Management of Anorexia Nervosa
The management of anorexia nervosa requires a comprehensive multidisciplinary approach involving medical, psychiatric, psychological, and nutritional expertise, with patients having BMI <16 kg/m² or severe purging behaviors requiring categorical restriction from training and competition until appropriate treatment and weight restoration. 1, 2
Assessment and Evaluation
Medical evaluation:
- Comprehensive physical examination
- Vital signs assessment
- Height, weight, and BMI calculation
- Laboratory testing: complete blood count, comprehensive metabolic panel
- Electrocardiogram 2
Psychiatric evaluation:
- Assessment of eating patterns and behaviors
- Weight control behaviors
- Co-occurring psychiatric disorders
- Trauma history 2
Risk Stratification and Treatment Level Determination
High Risk Criteria (Requiring Hospitalization):
- BMI <16 kg/m²
- Moderate-to-severe bulimia nervosa (purging >4 times/week)
- Medical instability (bradycardia, hypotension, electrolyte abnormalities)
- Suicidal ideation
- Failure of outpatient treatment 1, 2
Treatment Levels:
- Inpatient treatment: For medically unstable patients, severe malnutrition, or failed outpatient treatment
- Partial hospitalization/day treatment: Transition from inpatient or for moderate severity
- Outpatient treatment: Most common and preferred for stable patients 3
Treatment Components
1. Nutritional Rehabilitation
- Set individualized goals for weekly weight gain and target weight
- Implement structured meal planning with gradual increase in caloric intake
- Monitor for refeeding syndrome in severely malnourished patients
- For athletes: complete restriction from training and competition until BMI >18.5 kg/m² 1, 2
2. Psychotherapeutic Interventions
- Family-Based Treatment (FBT): First-line for adolescents and young adults with involved caregivers
- Cognitive-Behavioral Therapy (CBT): Addressing normalizing eating patterns, weight restoration, and body image disturbances
- Interpersonal Therapy (IPT): Addressing relationship problems and interpersonal issues 2
3. Medication Management
- No FDA-approved medications specifically for anorexia nervosa
- Medications may be used for co-occurring conditions (depression, anxiety)
- For binge-eating behaviors:
- Fluoxetine: 60 mg daily
- Other options: duloxetine, topiramate 2
4. Medical Monitoring
- Regular assessment of vital signs
- Ongoing laboratory monitoring
- Careful refeeding to avoid refeeding syndrome 2, 3
Special Considerations
Athletes with Anorexia
- Athletes diagnosed with anorexia nervosa who have BMI <16 kg/m² must be categorically restricted from training and competition
- Return to play only after:
- BMI >18.5 kg/m²
- Cessation of bingeing and purging
- Close follow-up with multidisciplinary team
- Team physician has ultimate authority in return-to-play decisions 1
High Mortality Risk Factors
- Longer duration of illness (>10 years)
- Lower BMI (<16 kg/m²)
- Alcohol abuse
- Poor social adjustment 1
Common Pitfalls to Avoid
- Underestimating the severity of anorexia as a serious mental illness
- Premature return to sports or activities before adequate weight restoration
- Failing to involve a multidisciplinary team
- Inadequate monitoring for medical complications
- Not addressing underlying trauma when present
- Focusing solely on weight rather than normalizing eating behaviors 1, 2
Multidisciplinary Team Approach
The most effective treatment involves coordination between:
- Psychiatrist/mental health professional
- Medical physician
- Nutritionist/dietitian
- Family therapist (especially for adolescents)
- For athletes: team physician and sports medicine specialists 2, 3, 4
Regular communication between team members is essential to monitor progress and adjust treatment plans accordingly. The team physician or primary care provider should coordinate care and make final decisions regarding medical clearance for activities 1, 2.