Eating Disorders in Primary Care: Diagnosis and Management

22 American Family Physician www.aafp.org/afp Volume 103, Number 1

◆

January 1, 2021

Eating disorders are potentially life-threatening

conditions characterized by disordered eating

and weight-control behaviors that impair physical

health and psychosocial functioning.

1-3

Adoles-

cence and early adulthood are vulnerable periods

for the development of eating disorders; however,

up to 8% of females and 2% of males are aected

during their lifetimes, including persons of all

ages, sizes, sexual and gender minority groups,

races, ethnicities, socioeconomic strata, and geo-

graphic locations.

1,4-6

Diagnostic characteristics of

specic eating disorders are presented in Table 1.

Persons with anorexia or bulimia nervosa have

a two- to sixfold increase in age-adjusted mor-

tality attributed to medical complications and

have suicide completion rates up to 18 times the

completion rates of peers.

7-10

At least one-third of

persons with disordered eating develop persistent

symptoms that remain 20 years postdiagnosis.

11,12

Co-occurring mood, anxiety, substance use,

personality, or somatic disorders are identied

in more than two-thirds of persons with eating

disorders.

1,13

Early intervention with symptom

improvement decreases the risk of a protracted

course and long-term pathology.

1,3,14,15

Eating Disorders in Primary Care:

Diagnosis and Management

David A. Klein, MD, MPH; Jillian E. Sylvester, MD; and Natasha A. Schvey, PhD

Uniformed Services University of the Health Sciences, Bethesda, Maryland

Additional content at https:// www.aafp.org/

afp/2021/0101/p22.html.

CME

This clinical content conforms to AAFP

criteria for CME. See CME Quiz on page 13.

Author disclosure: No relevant ﬁnancial

aliations.

Patient information: A handout on this

topic is available at https:// www.aafp.org/

afp/2015/0101/p46-s1.html.

Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behav-

iors that impair physical health and psychosocial functioning. Early intervention may decrease the risk of long-term

pathology and disability. Clinicians should interpret disordered eating and body image concerns and carefully monitor

patients’ height, weight, and body mass index trends for subtle changes. After

diagnosis, visits should include the sensitive review of psychosocial and clin-

ical factors, physical examination, orthostatic vital signs, and testing (e.g., a

metabolic panel with magnesium and phosphate levels, electrocardiography)

when indicated. Additional care team members (i.e., dietitian, therapist, and

caregivers) should provide a uniﬁed, evidence-based therapeutic approach.

The escalation of care should be based on health status (e.g., acute food refusal,

uncontrollable binge eating or purging, co-occurring conditions, suicidality,

test abnormalities), weight patterns, outpatient options, and social support. A

healthy weight range is determined by the degree of malnutrition and pre-ill-

ness trajectories. Weight gain of 2.2 to 4.4 lb per week stabilizes cardiovascular

health. Treatment options may include cognitive behavior interventions that

address body image and dietary and physical activity behaviors; family-based therapy, which is a ﬁrst-line treatment for

youths; and pharmacotherapy, which may treat co-occurring conditions, but should not be pursued alone. Evidence sup-

ports select antidepressants or topiramate for bulimia nervosa and lisdexamfetamine for binge-eating disorder. Remission

is suggested by healthy biopsychosocial functioning, cognitive ﬂexibility with eating, resolution of disordered behaviors

and decision-making, and if applicable, restoration of weight and menses. Prevention should emphasize a positive focus

Academy of Family Physicians.)

Illustration by Jonathan Dimes

This article has been updated to incorporate the January 2021 guidelines from the American Academy of Pediatrics.

mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

January 1, 2021

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Volume 103, Number 1 www.aafp.org/afp American Family Physician 23

EATING DISORDERS

Early Identiﬁcation

Clinicians, especially those caring for

adolescents and young adults, should

routinely conduct condential psy-

chosocial assessments that include

questions about eating behaviors,

body image, and mood.

5,16-18,60

e U.S.

Preventive Services Task Force is plan-

ning to review the health outcomes of

screening for eating disorders and the

performance of primary care–relevant

screening tools.

Clinicians should

monitor patients’ height, weight, and

body mass index (BMI) trends, includ-

ing percentile changes and growth

curves for youth to avoid missing crit-

ical windows for intervention before

pathology becomes entrenched

20,21,60

(eFigure A). Subtle changes in the

amount and speed of weight loss can

be as harmful as low weight.

20-22

Persons with restrictive eating dis-

orders may perceive benets from

the disorder, minimize pathology,

and resist treatment.

17,20,23

Clini-

cians should acknowledge that a

person’s motivation to change may

be compromised by malnutrition

or co-occurring conditions, lack of

self-awareness, or fear.

23-25

Disordered

thoughts and behaviors may provide

perceived structure, self-worth, and

safety in coping with dicult emo-

tions and stressors.

23-25

Initial praise

of the patient’s weight loss by family

members, peers, or clinicians may lead

to fear of regaining weight and body

image distortion.

In males, body

dissatisfaction may center on muscu-

larity and leanness, leading to rigid

routines and use of appearance- or

performance-enhancing substances.

“Bulk and cut” routines, which involve

cycles of excessive energy intake for

muscle building followed by caloric

decit to achieve visible muscularity,

may mimic binge-purge pathology.

e use of empathetic, nonjudgmen-

tal motivational interviewing tech-

niques (e.g., “I’m curious about your

meal preparation routine. Is it stressful

TABLE 1

Characteristics of Eating and Feeding Disorders

Anorexia nervosa

Restriction of food eaten, leading to signiﬁcantly low body weight

Intense fear of gaining weight or being “fat”

Body image distortion

Types: restrictive or binge eating/purging

Alternative diagnosis: atypical anorexia nervosa (i.e., weight is not signiﬁcantly low)*

Bulimia nervosa

Binge eating (i.e., eating more food than peers [e.g., over a two-hour period] accom-

panied by a perceived loss of control)

Repeated use of unhealthy behaviors to prevent weight gain, such as vomiting, misuse

of laxatives or diuretics, food restriction, or excessive exercise

Self-worth is overly based on body shape and weight

Behaviors occur at least weekly for at least three months and are distinctly separate

from anorexia nervosa

Alternative diagnoses: bulimia nervosa of low frequency and/or limited duration*;

purging disorder (i.e., recurrent purging to lose weight without binge eating)*

Binge-eating disorder

Recurrent episodes of binge eating (i.e., eating more food than peers [e.g., over a

two-hour period] accompanied by a perceived loss of control)

Associated with three of the following: eating faster than normal, eating until feeling

uncomfortable, eating large quantities of food when not hungry, feeling bad because

of embarrassment about eating behaviors, or eating followed by negative emotions

No behaviors to prevent weight gain

Behaviors occur at least weekly for at least three months and are distinctly separate

from anorexia nervosa or bulimia nervosa

Alternative diagnosis: binge-eating disorder of low frequency and/or limited duration*

Avoidant/restrictive food intake disorder

Avoidance of food intake because of one of the following: lack of interest, sensory

characteristics of food, concern about consequences of eating that lead to unmet

nutritional or energy needs

Associated with signiﬁcant weight loss, inadequate weight gain during growth,

nutritional deﬁciency, interference with psychosocial functioning, or dependence on

supplemental feeding

Not explained by food availability, culturally sanctioned practice, or other medical or

mental health condition

No disturbance in how body weight or shape is experienced by the person

Rumination disorder

Repeated regurgitation of food for at least one month

Not attributable to a gastrointestinal or other medical condition

Does not occur exclusively with another eating disorder

Pica

Eating nonnutritive, nonfood substances for at least one month

Eating behavior is developmentally inappropriate

Not part of a culturally supported or socially normative practice

Note: Signiﬁcant crossover between disorders can be observed (e.g., anorexia nervosa to

bulimia nervosa). Orthorexia nervosa is a proposed condition not formally recognized by

the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., and is characterized by an

obsessive focus on healthy food consumption, leading to impairment.

*—Disorder is in the category of other speciﬁed eating or feeding disorder (OSFED).

Information from reference 2.

24 American Family Physician www.aafp.org/afp Volume 103, Number 1

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EATING DISORDERS

for you?” or “Given your experiences,

your skepticism is appreciated.”) may

help overcome barriers and patient

resistance

16,17,25,28

(Table 2

24,29

). e

patient’s history should be corroborated

by family members and other contacts,

ideally. Clinicians should note objec-

tive ndings and interpret screening

tools such as the SCOFF questionnaire

in context because critical information

may be withheld

17,20,23,30

(eTable A).

Clinical Approach

e initial medical evaluation should

establish the diagnosis while exclud-

ing alternative or co-occurring diag-

noses (e.g., thyroid or gastrointestinal

disease) based on clarity of the clin-

ical picture. At all related medical

visits, pertinent psychosocial and

clinical factors should be reviewed.

A physical examination, monitoring

of orthostatic vital signs, laboratory

testing (e.g., a metabolic panel with

magnesium and phosphate levels),

and electrocardiography should also

be considered (Tables 3 and 4).

1,20,25,31

Goals should include the identication

of trends in nutrition, menstruation,

height, weight, and BMI; the estab-

lishment of motivation for change;

determination of medical and mental

health sequelae; and the provision of

unied, evidence-based care by team

members and caregivers.

3,60

erapeu-

tic relationships between the patient,

treatment team, and caregivers should

be based on rapport and trust.

17, 25

WEIGHT ASSESSMENT

e weigh-in process at the oce may

be viewed by patients as stressful and

requires sensitivity. Weight measure-

ments are ideally recorded with the

patient facing away from the scale in

a hospital gown. e extent to which

the clinician reveals weight is individ-

ualized. Because BMI percentiles do

not indicate how far extreme weights

deviate from the norm among youths,

clinicians should use reference data

TABLE 2

Practical Questions and Statements for the Assessment

and Treatment of Eating Disorders

Goal Questions or statements

Start a conver-

sation about

eating habits

I’m concerned about your eating. May we discuss how you typi-

cally eat?

Would it be okay if we discussed your eating habits?

Assess motiva-

tion to change

eating habits

How would your life be dierent if you didn’t need to spend so

much time thinking about your eating?

It sounds like your eating habits are really important for helping

you get through the day.

On a scale of 0 to 10, how conﬁdent are you that you could

change the way you eat?

On a scale of 0 to 10, how important is it for you to change your

eating? What would make it more important?

What do you like about the way you eat? What do you dislike?

What would be the beneﬁts of changing the way you eat?

What would be the downside of changing the way you eat?

What would make you more conﬁdent?

Determine the

antecedents and

consequences

of disordered

eating patterns

Do you ever feel that you lose control over the way you eat? How

often does that happen?

How does eating impact your ability to function during the day?

Do you feel tired?

How do you feel before you binge? After you binge? Before you

purge? After you purge?

Is it dicult to concentrate?

Some of my patients tell me that their weight or body shape

causes stress. Tell me about any experiences or struggles you

have had.

Sometimes people binge and purge when they are overwhelmed,

stressed, sad, or anxious; do any of those situations apply to you?

Sometimes people think about how they are eating all day to the

point that it is dicult to concentrate on anything else. Does that

happen to you?

What happens after you purge?

What would your ideal weight be? What is your healthy weight?

(To assess thought patterns, not to determine goal weight.)

When are you most likely to binge?

Develop coping

strategies

When you feel an urge to binge, what could you do instead of

bingeing? Consider activities that you could do in situations when

you are most likely to binge (or restrict food).

Change nega-

tive thinking

What can you control?

Who demands that you must be perfect?

Who determines how you think about yourself?

Adapted with permission from Williams PM, Goodie J, Motsinger CD. Treating eating disor-

ders in primary care. Am Fam Physician. 2008; 77(2): 193, with additional information from

reference 29.

January 1, 2021

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EATING DISORDERS

to determine the degree

of malnutrition (Table 5).

Next they should determine

an appropriate healthy

weight range in collabora-

tion with treatment team

members, based on pre-ill-

ness height, weight, and

BMI trajectories; age at

pubertal onset; and current

pubertal stage (aecting

expected body composi-

tion).

Describing weight

in terms of percent median

BMI, Z-score, and the

amount and rate of weight

change is more precise

and preferred over ideal,

expected, or median body

weight terminology.

adults, normative BMI data

and pre-illness trends can

guide clinical recommenda-

tions, acknowledging that

some persons are healthi-

est at higher weights. Home

weight measurement should

generally be discouraged.

NUTRITION

Traditional percentages of

daily nutritional recom-

mendations may be mislead-

ing.

5,20

Moderately active

adolescent females require

approximately 2,200 kcal

per day (adolescent males

need 2,800 kcal per day);

athletes and persons who

are hypermetabolic post-

recovery at any age require

more.

5,20

Daily caloric aver-

ages for adults can be found

at https:// health.gov/ our-

work/food-nutrition/2015-

2020-dietar y- guidelines.

Discussions around energy

intake will dier based on

patient factors and choice of

treatment. Some clinicians

frame nutrition in terms of

TABLE 3

Recommended History and Physical Examination in Persons

with Suspected or Diagnosed Eating Disorders

Component Findings of concern and associations

Eating- and weight-related questions

Weight history Fluctuations or extremes

Eating behaviors Calorie counting, irregular or decreased food intake, picky eating,

nuanced patterns or rules

Binge or loss-of-control

eating

Presence

Purging behavior Self-induced vomiting; use of diet pills, laxatives, diuretics, caeine

Exercise patterns Excessive or compulsive

Fear of gaining weight Pervasive

Weighing, body checking Frequent weighing, measuring, mirror use

Body image Dissatisfaction; preoccupation with weight and shape; use of ana-

bolic steroids or supplements

Self-esteem Inﬂuenced by weight, shape, control of eating

Co-occurring mental health conditions

Depression, anxiety Presence, current and prior treatment

Suicidality Ideation, plan, intent, prior suicide attempt

Substance use Stimulants, alcohol, prescription medication misuse, other

Self-injury Cutting, burning, self-punishing

Other History of trauma, obsessive or rigid thinking, impulsivity

Family and social factors

Social support Inability to involve family or friends in treatment plan; possible

source of stress

Family history Eating disorders; missed primary or co-occuring diagnosis

Physical symptoms

Menstrual patterns Amenorrhea (hypothalamic dysfunction, low estrogen state)

Targeted questions to

dierential diagnoses

Malignancy; diabetes mellitus; thyroid, celiac, inﬂammatory bowel

disease; other

Cardiac symptoms Dizziness, (pre-) syncope, exercise intolerance, palpitations, chest

pain (may suggest cardiac injury, malnutrition, or orthostasis)

Abdominal symptoms Constipation, delayed gastric emptying, decreased intestinal mobil-

ity, pancreatitis

Physical examination

Appearance Flat aect, guarded

Body mass index, includ-

ing trends and percentiles*

Down-trending or low; rapid weight loss

Weight, including trends

and percentiles*

Down-trending or low; rapid weight loss

Height, including trends

and percentiles*

Growth stunting

Blood pressure Hypotension (e.g., malnutrition, dehydration)

Heart rate Bradycardia (e.g., heart muscle wasting, metabolic changes)

Temperature Hypothermia (e.g., thermoregulatory dysfunction)

Hair Hair loss at scalp, lanugo

Mouth Erosion of dental enamel, poor dentition (e.g., in purging)

Salivary glands Hypertrophy of parotid (e.g., purging)

Skin and extremities Self-harm; muscle wasting, edema (e.g., hypoalbuminemia or

refeeding), dryness

Sexual maturity rating

(adolescents)

Delayed puberty

*—Using Centers for Disease Control and Prevention growth charts (www.cdc.gov/growthcharts).

Information from references 1, 20, 25, and 31.

26 American Family Physician www.aafp.org/afp Volume 103, Number 1

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EATING DISORDERS

portions, snacks, and meals, and avoid recommending cal-

orie counts, which may entrench disordered thinking. e

multidisciplinary team should guide portion size modi-

cations or reintroduction of foods that cause distress with

caregiver endorsement. Weight gain of 2.2 to 4.4 lb (1 to 2

kg) per week stabilizes cardiovascular health.

3,32

Treatment Options

ESTABLISHING A TREATMENT PLAN

Most patients receive optimal care in the outpatient set-

ting.

3,33,34

e ideal outpatient treatment team should

include an experienced therapist, dietitian, and a clini-

cian who is knowledgeable about eating disorder–specic

medical evaluations, potentially in a community-based

specialized center.

3,33,60

Medical hospitalization (e.g., sur-

veillance for refeeding syndrome) or psychiatric hospital-

ization (e.g., suicidality) may be necessary depending on

health status, weight trajectory, outpatient options, and

social support factors

3,20,35

(Table 6

Patients who need professional supervision and structure

to eat, gain weight, or avoid disordered behaviors, or for

whom outpatient treatment has not been successful, may

require residential care (i.e., constant care), partial hospital-

ization (e.g., day program), or intensive outpatient care (e.g.,

partial day, nondaily; Figure 1).

3,20,33,60

Requiring feeding

without a patient’s consent should be guided by legal stan-

dards and by experts in specialty centers.

BEHAVIORAL INTERVENTIONS

Cognitive behavior therapy (CBT), which can be

applied in person or by self-help or guided self-

help, is an evidence-based treatment for adults

that has also demonstrated eectiveness for

youth.

CBT targets the overvaluation of body

shape and weight and subsequent cycles of dietary

restraint, disinhibited eating, and compensatory

behaviors

1,17

(Table 7

3,5,17,24,34,36-38

). Direct engage-

ment with a patient’s social support system may

be critical because eating is considered a social

activity.

Treatment of less common eating disor-

ders is not discussed because of limited data.

Anorexia Nervosa. Family-based therapy is rec-

ommended as a rst-line treatment for youth and

some young adults.

3,34,39

Studies of family-based

therapy demonstrate higher remission rates and

increased weight gain compared with individual

therapy.

34,36,39

Family-based therapy empowers

parents to play a vital role in facilitating patients’

weight gain before progressively returning con-

trol to the patient.

Short hospitalizations for

medical stabilization followed by family-based

therapy or outpatient programs have similar out-

comes as prolonged hospitalization

32,40

; therefore,

the safest, least intensive treatment environment

is recommended.

In adults, CBT, family-based

therapy, focal psychodynamic psychotherapy,

interpersonal psychotherapy, and specialist sup-

portive clinical management have demonstrated

eectiveness and can be implemented based on

patient preferences.

17,34,42,43

Bulimia Nervosa. Among adolescents, guide-

lines recommend family-based therapy and,

alternatively, CBT as appropriate treatments.

1,17,3 4

Adults benet from therapist-guided and

TABLE 4

Recommended Studies in Persons with Suspected

or Diagnosed Eating Disorders

Component Findings of concern and associations

Laboratory testing*

Amylase Increased (may suggest purging)

Basic metabolic

panel

Decreased sodium (water-loading), potassium,

chloride, glucose; indications of metabolic acidosis

(laxatives) or alkalosis (vomiting); acute renal injury

Calcium Decreased

Cholesterol Increased

Complete blood

count

Bone marrow hypoplasia (thrombocytopenia,

anemia, leukopenia)

Magnesium Decreased

Phosphorus Decreased

Prealbumin Decreased

Thyroid testing Sick euthyroid syndrome (decreased thyroxine or

triiodothyronine without overt hypothyroidism)

Other studies

Dual energy x-ray

absorptiometry†

Low bone mineral density, osteopenia, osteoporosis

Electrocardiog-

raphy

Bradycardia, arrhythmias (heart failure, electrolyte

disorders), prolongation of the corrected QT interval

Orthostatic vital

signs

Hypotension, tachycardia (may suggest dehydration

or autonomic instability)

*—Initial and repeat testing is individualized, based on test, degree of illness, and

co-occurring conditions. Additional laboratory testing, when indicated, may

include elucidation of: hydration status (urinalysis), inﬂammatory conditions

(erythrocyte sedimentation rate, C-reactive protein), hepatic disease (liver func-

tion tests), gastrointestinal disease (celiac test, fecal calprotectin), pancreatitis

(lipase), nutritional deﬁciencies (vitamin D, vitamin B

, ferritin, thiamine), diabetes

mellitus (A1C), or amenorrhea, delayed puberty, or a prolonged eating disorder

(serum luteinizing hormone, follicle-stimulating hormone, testosterone or estra-

diol, prolactin, pregnancy testing, other nuanced testing).

†—Generally indicated if there is a history of long bone or stress fracture, amen-

orrhea for more than six months, or hypogonadism.

Information from references 1, 20, 25, and 31.

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EATING DISORDERS

self-guided forms of CBT or interper-

sonal psychotherapy.

17,34,37

Binge-Eating Disorder. Meta-analytic

data support treatment with CBT and

self-guided therapy.

In-person CBT

more eectively decreases binge eating

and therapy dropout than self-guided

CBT at six months and confers mark-

edly better outcomes than weight-loss

therapies.

Patients who exhibit a

rapid decrease in binge-eating behav-

iors (e.g., by two-thirds) in the rst

month of treatment are more likely to

have sustained remission, regardless of

treatment modality, than patients who

do not.

PHARMACOTHERAPY

Pharmacotherapy should not be pur-

sued as a monotherapy for eating dis-

orders,

17, 3 4

but it may be a worthwhile

adjunctive therapy, specically in

the presence of co-occurring mental

health conditions.

45,46

Patient sensitiv-

ities or fear of weight gain limits tol-

erability.

20,46,47

Medications that aect

electrolytes or heart rate, or that pro-

long the corrected QT interval, should

be prescribed with caution.

20,45,46

Anorexia Nervosa. ere are no

medications approved by the U.S.

Food and Drug Administration (FDA)

to treat anorexia nervosa. A recent

multicenter, randomized controlled

trial of 10 mg of olanzapine (Zyprexa)

demonstrated modest benet in induc-

ing weight gain and appetite without

metabolic syndrome components.

Selective serotonin reuptake inhibi-

tors (SSRIs) are commonly prescribed

despite a weak evidence base con-

sisting of few randomized controlled

trials.

46,47

Bupropion (Wellbutrin) is

contraindicated in anorexia and buli-

mia nervosa because of the risk of

seizure.

40,46,47

Bulimia Nervosa. Fluoxetine

(Prozac) is an FDA-approved treat-

ment in adolescents and adults; dos-

ages titrated to 60 mg per day resulted

in substantial decreases in bingeing

TABLE 5

Degree of Malnutrition for Adolescents and Young Adults

with Eating Disorders

Measure

Severity*

Mild Moderate Severe

Percent

median BMI†

80% to 90% 70% to 79% < 70%

BMI Z-score‡ –1 to –1.9 –2 to –2.9 –3 or greater

Weight loss > 10% pre-illness

weight

> 15% pre-illness

weight

> 20% pre-illness weight in

one year or > 10% pre-illness

weight in six months

BMI = body mass index; weight (kg)/[height (m

)].

*—One or more of the ﬁndings suggests mild, moderate, or severe malnutrition. Healthy

weight range should reﬂect previous height, weight, and BMI percentiles, pubertal stage, and

growth trajectory.

†—The percent median BMI is calculated by BMI divided by median BMI for age and sex. The

median BMI can be found in the BMIAGE data ﬁle (column P50) at https:// www.cdc.gov/

growth charts/data/zscore/bmiagerev.xls.

‡—The Z-score can be found using a tool such as https:// zscore.research.chop.edu/index.php.

Adapted with permission from Golden NH, Katzman DK, Sawyer SM, et al.; Society for Adoles-

cent Health and Medicine. Position paper: medical management of restrictive eating disorders

in adolescents and young adults. J Adolesc Health. 2015; 56(1): 123.

TABLE 6

Factors that Support Hospitalization in Persons

with Eating Disorders*

Acute food refusal

Acute medical complications of malnu-

trition or purging (e.g., syncope, seizure,

heart failure, pancreatitis, hematemesis)

Arrested growth and development

Co-occurring behavior or medical

conditions that limit outpatient manage-

ment (e.g., severe depression, obsessive

compulsive disorder, type 1 diabetes

mellitus, suicidality)

Dehydration

Electrocardiogram abnormalities

(e.g., prolonged corrected QT interval)

Electrolyte disturbances (e.g., hypokale-

mia, hyponatremia, hypophosphatemia)

Failure of outpatient treatment†

Median body mass index ≤ 75% for

age and sex

Physiologic instability, including

autonomic dysfunction

Bradycardia‡ (< 50 beats per

minute during day; < 45 beats per

minute at night)

Hypotension (< 90/45 mm Hg)

Hypothermia (< 96°F [35.6°C])

Orthostatic increase in pulse (>

20 beats per minute) or decrease

in blood pressure (> 20 mm Hg

systolic or > 10 mm Hg diastolic)

Uncontrollable bingeing and

purging

*—Hospitalization decisions should incorporate the patient’s entire clinical presentation,

including physical and emotional health, speed of weight loss, outpatient treatment options,

and family support. One or more factors listed above may support admission.

†—Failure of outpatient treatment is highly individualized.

‡—Bradycardia may be physiologic in some athletes but may be pathologic if accompanied by

hypothalamic dysfunction (e.g., orthostasis, amenorrhea, temperature dysregulation), dizziness,

electrocardiogram abnormalities (e.g., corrected QT interval prolongation), extremely low heart

rates, or compulsive exercise. This determination may require consultation with a cardiologist.

Adapted with permission from Golden NH, Katzman DK, Sawyer SM, et al.; Society for Adoles-

cent Health and Medicine. Position paper: medical management of restrictive eating disorders

in adolescents and young adults. J Adolesc Health. 2015; 56(1): 124.

28 American Family Physician www.aafp.org/afp Volume 103, Number 1

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January 1, 2021

EATING DISORDERS

and purging compared with placebo and lower dosages.

36,46

Studies of other SSRIs have found benet at high dosages;

however, high-dose citalopram (Celexa) and escitalopram

(Lexapro) increase the risk of corrected QT interval pro-

longation.

Topiramate (Topamax) may decrease bingeing

and purging behaviors, but it may also limit appetite cues,

potentially complicating treatment.

46,49

Binge-Eating Disorder. Lisdexamfetamine (Vyvanse),

approved by the FDA for binge-eating disorder, and topira-

mate decrease binge-eating episodes and may lead to weight

stabilization or loss.

37,4 6 , 50

SSRIs, tricyclic antidepressants,

anticonvulsants, and appetite suppressants may decrease

binge eating, with a variable eect on weight.

BONE HEALTH

Among patients with weight loss, weight restoration is

important for the recovery of bone mineral density.

3,20,47,51

However, weight restoration in females without resump-

tion of menses indicates ongoing compromise.

Func-

tional hypothalamic amenorrhea (i.e., anovulation linked

to weight loss, excessive exercise, or

stress) has been reviewed recently.

31,52

Hormonal contraceptives have not

been associated with improved bone

mineral density and may mask natural

resumption of menses, an important

recovery marker, but eective contra-

ception should be oered to patients

who want to prevent pregnancy.

31,52

Short-term transdermal 17-beta estra-

diol (e.g., 100-mcg patch, or incremental

doses if bone age is less than 15) avoids

rst-pass liver metabolism and may be

given with cyclic oral progestin (e.g.,

medroxyprogesterone [Provera], 2.5 mg

per day, 10 days per month) to improve

bone health aer six to 12 months

of nonpharmacologic therapy.

17,52,53

Resumption of menses, which may

take longer than one year to achieve,

is associated with return to pre-illness

(or slightly higher) weight and a serum

estradiol measurement greater than

30 pg per mL (110.13 pmol per L).

SPORTS PARTICIPATION

Participation in athletics may interfere

with the healing process by allowing

untreated disordered behaviors to con-

tinue. erefore, participation requires

considering a patient’s clinical and

psychosocial context and their ability

to increase nutritional consumption

to compensate for additional energy

expenditure. Shared decision-making

between the athlete, treatment team,

and caregivers should prioritize recov-

ery. One decision tool for patients with

female athlete triad (i.e., menstrual

dysfunction, low energy availability,

and decreased bone mineral density)

FIGURE 1

Algorithm for the medical management of patients with suspected or

diagnosed eating disorders.

Information from references 3, 20, 33, and 60.

History: review psychosocial and clinical factors (e.g., cognitions about eating,

body image, self-esteem; eating and compensatory behaviors; [pre-] syncope,

exercise intolerance, palpitations, chest pain, menstrual patterns, social support)

Physical examination (e.g., vital signs, height, weight, body mass index)

Testing (e.g., orthostatic vital signs; complete blood count, basic metabolic panel,

serum calcium, magnesium, and phosphate levels; electrocardiography)

Assess:

Accuracy of diagnosis; presence of alternative

or co-occurring diagnoses

Motivation for change

Nutritional, menstrual, anthropometric trends

Medical and mental health sequelae

Degree of malnutrition; healthy weight range based on

pre-illness anthropometric trajectories/pubertal status

Determine lowest level of safe and eective care

Professional supervision

and structure needed for

patient to eat, gain weight,

avoid disordered behav-

iors; treatment failure

Residential treatment

(e.g., constant care)

Partial hospitalization

(e.g., day program)

Intensive outpatient

(e.g., partial day, nondaily)

Ensure the presence of uniﬁed, evidence-based care across team

members and caregivers; goal setting; follow-up planning

Imminent threat to health

Medical hospitalization

(e.g., surveillance for

refeeding syndrome;

cardiac monitoring)

Psychiatric hospitalization

(e.g., suicidality), include

health status, weight trajec-

tory, outpatient options,

and social support

Typically preferred

Outpatient treatment

Team includes an

experienced therapist,

dietitian, and clinician

knowledgeable about

eating disorder–speciﬁc

medical evaluations

January 1, 2021

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EATING DISORDERS

is shown in eTable B, which categorically restricts sports

participation with disordered eating and a BMI of less than

16 kg per m

or purging more than four times per week.

OTHER TREATMENT CONSIDERATIONS

Weight restoration in patients with anorexia ner-

vosa resolves most associated medical complications.

School-aged patients may benet from a 504 plan allowing

meal accommodations (e.g., with a trusted adult) and peri-

odic snacking. Caregivers should be empowered to monitor

social media use and restrict access to pro-anorexia (pro-

ana) and pro-bulimia (pro-mia) websites. Attention-decit

symptoms may emerge with poor nutrition and resolve with

weight restoration; stimulant use may cause weight loss and

TABLE 7

Principles of Major Psychotherapy Modalities for Patients with Eating Disorders

Psychotherapy

modality General treatment principles Typical treatment timelines

Cognitive

behavior

therapy

Individual-focused therapy that targets the patient’s distorted cognitions and

associated problematic eating behaviors

Identify psychological issues and determine how dietary/emotional factors

aect behaviors

May involve meal planning, challenging dysfunctional automatic thoughts

(e.g., all-or-nothing thinking), behavior experiments, exposure to feared

foods, and relapse prevention

Completion of food records may be helpful in binge-eating disorder

Recommended for use in patients with bulimia nervosa, anorexia nervosa,

and binge-eating disorder

Weekly sessions over four to 12

months depending on condition

Early stages may include sessions

two times per week

Can be completed in individual or

group environments

Family-based

therapy

Treatment plan focused on behaviors and education within a family unit.

Family members are not to blame, should conceptualize and frame the eating

disorder as separate from the person, and are vital to therapeutic success by

“uniting” against the disorder.

Phase 1: empowers parents in promoting healthy eating behaviors and to

restore patient’s weight

Phase 2: autonomy in feeding is gradually shifted back to patient

Phase 3: facilitates improved family communication and independence

Recommended for use in adolescents and young adults with anorexia

nervosa and bulimia nervosa

Occurs over six to 12 months,

consisting of 18 to 20 sessions

Self-guided

treatment

Utilizes cognitive behavior therapy principles in self-driven format

Self-monitoring of eating behaviors and inward reﬂection of their underlying

causes

Components of treatment include nutrition education about healthy

eating and development of coping strategies to triggering situations and to

decrease the risk of relapse

Treatment can be delivered via internet, mobile application, or written material

Recommended for use in bulimia nervosa and binge-eating disorder

Typical timeline: self-paced course,

between four and 12 months

Consider supplementing self-help

programming with brief, in-person

sessions

Progress to alternative therapy if

ineective after four weeks

Specialist sup-

portive clinical

management

Psychoeducation model based on “gentle coaching”

Patient-driven therapy founded on therapeutic relationship

Education provided on mutually agreed-upon symptom targets

Goal-directed therapy to decrease these symptoms

Aims to link symptoms and abnormal eating behaviors

Recommended for use in adults with anorexia nervosa; low-quality studies

suggest beneﬁt in bulimia nervosa

Typically consists of 20 or more

weekly sessions spread out over

one year

Information from references 3, 5, 17, 24, 34, and 36-38.

30 American Family Physician www.aafp.org/afp Volume 103, Number 1

◆

January 1, 2021

EATING DISORDERS

decrease appetite cues, impeding treatment. Patients who

purge should seek regular dental care.

17, 2 4

Family members

may benet from individual or family-based counseling.

Markers of Recovery

Restoring the patient’s healthy relationship with food

involves fostering cognitive exibility around eating, elim-

inating harmful behaviors, and reducing body dissatis-

faction and overvaluation of shape and weight.

Among

patients with weight loss, restoration of weight and menses

(if applicable) is a critical rst step in improving overall bio-

psychosocial functioning.

Prevention

For patients of all weight strata, caregivers and clinicians

should support healthy, sustainable lifestyle choices such as

optimizing family meals, physical activity, and consump-

tion of fruits, vegetables, whole grains, legumes, and water,

while limiting sweetened beverages, rened carbohydrates,

and entertainment-based screen time.

Caregivers should

be counseled to refrain from commenting on dieting or

on weight or other appearance-related attributes. Body

dissatisfaction should not serve as the impetus for weight-

loss eorts; instead, health and specic health-related goals

should be emphasized.

Acceptance of larger body size

may be an important therapeutic target.

If necessary, neu-

tral terms such as “weight” or “BMI” are less stigmatizing

than “fat,” “large,” or “obese.”

Weight-based victimization

should be assessed and confronted because it may contribute

to eating pathology and weight gain.

5,16,57

Online resources

are available for family members (https:// www.feast-ed.org),

clinicians (https:// www.aedweb.org), and patients with dis-

ordered eating (https:// www.nationaleatingdisorders.org).

This article updates previous articles on this topic by Harrington,

et al.

; Williams, et al.

; and Pritts and Susman.

Data Sources: A PubMed search was completed using the MeSH

function with the key phrases eating disorder, anorexia nervosa,

bulimia nervosa, binge eating disorder, and one of the following:

diagnosis, evaluation, management, or treatment. The reference

lists of speciﬁc cited references were searched for additional

studies of interest. The search included meta-analyses, ran-

domized controlled trials, clinical trials, and reviews published

after January 1, 2015. Other queries included Essential Evidence

Plus and the Cochrane Database of Systematic Reviews. Search

dates: April through June 2020.

The authors thank Arielle Pearlman for her editorial assistance in

preparation of the manuscript.

The contents of this article are solely the responsibility of the

authors and do not necessarily represent the ocial views of

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation

Evidence

rating Comments

In patients with eating disorders, early intervention and symptom improvement

decrease the risk of a protracted course with long-term pathology.

1,3,11,12,14,15,20,21

C Observational studies and a meta-

analysis of observational studies

Most patients with eating disorders receive optimal care in an outpatient setting.

The outpatient care team should include an experienced therapist, a dietitian, and

a clinician knowledgeable about eating disorder–speciﬁc medical evaluations.

3,33

C Expert opinion

Family-based therapy should be a ﬁrst-line treatment for youths with anorexia

nervosa and bulimia nervosa.

1,3,17,34,36,39,41

A Randomized controlled trials

(patient-oriented outcome)

Medications should not be used as monotherapy in the treatment of anorexia

nervosa or bulimia nervosa.

17, 3 4, 37,4 5 ,47

B Randomized controlled trials (limited-

quality patient-oriented outcome)

Lisdexamfetamine (Vyvanse) can be eective in reducing binge-eating behaviors

in persons with binge-eating disorder.

38,46,50

B Randomized controlled trials

(patient-oriented outcome)

Contraceptives should be oered to patients with disordered eating who want

to prevent pregnancy, but they have not been associated with improved bone

mineral density and may mask resumption of menses.

31,52,53

C Randomized controlled trial (disease-

oriented outcome) and a systematic

review of observational studies

Caregivers and clinicians should focus on positive body image instead of weight

or dieting to prevent disordered eating.

C Expert opinion

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-

oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https:// www.aafp.

org/afpsort.

January 1, 2021

◆

Volume 103, Number 1 www.aafp.org/afp American Family Physician 31

EATING DISORDERS

the Uniformed Services University of the Health Sciences; the

Departments of the Air Force, Army, Navy, or the U.S. military at

large; the Department of Defense; or the U.S. government.

The Authors

DAVID A. KLEIN, MD, MPH, FAAFP, is the Chief of Medical

Sta, 316th Medical Group, Joint Base Anacostia-Bolling,

Washington, DC, and an associate professor in the Depart-

ments of Family Medicine and Pediatrics at the Uniformed

Services University of the Health Sciences, Bethesda, Md.

JILLIAN E. SYLVESTER, MD, CAQ, FAAFP, is an assistant

professor in the Department of Family Medicine at the Uni-

formed Services University of the Health Sciences, an adjunct

assistant professor in the Department of Family Medicine at

Saint Louis University, and a member of the teaching faculty

at the Southwest Illinois Family Medicine Residency at Saint

Louis University.

NATASHA A. SCHVEY, PhD, is an assistant professor in the

Department of Medical and Clinical Psychology at the Uni-

formed Services University of the Health Sciences, and a

research collaborator for the Section on Growth and Obesity

at the National Institutes of Health, Bethesda, Md.

Address correspondence to David A. Klein, MD, MPH, 316th

Medical Group, Joint Base Anacostia-Bolling, 238 Brookley

Ave. SW, Washington, DC 20373 (email: david.a.klein26.mil@

mail.mil). Reprints are not available from the authors.

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eFIGURE A

BMI = body mass index; weight (kg)/[height (m

)].

The growth trajectory of an 11-year-old with anorexia nervosa. Height, weight, and BMI measurements should be

carefully plotted on Centers for Disease Control and Prevention growth charts (https:// www.cdc.gov/growthcharts)

during examinations. (A) Verify measurements. The minor height measurement error (arrow) suggested height loss

over time. The corrected measurement resulted in a more robust drop in the BMI percentile. (B) Identify trends.

Careful attention to the patient’s weight percentile changes (arrows) during the 10-year-old wellness visit may have

prompted discussion about eating patterns, body image, and close follow-up. The weight percentile decreased

despite an absolute increase in weight attributed to appropriate linear growth. (C) Note the profound change (arrows)

in BMI percentile once the eating disorder became entrenched.

3 4 5 6 7 8 9 10 11 12 13

Age (years)

BMI (kg per m

)

BMI (kg per m

)

3 4 5 6 7 8 9 10 11 12 13

38%

68%

54%

17%

43%

53%

34%

30%

36%

16%

Age (years)

Length (inches)

3 4 5 6 7 8 9 10 11 12 13

Age (years)

152

148

144

140

136

132

128

124

120

116

112

108

104

100

Length (centimeters)

62%

53%

59%

60%

43%

64%

55%

58%

77%

75%

73%

70%

77%

3 4 5 6 7 8 9 10 11 12 13

Weight (kg)

3 4 5 6 7 8 9 10 11 12 13

Age (years)

Weight (lb)

57%

59%

69%

71%

39%

17%

26%

49%

54%

47%

53%

49%

52%

67%

55%

56%

41%

52%

50%

60%

40%

BONUS DIGITAL CONTENT

EATING DISORDERS

eTABLE B

Female Athlete Triad: A Proposed Tool to Guide Return-to-Play Recommendations*

Risk factors

Magnitude of risk

Low risk = 0 points each Moderate risk = 1 point each High risk = 2 points each

Low energy availability

with or without an eating

disorder

No dietary restriction Some dietary restriction; current

or previous eating disorder

Meets DSM-5 criteria for current or

previous eating disorder

Low BMI or expected

weight

BMI = 18.5 kg per m

or more, 90% or more

of expected weight, or

weight stable

BMI = 17.5 kg per m

to less than

18.5 kg per m

, less than 90%

of expected weight, or monthly

weight loss of 5% to less than 10%

BMI = less than 17.5 kg per m

, less

than 85% of expected weight, or

monthly weight loss of 10% or more

Delayed menarche Menarche at younger

than 15 years

Menarche at 15 years to younger

than 16 years

Menarche at 16 years or older

Oligomenorrhea or amen-

orrhea (current or previous)

More than nine menses

in 12 months

Six to nine menses in 12 months Fewer than six menses in 12 months

Low bone mineral density† Z-score = –1.0 or more Z-score = –1.0 to less than –2.0,

particularly in patients involved in

weight-bearing sports

Z-score = –2.0 or less

Stress reaction or fracture None One Two or more, or one or more high-risk

fractures (e.g., trabecular site such as

femoral neck, sacrum, or pelvis)

Cumulative risk points + points + points

= Total score

Note: BMI percentile (based on 50th percentile population measurements) is used to calculate expected weight for persons younger than 20 years.

A calculator can be found at https:// www.cdc.gov/healthyweight/bmi/calculator.html.

BMI = body mass index; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th ed.

Full clearance = 0 to 1 point; provisional or limited clearance = 2 to 5 points; restricted from training or competition = 6 or more points.

*—The athlete’s overall clinical and psychosocial context should guide application of this proposed decision tool. Athletes with an eating disorder

and a BMI less than 16 kg per m

or purging more than four times per week should be categorically restricted from training and participation.

†—Bone mineral density testing is indicated for individuals with two or more moderate-risk factors or one high-risk factor. Osteoporosis is deﬁned

as bone mineral density Z-score of –2.0 or less (or –1.0 or less if patient participating in weight-bearing sport) and a clinically signiﬁcant stress

fracture (ﬁve to 19 years of age) or presence of a secondary cause (20 years or older).

Adapted with permission from De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and

return to play of the female athlete triad: 1st international conference held in San Francisco, California, May 2012 and 2nd international conference

held in Indianapolis, Indiana, May 2013. Br J Sports Med. 2014; 48(4): 289.

eTABLE A

SCOFF Questionnaire: Screening for Eating Disorders

Do you make yourself Sick because you feel uncomfortably full?

Do you worry you have lost Control over how much you eat?

Have you recently lost more than One stone (14 lb [6 kg]) in a three-month period?

Do you believe yourself to be Fat when others say you are too thin?

Would you say that Food dominates your life?

Note: One point is given for every “yes” answer; a score of 2 or more indicates the

patient likely has anorexia nervosa or bulimia nervosa.

Adapted with permission from Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire:

assessment of a new screening tool for eating disorders. BMJ. 1999; 319(7223): 1467.