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Editor's Note: This article has been updated to incorporate the January 2021 guidelines from the American Academy of Pediatrics.

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2021;103(1):22-32

Related letter: The Role of Weight Stigma in the Development of Eating Disorders

Patient information: See related handout on eating disorders.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behaviors 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 clinical 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-illness 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 supports 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 on body image instead of a focus on weight or dieting. .

Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behaviors that impair physical health and psychosocial functioning.13 Adolescence and early adulthood are vulnerable periods for the development of eating disorders; however, up to 8% of females and 2% of males are affected during their lifetimes, including persons of all ages, sizes, sexual and gender minority groups, races, ethnicities, socioeconomic strata, and geographic locations.1,46 Diagnostic characteristics of specific eating disorders are presented in Table 1.2

Clinical recommendationEvidence ratingComments
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 CObservational 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 CExpert 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 ARandomized controlled trials (patient-oriented outcome)
Medications should not be used as monotherapy in the treatment of anorexia nervosa or bulimia nervosa.17,34,37,45,47 BRandomized controlled trials (limited-quality patient-oriented outcome)
Lisdexamfetamine (Vyvanse) can be effective in reducing binge-eating behaviors in persons with binge-eating disorder. [corrected]38,46,50 BRandomized controlled trials (patient-oriented outcome)
Contraceptives should be offered 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 CRandomized 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.5 CExpert opinion
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] accompanied 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

Persons with anorexia or bulimia nervosa have a two- to sixfold increase in age-adjusted mortality attributed to medical complications and have suicide completion rates up to 18 times the completion rates of peers.710 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 identified 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

Early Identification

Clinicians, especially those caring for adolescents and young adults, should routinely conduct confidential psychosocial assessments that include questions about eating behaviors, body image, and mood.5,1618,60 The U.S. Preventive Services Task Force is planning to review the health outcomes of screening for eating disorders and the performance of primary care–relevant screening tools.19 Clinicians should monitor patients' height, weight, and body mass index (BMI) trends, including percentile changes and growth curves for youth to avoid missing critical windows for intervention before pathology becomes entrenched20,21,60 (eFigure A). Subtle changes in the amount and speed of weight loss can be as harmful as low weight.2022

Persons with restrictive eating disorders may perceive benefits from the disorder, minimize pathology, and resist treatment.17,20,23 Clinicians should acknowledge that a person's motivation to change may be compromised by malnutrition or co-occurring conditions, lack of self-awareness, or fear.2325 Disordered thoughts and behaviors may provide perceived structure, self-worth, and safety in coping with difficult emotions and stressors.2325 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.5 In males, body dissatisfaction may center on muscularity and leanness, leading to rigid routines and use of appearance- or performance-enhancing substances.26 “Bulk and cut” routines, which involve cycles of excessive energy intake for muscle building followed by caloric deficit to achieve visible muscularity, may mimic binge-purge pathology.27

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