Which recommendations on screening, diagnosing, and treating eating disorders are most helpful?

Most medical professionals would agree that people with eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED), have serious diseases that result in greater morbidity and mortality compared with those in the general population. Although these do not represent the entire spectrum of eating disorders, these are the ones with the most available research data.

Dr. Santina J.G. Wheat

There might be some disagreements on who should be screened, how they should be screened and diagnosed, and how to develop a treatment plan. Some of these may be due to recent changes in physicians’ thinking about who can get an eating disorder. Eating disorders were previously thought to be diseases of affluent white females. Over the past few years, however, it has become more widely accepted that eating disorders may be found across people of a variety of identities and socioeconomic statuses. Clinicians have also become concerned that the incidence of eating disorders has increased and that part of this occurred during the COVID pandemic.

APA’s guideline

In February 2023, the American Psychiatric Association released its first update to the Guideline of Treatment of Patients with Eating Disorders. This is the first update to the guideline since 2006. The guideline was updated with the additional evidence that is now available as further studies have been published since the last update. The 2023 guideline provides nine recommendations for assessment and determination of a treatment plan. It then provides three recommendations specifically for AN and two recommendations each for BN and BED. The introduction acknowledges an unsuccessful attempt to provide recommendations for avoidant/restrictive food intake disorder due to the paucity of evidence on this disease.

The first recommendation within the guidelines indicates “the clinician should be sure to ask all patients about the presence of eating disorder symptoms as part of their standard psychiatric evaluation.” This recommendation is provided as there are many with normal or elevated BMI who may have eating disorders and the identification could provide the prevention of significant morbidity and mortality. It includes screening questions that can be used and standardized screening questionnaires.

Other recommendations go on to describe further evaluation for diagnosis, aspects of the history that should be obtained, and specific treatment modalities that can be used, including cognitive behavioral therapy and oral medications that have been approved for use in eating disorder treatments.¹

AAP’s clinical report

These guidelines add to the recommendations provided by the American Academy of Pediatrics, which published a clinical report on the Identification and Management of Eating Disorders in Children and Adolescents in January 2021. In this guidance document, the AAP recommends screening for eating disorders in any children or adolescents with “reported dieting, body image dissatisfaction, experiences of weight-based stigma, or changes in eating or exercise” and those with weight loss or rapid weight fluctuations.

If there are concerns, then a full assessment is warranted, the recommendations say. When a patient is diagnosed with an eating disorder, this clinical report also provides recommendations on history, exam, and treatment pathways.²