Clinical Practice Guideline for Eating Disorders.

Full Version

  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. Annexes
  17. Bibliography
  18. Full list of tables and figures

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1. Introduction


The development of the evidence-based clinical practice guideline elaboration Programme for the NHS is being carried out 2ithin the framework of the development of the Quality Plan of the Ministry of Health and Consumer Affairs (MSC), through the National Health System (NHS)’s Quality Agency.

In the initial phase of this Programme (2006), the development of eight CPGs has been prioritised. A collaboration agreement has been established between the ISCIII and health technology assessment agencies and units and the Iberoamerican Cochrane Centre. The Health Sciences Institute of Aragón is in charge of the Programme’s coordination activities.

In the bilateral agreement between the CAHTA of Catalonia and the ISCIII it was agreed to develop a CPG for eating disorders: anorexia nervosa (AN), bulimia nervosa (BN) and atypical or unspecified eating disorders (EDNOS), based on the best scientific evidence available, which would address the most important areas for the NHS, in a coordinated manner and with shared methodology which would be determined by a group of NHS professionals experienced in CPG development. These professionals have comprised the methodological group and the panel of collaborators of the CPG development programme 1.


In the last decades, eating disorders have gained increasing sociosanitary relevance due to their severity, complexity and difficulty in establishing a diagnosis and specific treatment. Eating disorders are pathologies of multifactorial ethiology where genetic, biological, personality, family and sociocultural factors converge, affecting mainly children, adolescents and young adults.

There are is no data available in Spain that analyses the economic burden of eating disorder treatments nor studies that assess the cost-effectiveness of different treatments. However, different studies conducted in countries of the European Union2-7 indicate that direct costs (diagnosis, treatment and monitoring or follow-up) and especially indirect costs (economic losses derived from the disease that impact the patient and his/her social setting) entail a high economic burden and considerably decrease the quality of life of patients with eating disorders. According to a German study that was carried out in 2002, in the case of AN, average hospitalisation cost is 3.5 times higher than the general hospitalisation average 4.

In 2002, Gowers SG, et al.8 published the results of a survey conducted in 12 countries that were participating in the European project COST Action B6, which aimed to explore consensus and differences in the therapeutic approaches indicated for adolescents with AN (several different Spanish hospitals participated in this project). Results demonstrated significant agreement between the interviewed countries regarding the need to offer a wide array of services at the different levels of care. However, considerable differences were detected in terms of strategies, especially in hospital admission criteria, use of day centres/day hospitals, etc.

In the case of AN1, according to the Atlas of Variations in medical practice of the NHS, where the variability in admissions into acute care public or publicly funded9 hospitals, are described and mapped, a low hospitalisation incidence is observed in AN with, 0.32 admissions per 10,000 inhabitants and year. Hospitalisation rates for AN ranged between 0.08 –practically nil- and 1.47 admissions per 10,000 inhabitants and year. In terms of the weighted variation coefficient, the figures confirmed the wide variation among the different health areas in 70% of AN cases. After consideration of the variation randomised effect, the systematic component of variation of the health areas included in the percentiles 5 to 95 shows high variability (SCV5-95 = 0,26). The ample variation found may be related either to demand factors (different morbidity, socio-economic differences of the cities and towns) or to offer factors (practice style, healthcare resources, different policies for the development of mental care procedures, etc. The variability observed in hospitalisation rates among Spanish provinces is significant and accounts for a 40% of the variability in hospitalisation rates in cases of AN. Upon multilevel analysis, provincial level accounts for a larger variance proportion than in the region (regional level), reinforcing the hypothesis that the different provincial development of psychiatric models and services is behind the variations found. The remaining studied factors (age, gender, available income, educational level, predisposition to hospitalisation) do not appear to exert an influence upon the variability observed in hospitalisation rates in AN, save for the recorded unemployment that works in the opposite way: in areas with more recorded unemployment, the probability of hospitalisation is lower. No data are available for BN or eating disorder not otherwise specified (EDNOS-atypical eating disorders).

Different governmental Spanish and foreign institutions have published guides, recommendations and protocols on EDs in the last years, of which the following stand out:

  1. Osona (2008)10 and the Gerona health region (2006)11 from the Department of Health-Catalan Health Service
  2. semFYC (prevention activities and health promotion group) (2007)12, (2005)13.
  3. American Psychiatric Association (2006)14.
  4. Action Manual of the Ministry of Health and Consumer Affairs on the scientific evidence regarding specialised nutritional support (2006)15.
  5. General subdirectorate of Mental Health- Health Service of Murcia (2005)16.
  6. Official College and Board of Physicians of Barcelona (2005)17.
  7. Royal Australian and New Zealand College of Psychiatrists (2004)18.
  8. National Health Institute (INSALUD, 2000)19, (1995)20.

However, there is a need for a guide adapted to the Spanish population using the best possible methodology and based on the best available evidence.

Recently, other important actions related with eating disorders have been carried out in our context, such as: NAOS and PAOS programme for the prevention of obesity in children and a healthy diet; the Social Pact of the Madrid for the prevention of eating disorders; Image and Self-Esteem Foundation, and pacts between user federations (FEACAB and ADANER) and the MSC.


Magnitude of the problem

Estimations on the incidence and prevalence of eating disorders vary depending on the studied population and assessment tools employed. Therefore, in order to compare data from different national and international sources it is essential that the study design be the same. The study in “two phases” is the most appropriate methodology for the detection of cases in the community. The first phase consists of screening using self-report symptom questionnaires. In the second phase, assessment is carried out by means of clinical interviews that are conducted with individuals who obtained scores above the cut-off point in the screening questionnaire (“at risk” subjects), meaning only a subsample of the total initially screened sample is interviewed.

Within the studies that use correct two-phase methodology, very few perform random sampling of participants who score below the cut-off point of the screening questionnaire to interviews, which leads to a subestimation of the prevalence of eating disorders by not taking false negatives into account21-23. An additional problem is the use of different cut-off points in screening questionnaires.

In spite of these methodological difficulties, the increased prevalence of eating disorders is significant, especially in developed or developing countries, while it is nearly inexistent in third-world countries. Increased prevalence is attributable to increased incidence and duration and chronicity of these clinical pictures.

Based on two-phase studies conducted in Spain (Tables 1 and 2) on the highest risk population, women ranging from 12 to 21 years of age, a prevalence of 0.14% to 0.9% is obtained for AN, 0.41% to 2.9% for BN and 2.76% to 5.3% in the case of EDNOS. In total, we would be looking at an eating disorder prevalence of 4.1% to 6.41%. In the case of male adolescents, even though there are fewer studies available, a prevalence of 0% for AN, 0% to 0.36% for BN and 0.18% to 0.77% for EDNOS is obtained, with a total prevalence of 0.27% to 0.90%21-29.

These numbers are similar to those presented in the NICE CPG (2004), where prevalence in of EDNOS, BN and AN in women ranges from 1% to 3.3%, 0.5% to 1.0% and 0.7%, respectively, and also to those in the Systematic Review of Scientific Evidence (SRSE) (2006) which reports prevalence in Western Europe and the United States (0.7% to 3% of EDNOS in the community, 1% of BN in women and 0.3% of AN in young women).

Several studies on the incidence of eating disorders that have been published in North America and Europe present a 5- to 6-fold increase in incidence between 1960 and 1970. In 1998, a review presented by Pawluck, et al. on the general population of the United States reported that annual incidence of AN was 19 per 100,000 in women and 2 per 100,000 in males30. In the review presented by Hoek in 2003, incidence was 8 cases per 100,000 inhabitants for AN and 12 cases per 100,000 inhabitants for BN32.

In a recent study in the United Kingdom (UK), incidence for AN in 2000 was 4.7 per 100,000 inhabitants (95% CI: 3.6 to 5.8) and 4.2 per 100,000 inhabitants in 1993 (95% CI: 3.4 to 5.0). In Holland, incidence of AN was 7.7 (95% CI: 5.9 to 10.0) per 100,000 inhabitants/year between 1995-1999 and 7.4 between 1985 and 198933. In Navarra, a population survey in 1,076 13-year old girls was used to estimate an eating disorder incidence of 4.8% (95% CI: 2.84 to 6.82) in a period of 18 months, corresponding to: 0.3% AN (95% CI: 0.16 to 0.48): 0.3% BN (95% CI: 0.15 to 0.49) and 4.2% EDNOS (95% CI: 2.04 to 6.34) 34.

Incidence was greater in women aged 15 to 19 years: they constitute approximately 40% of identified cases in studies both in the US and Europe30, 31, 33. There are very few studies that report data on AN in prepubertal children or in adults31. There are also scarce studies that present incidence data of AN in men. Of all the aforementioned studies, we can conclude that incidence is lower than 1 per 100,000 inhabitants/year33. All these sources establish an eating disorder prevalence ratio of 1 to 9 in males versus women.

Table 1. Studies on the prevalence of eating disorders in adolescent females in Spain

Madrid, 199724
Morandé G and Casas J.
723 15 0,69 1,24 2,76 4,69
Zaragoza, 199826
Ruiz P et al.
2.193 12-18 0,14 0,55 3,83 4,52
Navarra, 200027
Pérez-Gaspar M et al.
2.862 12-21 0,31 0,77 3,07 4,15
Reus, 200829
Olesti M et al.
551 12-21 0,9 2,9 5,3 9,1

Table 2. Studies on the prevalence of eating disorders in adolescent males and females in Spain

Madrid, 199925
Morandé G et al.
1.314 15 0,00 a 0,69 0,36 a 1,24 0,54 a 2,76 3,04
Valencia, 200321
Rojo L et al.
544 12-18 0,00 a 0,45 0,00 a 0,41 0,77 a 4,71 2,91
Ciudad Real, 200522
Rodríguez-Cano T et al.
1.766 12-15 0,00 a 0,17 0,00 a 1,38 0,60 a 4,86 3,71
Osona (Barcelona), 200628 Arrufat F
2.280 14-16 0,00 a 0,35 0,09 a 0,44 0,18 a 2,70 1,90
Madrid, 200723
Peláez MA et al.
1.545 12-21 0,00 a 0,33 0,16 a 2,29 0,48 a 2,72 3,43


1N= 2,188 AN discharges, recorded during 2003 and 2004 in 156 health areas of 15 autonomous communities.

Section 01 Bibliography

  1. 1. Grupo de trabajo sobre guías de práctica clínica. Elaboración de Guías de Práctica Clínica en el Sistema Nacional de Salud. Manual metodológico. Madrid: Plan de Calidad para el Sistema Nacional de Salud del Ministerio de Sanidad y Consumo: Instituto Aragonés de Ciencias de la Salud-I+CS; 2007. Guías de Práctica Clínica en el Sistema Nacional de Salud: I+CS Nº2006/1.
  2. 2. Meade C, Gold L, Burls A. How effective is out-patient care compared to in-patient care for treatment of anorexia nervosa? A sistematic review. Eur Eat Disord Rev. 2001;9:229-41.
  3. 3. Birchall H, Palmer R,Waine J, Gadsby K, Gatward N. Intensive day programme treatment for severe anorexia nervosa The Leicester experience. Psychiatr Bull. 2002;26:334-6.
  4. 4. Krauth C, Buser K, Vogel H. How high are the costs of eating disorders anorexia nervosa and bulimia nervosa for German society? Eur J Health Econ. 2002;3(4):244-50.
  5. 5. Koran LM, Agras WS, Rossiter EM, Arnow B, Schneider JA, Telch CF, et al. Comparing the cost effectiveness of psychiatric treatments: bulimia nervosa. Psychiatry Res. 1995;58(1):13-21.
  6. 6. KalisvSHrt JL, Hergenroeder AC. Hospitalization of patients with eating disorders on adolescent medical units is threatened by current reimbursement systems. Int J Adolesc Med Health. 2007;19(2):155-65.
  7. 7. Cordy H. A European Collaboration on the efficiency of psichotherapeutic treatment of patients with eating disorders. Eur Eat Disord Rev. 2005;13:153-8.
  8. 8. Gowers S, Edwards S, Fleminger S, Massoubre C, Wallin U, Canalda G. Treatment aims and philosopbhy in the treatment of adolescent anorexia nervosa in Europe. Eur Eat Disord Rev. 2002;10:271-80.
  9. 9. Aizpuru F, Latorre K, Ibáñez B, Pérez de Arriba J, Mosquera F, Bernal-Delgado E, por el Grupo Atlas-VPM. Variabilidad en la tasa de hospitalizaciones por problemas de salud mental en centros hospitalarios de agudos. Atlas Var Pract Med SNS. 2008;3(1):199-216.
  10. 10. Guia per a l'abordatge dels trastorns de la conducta alimentària a Osona. Regió Sanitària Catalunya Central. Servei Català de la Salut. Departament de Salut. Generalitat de Catalunya; 2008.
  11. 11. Pla pilot d'atenció als trastorns de la conducta alimentària (TCA). Protocol d'atenció integrat i específic en TCA. Girona:Atenció primària i xarxa de salut mental de la Regió Sanitària Girona. Servei Català de la Salut. Departament de Salut. Generalitat de Catalunya; 2006.
  12. 12. Fernández-Alonso MC, Buitrago-Ramírez F, Ciurana-Misol R, Chocrón-Bentata L, García-Campayo J, Grupo de Trabajo de Prevención de los Trastornos de Salud Mental del PAPPS. Programa de prevención en salud mental en atención primaria. Aten Primaria.2007;39(Supl 3):88-108.
  13. 13. Fernández-Alonso MC, Buitrago-Ramírez F, Ciurana-Misol R, Chocrón-Bentata L, GarcíaCampayo J, Grupo de Trabajo de Prevención de los Trastornos de Salud Mental del PAPPS. Prevención de los trastornos de salud mental desde atención primaria. Aten Primaria.2005;36(Supl 2):85-96.
  14. 14. Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders, third edition. American Psychiatric Association Steering Committee on Practice Guidelines, 2006.
  15. 15. Toquero de la Torre, coordinador. Álvarez Hernández J, Burgos Peláez R, Lama More RA, Miján de la Torre, A. Evidencia científica en soporte nutricional especializado. Paciente pediátrico, con trastornos de la conducta alimentaria, obeso y geriátrico. Manual de actuación. Madrid: Organización Médica Colegial de España. Ministerio de Sanidad y Consumo; 2006.
  16. 16. Guía práctica clínica de los trastornos de conducta alimentaria. Murcia: Subdirección General de Salud Mental. Servicio Murciano de Salud; 2005.
  17. 17. Detecció i orientacions terapèutiques en els trastorns del comportament alimentari. Quaderns de la bona praxi; junio 2005. Barcelona: Col•legi Oficial de Metges de Barcelona. Quadern 19. Available at: Nueva ventana
  18. 18. Beumont P, Hay P, Beumont D, Birmingham L, Derham H, Jordan A, et al. Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa. Aust N Z J Psychiatry. 2004;38(9):659-70.
  19. 19. Moral Iglesias L, coordinador. Trastornos del comportamiento alimentario. Criterios de ordenación de recursos y actividades. Madrid: Instituto Nacional de la Salud. Ministerio de Sanidad y Consumo; 2000.
  20. 20. Protocolo de trastornos del comportamiento alimentario. Madrid: Instituto Nacional de la Salud. Ministerio de Sanidad y Consumo; 1995.
  21. 21. Rojo L, Livianos L, Conesa L, García A, Domínguez A, Rodrigo G, et al. Epidemiology and risk factors of eating disorders: a two-stage epidemiologic study in a Spanish population aged 12-18 years. Int J Eat Disord. 2003;34(3):281-91.
  22. 22. Rodríguez-Cano T, Beato-Fernández L, Belmonte-Llario A. New contributions to the prevalence of eating disorders in Spanish adolescents: detection of false negatives. Eur Psychiatry.2005;20(2):173-8.
  23. 23. Peláez Fernández MA, Labrador FJ, Raich RM. Prevalence of eating disorders among adolescent and young adult scholastic population in the region of Madrid (Spain). J Psychosom Res. 2007;62(6):681-90.
  24. 24. Morandé G, Casas J. Trastornos de la conducta alimentaria en adolescentes. Anorexia nerviosa, bulimia y cuadros afines. Pediatr Integral. 1997;3(2):243-60.
  25. 25. Morandé G, Celada J, Casas JJ. Prevalence of eating disorders in a Spanish school-age population. J Adolesc Health. 1999;24(3):212-9.
  26. 26. Ruiz P,Alonso J,Velilla J, Lobo A, Martín A, Paumard C, et al. Estudio de prevalencia de trastornos de la conducta alimentaria en adolescentes de Zaragoza. Rev Psiquiatr Infanto Juv.1998;3:148-62.
  27. 27. Pérez-Gaspar M, Gual P, de Irala-Estévez J, Martínez-González MA, Lahortiga F, Cervera S. Prevalencia de trastornos de la conducta alimentaria en las adolescentes navarras. Med Clin (Barc). 2000;114(13):481-6.
  28. 28. Arrufat F. Prevalencia de trastornos de la conducta alimentaria en la población adolescente de la comarca de Osona [tesis doctoral]. Barcelona: Universidad de Barcelona; 2006.
  29. 29. Olesti M, Piñol JL, Martín N, De la Fuente M, Riera A, Bofarull JMª, et al. Prevalencia de anorexia nerviosa, bulimia nerviosa y otros TCA en adolescentes femeninas de Reus. An Pediatr (Barc). 2008;68(1):18-23.
  30. 30. National Collaborating Centre for Mental Health. Eating disorders. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Leicester / London: The British Psychological Society. The Royal College of Psychiatrists; 2004.
  31. 31. Berkman ND, Bulik CM, Brownley KA, Lohr KN, Sedway JA, Rooks A, et al. Management of eating disorders. Rockville, MD (US): Agency for Healthcare Research and Quality; 2006. Informe núm. 135.
  32. 32. Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Curr Opin Psychiatry. 2006;19(4):389-94.
  33. 33. Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord. 2003;34(4):383-96.
  34. 34. Lahortiga-Ramos F, de Irala-Estévez J, Cano-Prous A, Gual García P. Incidence of eating disorders in Navarra (Spain). Eur J Psychiatry. 2005;20:179-85.

Figures y Tables

Table 1. Studies on the prevalence of eating disorders in adolescent females in Spain Abrir nueva ventana (pdf, 17 Kb.)

Table 2. Studies on the prevalence of eating disorders in adolescent males and females in Spain Abrir nueva ventana (pdf, 19 Kb)

Latest update: January 2010

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