What are the guidelines for treating anorexia?

Guidelines for Anorexia Nervosa Treatment

The treatment of anorexia nervosa requires a comprehensive multidisciplinary approach that includes medical monitoring, nutritional rehabilitation with individualized weekly weight gain goals, and eating disorder-focused psychotherapy, with family-based treatment being the first-line approach for adolescents and young adults with involved caregivers. 1

Initial Assessment and Evaluation

The American Psychiatric Association (APA) recommends a thorough initial evaluation including:

• Medical Assessment:

  • Vital signs (temperature, resting heart rate, blood pressure, orthostatic measurements)
  • Height, weight, and BMI calculation (or percent median BMI/BMI percentile for youth)
  • Physical examination for signs of malnutrition or purging behaviors
  • Laboratory tests: complete blood count, comprehensive metabolic panel
  • Electrocardiogram for patients with restrictive eating disorders or severe purging 1

• Psychiatric Evaluation:

  • Weight history (maximum, minimum, recent changes)
  • Eating patterns and behaviors (restriction, avoidance, binge eating)
  • Food repertoire changes
  • Compensatory behaviors (exercise, purging, medication use)
  • Food/weight/body shape preoccupation
  • Prior treatment history and response
  • Psychosocial impairment
  • Family history of eating disorders and other conditions 1

• Co-occurring Conditions:

  • Psychiatric comorbidities
  • Medical comorbidities
  • Comprehensive review of systems 1

Treatment Approaches for Anorexia Nervosa

Nutritional Rehabilitation

• Set individualized weekly weight gain goals and target weight
• Implement structured meal planning with gradual caloric increases
• For severely malnourished patients (BMI <16 kg/m²), begin refeeding slowly to prevent refeeding syndrome
• Goal: achieve BMI >18.5 kg/m² 1, 2

Psychotherapeutic Interventions

• For Adults:

  • Eating disorder-focused psychotherapy that addresses:
    • Normalizing eating behaviors
    • Weight restoration
    • Fear of weight gain
    • Body image disturbance 1

• For Adolescents and Young Adults:

  • Family-Based Treatment (FBT) as first-line approach when caregivers are involved
  • Focus on caregiver education to normalize eating behaviors and restore weight 1, 2

• Cognitive Behavioral Therapy (CBT):

  • Focus on what foods can be eaten rather than restrictions
  • Challenge dysfunctional thoughts about "forbidden" foods
  • Address anxiety around eating and weight gain 2

Treatment Settings and Monitoring

• Treatment setting should be determined based on:

  • Medical stability
  • Psychiatric comorbidities
  • Suicidal risk
  • Previous treatment response
  • Psychosocial context 3

• Regular monitoring includes:

  • Weight and nutritional status
  • Vital signs
  • Eating behaviors
  • Psychological symptoms 2

Special Considerations

Athletes with Anorexia

• Athletes with BMI <16 kg/m² require categorical restriction from training and competition
• Return to play only after:
  • Achieving BMI >18.5 kg/m²
  • Cessation of bingeing/purging behaviors
  • Establishment of regular follow-up with treatment team 2

Refeeding Syndrome Prevention

• Major danger during nutritional rehabilitation
• Most likely in severely malnourished patients
• Characterized by fluid/electrolyte disturbances, cardiac complications
• Prevention through slow refeeding and careful monitoring of:
  • Body weight
  • Heart rate and rhythm
  • Serum electrolytes (especially phosphorus) 4

Prognosis and Common Pitfalls

Negative Prognostic Factors

• Longer illness duration
• Lower BMI
• Alcohol abuse
• Poor social adaptation 2

Treatment Pitfalls to Avoid

• Underestimating anorexia's severity as a mental illness
• Premature return to sports/activities before adequate weight restoration
• Failing to involve a multidisciplinary team
• Inadequate monitoring for medical complications
• Not addressing underlying trauma
• Focusing solely on weight rather than normalizing eating behaviors 2

Current Treatment Limitations

Despite established guidelines, many patients with anorexia nervosa do not derive sufficient benefit from existing treatments. No medications are currently FDA-approved specifically for anorexia nervosa, highlighting the need for continued research into more effective interventions 5.

Treatment of anorexia nervosa is typically a long-term process requiring periodic reevaluation to determine ongoing treatment needs, as these conditions are often chronic and necessitate extended follow-up 2.