, both in outpatient and inpatient care, for patients with AN who are in the stage of body weight restoration.
D Total parenteral nutrition should not be used in patients with AN unless the patient refuses nasogastric feeding and/or when there is gastrointestinal dysfunction. Enteral or parenteral re-nutrition must be applied using strict medical criteria and its duration will depend on when the patient is able to resume oral feeding.
General Recommendations on Medical Measures (GM) for Eating Disorders (Questions 9.1.-9.2.)
Eating Disorders
9.GM.01. Nutritional support for patients with eating disorders will be selected based on the patient’s degree of malnutrition and collaboration, and always with the psychiatrist’s approval.
9.GM.02. Before initiating artificial nutrition the patient’s degree of collaboration must be assessed and an attempt must always be made to convince him/her of the benefits of natural feeding.
9.GM.03. In day hospitals, nutritional support for low-weight patients, where an oral diet is insufficient, can be supplemented with artificial nutrition (oral enteral nutrition). To ensure its intake, it must be administered during the day hospital’s hours, providing supplementary energy ranging from 300 to 1,000 kcal/day.
9.GM.04. Oral nutritional support in eating disorder inpatients is deemed adequate (favourable progress) when a ponderal gain greater than 0.5 kg per week is produced, with up to 1 kg increments being the usual during that period. Sometimes, when the patient with moderate malnutrition resists resuming normal feeding, the diet can be reduced by 500-700 kcal and be supplemented by complementary oral enteral nutrition in the same amount, which must be administered after meals and not instead of meals.
9.GM.05. In the case of severe malnutrition, extreme starvation, poor progress or lack of cooperation of the patient in terms of eating, artificial nutrition treatment is indicated. If possible, an oral diet with or without oral enteral nutrition is always the first step, followed by a 3 to 6 day period to assess the degree of collaboration and medical-nutritional evolution.
9.GM.06. Regarding estimated energetic requirements, it is recommended that caloric needs at the beginning always be below the usual, that real weight, as opposed to ideal weight, is used to make the estimation and that in cases of severe malnutrition energetic requirements be 25 to 30 kcal/kg real weight or total kcal not higher than 1,000/day.
Anorexia nervosa
D 9.GM.1. In feeding guidelines for children and adolescents with anorexia Nervosa, carers should be included in any dietary information, education and meal planning.
D 9.GM.2. Feeding against the will of the patient should be used as a last resort in the management of AN.
D 9.GM.3. Feeding against the will of the patient is an intervention that must be performed by experts in the management of eating disorders and related clinical complications.
D 9.GM.4. Legal requirements must be taken into account and complied with when deciding whether to feed a patient against his/her will.
D 9.GM.5. Health care professionals must be careful with the healthy weight restoration process in children and adolescents with AN, administering the nutrients and energy required by providing an adequate diet in order to promote normal growth and development.
Bulimia nervosa
D 9.GM.6. Patients with BN who frequently vomit and abuse laxatives can develop abnormalities in electrolyte balance.
D 9.GM.7. When electrolyte imbalance is detected, in most cases elimination of the behaviour that caused it is sufficient to correct the problem. In a small number of cases, oral administration of electrolytes whose plasmatic levels are insufficient is necessary to restore normal levels, except in cases involving gastrointestinal absorption.
D 9.GM.8. In the case of laxative misuse, patients with BN must be advised on how to decrease and stop abuse. This process must be carried out gradually. Patients must also be informed that the use of laxatives does not decrease nutrient absorption.
D 9.GM.9. Patients who vomit habitually must have regular dental check-ups and be provided with dental hygiene advice.
Psychological Therapies for Eating Disorders
Cognitive-Behavioural therapy (Question 9.3.)
Bulimia nervosa
A CBT-BN is a specifically adapted form of CBT and it is recommended that 16 to 20 sessions are performed over 4 or 5 months of treatment.
B Patients with BN who do not respond to or refuse to receive CBT treatment may be offered alternative psychological treatment.
D Adolescents with BN can be treated with CBT adapted to their age, level of development, and, if appropriate, the family’s intervention can be incorporated.
Binge-Eating Disorder
A A specifically adapted form of CBT can be offered to adults with binge-eating disorder (BED).
Self-Help (guided or not) (Question 9.4.)
Bulimia nervosa
B A possible first step in BN treatment is initiating a SH programme (guided or not).
B SH (guided or not) is sufficient only in a small number of patients with BN.
Interpersonal Therapy (Question 9.5.)
Bulimia nervosa
B IPT should be considered an alternative to CBT although patients should be informed that it requires 8 to 12 months to achieve results similar to those obtained with CBT.
Binge-Eating Disorder
B IPT-BED can be offered to patients with persistent BED.
Family Therapy (systemic or not) (Question 9.6)
Anorexia nervosa
B FT is indicated in children and adolescents with AN.
D Family members of children with AN and siblings and family members of adolescents with AN can be included in treatment, taking part in improving communication, supporting behavioural treatment and sharing therapeutic information.
D Children and adolescents with AN can be offered individual appointments with health care professionals, separate from those in which the family is involved.
D The effects of AN on siblings and other family members justifies their involvement in treatment.
General Recommendations for Psychological Therapy (GP) in Eating Disorders (GP) (Questions 9.3.-9.8.)
Anorexia nervosa
D 9.GP.1. The psychological therapies to be assessed for eating disorders are: CBT, SFT, IPT, PDT and BT.
D 9.GP.2. In the case of patients who require special care, the selection of the psychological treatment model that will be offered is even more important.
D 9.GP.3. The objective of psychological treatment is to reduce risk, to encourage weight gain by means of a healthy diet, to reduce other symptoms related with eating disorders and to facilitate physical and psychological recovery.
D 9.GP.4. Most psychological treatments for patients with AN can be performed on an outpatient basis (with physical monitoring) by professionals specialised in eating disorders.
D 9.GP.5. The duration of psychological treatment should be of at least 6 months when performed on an outpatient basis (with physical monitoring) and 12 months for inpatients.
D 9.GP.6. For patients with AN who have undergone outpatient psychological therapy but have not improved or have deteriorated, the indication of more intensive treatments (combined individual and family therapy, day or inpatient care) must be considered.
D 9.GP.7. For inpatients with AN, a treatment programme aimed at suppressing symptoms and achieving normal weight should be established. Adequate physical monitoring is important during renutrition.
D 9.GP.8. Psychological treatments must be aimed at modifying behavioural attitudes, attitudes related to weight and body shape and the fear of gaining weight.
D 9.GP.9. The use of excessively rigid behaviour modification programmes is not recommended for inpatients with AN.
D 9.GP.10. Following hospital discharge, patients with AN should be offered outpatient care that includes monitoring of normal weight restoration and psychological intervention that focuses on eating behaviour, attitudes to weight and shape and the fear of social response regarding weight gain, along with regular physical and psychological follow-up. Follow-up duration must be of at least 12 months.
D 9.GP.11. In children and adolescents with AN who require inpatient treatment and urgent weight restoration, age-related educational and social needs should be taken into account.
Binge-Eating Disorder
A 9.GP.12. Patients must be informed that all psychological treatments have a limited effect on body weight.
B 9.GP.13. A possible first step in the treatment of patients with BED is to encourage them to follow a SH programme (guided or not).
B 9.GP.14. Health care professionals can consider providing BED patients with SH programmes (guided or not) that may yield positive results. However, this treatment is only effective in a limited number of patients with BED.
D 9.GP.15. If there is a lack of evidence to guide the care of patients with EDNOS or BED, health care professionals are recommended to follow the eating disorder treatment that most resembles the eating disorder the patient presents.
D 9.GP.16. When psychological treatments are performed on patients with BED, it may be necessary in some cases to treat comorbid obesity.
D 9.GP.17. Adolescents with BED must be provided with psychological treatments adapted to their developmental stage.
Pharmacological Treatment of Eating Disorders
Antidepressants (Questions 9.9.)
Bulimia nervosa
B Patients should be informed that antidepressant treatment can reduce the frequency of binge-eating and purging episodes but effects are not immediate.
B In the treatment of BN, pharmacological treatments other than antidepressants are not recommended.
D The dose of fluoxetine used in patients with BN is greater than the dose used for treating depression (60 mg/day).
D Amongst SSRI antidepressants, fluoxetine is the first-choice drug for treatment of BN, in terms of acceptability, tolerability and symptom reduction.
Binge-Eating Disorder
B SSRI antidepressant treatment can be offered to a patient with BED, regardless of whether he/she follows a guided SH programme or not.
B Patients must be informed that SSRI antidepressant treatment can reduce the frequency of binge-eating, but the duration of long-term effects is unknown. Antidepressant treatment may be beneficial for a small number of patients.
General Recommendations for Pharmacological Treatment (GPH) of Eating Disorders (Questions 9.9.-9.15.)
Anorexia nervosa
D 9.GH.1. Pharmacological treatment is not recommended as the only primary treatment for patients with AN.
D 9.GH.2. Caution should be exercised when prescribing pharmacological treatment for patients with AN who have associated comorbidities such as obsessive-compulsive disorder (OCD) or depression.
D 9.GH.3. Given the risk of heart complications presented by patients with AN, prescription of drugs whose side effects may affect cardiac function must be avoided.
D 9.GH.4. If drugs with adverse cardiovascular effects are administered, ECG monitoring of patients should be carried out.
D 9.GH.5. All patients with AN must be warned of the adverse effects of pharmacological treatments.
Binge-Eating Disorder
D 9.GF.6. In the absence of evidence to guide the management of BED, it is recommended that the clinician treat the patient based on the eating problem that most closely resembles the patient’s eating disorder according to BN or AN guides.
Treatment of Eating Disorders in the Presence of Comorbidities (Question 9.18)
Eating Disorders with Organic Disorders
D 9.18.1. Treatment of clinical and subclinical cases of eating disorders in patients with diabetes mellitus (DM) is essential given the increased risk in this group.
D 9.18.2. Patients with Type 1 DM and an eating disorder must be monitored due to the high risk of developing retinopathy and other complications.
D 9.18.3. Young people with type 1 DM and poor adherence to antidiabetic treatment should be assessed for the probable presence of an eating disorder.
Treatment of Chronic Eating Disorders (Question 9.19.)
9.19.1. The health care professional in charge of the management of chronic eating disorder cases should inform the patient on the possibility of recovery and advise him/her to see the specialist regularly regardless of the number of years elapsed and previous therapeutic failures.
9.19.2. It is necessary to have access to health care resources that are able to provide long-term treatments and follow-up on the evolution of chronic eating disorder cases, as well as to have social support to decrease future disability.
Treatment of Eating Disorders in Special Cases (Question 9.20.)
D 9.20.1. Pregnant patients with AN, whether it is the first episode or a relapse, require intensive prenatal care with adequate nutrition and follow-up of foetal development.
D 9.20.2. Pregnant women with eating disorders require careful follow-up throughout pregnancy and the postpartum period.

10. Assessment of Eating Disorders (Questions 10.1.-10.2.)
D 10.1.1. Assessment of patients with eating disorders should be comprehensive and include physical, psychological and social aspects, as well as a complete assessment of risk to self.
D 10.1.2. The therapeutic process modifies the level of risk for the mental and physical health of patients with eating disorders, and thus should be monitored throughout treatment.
D 10.1.3. Throughout treatment, health care professionals who evaluate children and adolescents with eating disorders should be alert to possible indicators of abuse (emotional, physical and sexual) to ensure an early response to this problem.
D 10.1.4. Health care professionals who work with children and adolescents with eating disorders should familiarise themselves with national CPGs and current legislation regarding confidentiality.
10.1.5. It is recommended to use questionnaires adapted and validated in the Spanish population in the assessment of eating disorders.
At present, the following specific instruments for eating disorders are recommended: EAT, EDI, BULIT, BITE, SCOFF, ACTA and ABOS (the selection of the version should be based on the patient’s age and other application criteria).
To assess aspects related with eating disorders, the following questionnaires are recommended: BSQ, BIA, BAT, BES and CIMEC (the selection of the version should be based on age and other application criteria).
10.2. The use of questionnaires adapted and validated in the Spanish population is recommended for the psychopathological assessment of eating disorders. At present, the following instruments for psychopathological assessment of eating disorders are suggested (version selection based on patient’s age and other application criteria): Impulsiveness: BIS-11
Depression: BDI, HAM-D, CDI
Personality: MCMI-III, MACI, TCI-R, IPDE
Obsessiveness: Y-BOCS

11. Prognosis of Eating Disorders (chapter without recommendations)

12. Legal aspects concerning patients with eating disorders in Spain (questions 12.1.-12.2.)
12.1. The use of the legal route is recommended in cases where the professional deems appropriate to safeguard the patient’s health, while upholding his/her right to be listened to and properly informed on the process and medical and legal measures that will be applied. Clearly conveying the procedure is not only respectful to the right to information, but can also facilitate the cooperation and motivation of the patient and his/her environment in the procedure of complete hospitalisation (According to current legislation).
12.2. One of the characteristic symptoms of eating disorders, and especially of AN, is the lack of awareness of the disease. The disease itself often entails a lack of sufficient judgement to provide valid and unmarred consent regarding treatment acceptance and decision. Hence, if a minor presenting AN and serious health risks refuses treatment, the use of appropriate legal and judicial routes should be employed. (According to current legislation).
12.3. The necessary balance between different clashing rights requires the professional to observe and interpret the best solution in each case. However, it is always important to inform and listen carefully to both parties in order for them to understand the relationship between safeguarding health and the physician’s decision. (According to current legislation).

Latest update: January 2010

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