establishment of initial contact, sympathy and rapport with patient. Also restoration of the patient to a target weight, which is often a compromise between the 'ideal' weight based on the patient's height and what weight the patient thinks s/he should be. NICE previously suggested (2) that, in general, an average weekly weight gain of 0.5-1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3500 to 7000 extra calories a week - there is no suggested weight gain in the updated guidance (3)
the condition should be monitored via regular weighing - if a patient has a BMI below 17 for longer than 3 months despite simple measures then referral should be made to a psychiatrist with a specific interest in eating disorders (1). If a patient has a BMI of less than 13 then admission should be requested (1)
referral (3)
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
acute medical care (including emergency admission) should be provided for people with an eating disorder who have severe electrolyte imbalance, severe malnutrition, severe dehydration or signs of incipient organ failure
acute medical care should be provided 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
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
when deciding whether day patient or inpatient care is most appropriate, take into account:
the person's BMI or weight, and whether these can be safely managed in a day patient service or whether the rate of weight loss (for example more than 1 kg a week) means they need inpatient care
whether inpatient care is needed to actively monitor medical risk parameters such as blood tests, physical observations and ECG (for example bradycardia below 40 beats per minute or a prolonged QT interval) that have values or rates of change in the concern or alert ranges: refer to Box 1 in Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN), or Guidance 1 and 2 in junior MARSIPAN
the person's current physical health and whether this is significantly declining
whether the parents or carers of children and young people can support them and keep them from significant harm as a day patient
NICE guidance notes that (2,3):
assessment and management of anorexia nervosa in primary care:
although weight and BMI are important indicators they should not be considered the sole indicators of physical risk (as they are unreliable in adults and especially in children)
in assessing whether a person has anorexia nervosa, attention should be paid to the overall clinical assessment (repeated over time), including rate of weight loss, growth rates in children, objective physical signs and appropriate laboratory tests
patients with enduring anorexia nervosa not under the care of a secondary care service should be offered an annual physical and mental health review by their GP
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: discharge them to primary care tell them they can ask their GP to refer them again for treatment at any time
psychological treatment of anorexia nervosa:
for adults with anorexia nervosa, consider one of:
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
specialist supportive clinical management (SSCM).
aims of psychological treatment should be to reduce risk, to encourage weight gain and healthy eating, to reduce other symptoms related to an eating disorder, and to facilitate psychological and physical recovery
most people with anorexia nervosa should be managed on an outpatient basis, with psychological treatment (with physical monitoring) provided by a healthcare professional competent to give it and to assess the physical risk of people with eating disorders
outpatient psychological treatment for anorexia nervosa should normally be of at least 6 months' duration
dietary counselling should not be provided as the sole treatment for anorexia nervosa
pharmacological treatment of anorexia nervosa
see linked item
managing weight gain was described in the 2004 guidance (2) and suggested:
in general, an average weekly weight gain of 0.5-1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3500 to 7000 extra calories a week.
regular physical monitoring, and in some cases treatment with a multi-vitamin/multi-mineral supplement in oral form, is recommended for people with anorexia nervosa during both inpatient and outpatient weight restoration
total parenteral nutrition should not be used for people with anorexia nervosa, unless there is significant gastrointestinal dysfunction
dietary advice for people with anorexia nervosa:
only offer dietary counselling as part of a multidisciplinary approach
encourage people with anorexia nervosa to take an age-appropriate oral multivitamin 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)
assessment and monitoring of physical health in anorexia nervosa (3)
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:
weight or BMI (adjusted for age if appropriate)
blood pressure
relevant blood tests
any problems with daily functioning assessment of risk (related to both physical and mental health)
an ECG, for people with purging behaviours and/or significant weight changes
a discussion of treatment options
managing risk
healthcare professionals should monitor physical risk in patients with anorexia nervosa. If this leads to the identification of increased physical risk, the frequency of the monitoring and nature of the investigations should be adjusted accordingly
people with anorexia nervosa and their carers should be informed if the risk to their physical health is high
the involvement of a physician or paediatrician with expertise in the treatment of medically at-risk patients with anorexia nervosa should be considered for all individuals who are medically at-risk
pregnant women with either current or remitted anorexia nervosa should be considered for more intensive prenatal care to ensure adequate prenatal nutrition and fetal development
seek specialist paediatric or endocrinological advice before starting any hormonal treatment for low bone mineral density. Coordinate any treatment with the eating disorders team
see linked item regarding management of bone mineral density in anorexia nervosa
whenever possible patients should be engaged and treated before reaching severe emaciation
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