Bibliographic Source(s)

• Finnish Medical Society Duodecim. Eating disorders among children and adolescents. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2007 Mar 28 [Various].

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Eating disorders among children and adolescents. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2005 Feb 8 [Various].

Guideline Category

Counseling
Diagnosis
Evaluation
Management
Treatment

Intended Users

Health Care Providers
Physicians
Psychologists/Non-physician Behavioral Health Clinicians

Guideline Objective(s)

Evidence-Based Medicine Guidelines collect summarize and update the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations.

Target Population

Children and adolescents with known or suspected eating disorders such as anorexia nervosa or bulimia nervosa

Interventions and Practices Considered

Diagnosis/Evaluation

1. Screening questionnaire
2. Evaluation for signs and symptoms of eating disorders
3. Laboratory tests to evaluate for anemia and low blood glucose levels (anorexia nervosa) or for hypokalaemia and increased serum amylase (bulimia nervosa)

Treatment/Management/Counseling

1. Treatment of severe malnutrition in a somatic ward
2. Psychotherapy (individual and family)
3. Cognitive therapy and medication (bulimia nervosa)
4. Psychopharmaceuticals (e.g. neuroleptics and antidepressants)

Note: Guideline developers considered several other prevention and treatment options. For a list of these see the "Major Recommendations" field below.

Major Outcomes Considered

• Eating disorder symptomatology
• Weight gain
• Efficacy of treatment at reducing symptoms of eating disorders and improving prognosis
• Mortality

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

The evidence reviewed was collected from the Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). In addition the Cochrane Library and medical journals were searched specifically for original publications.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

1. Quality of Evidence: High

   Further research is very unlikely to change confidence in the estimate of effect

   • Several high-quality studies with consistent results
   • In special cases: one large high-quality multi-centre trial

2. Quality of Evidence: Moderate

   Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

   • One high-quality study
   • Several studies with some limitations

3. Quality of Evidence: Low

   Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

   • One or more studies with severe limitations

4. Quality of Evidence: Very Low

   Any estimate of effect is very uncertain.

   • Expert opinion
   • No direct research evidence
   • One or more studies with very severe limitations

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Major Recommendations

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Objectives

• Remember that eating disorders are very common among adolescent girls and especially bulimic disorders are encountered in boys as well.
• One must remember to look for signs of an eating disorder; patients seldom report it themselves.
• The diagnosis and planning of treatment are the responsibility of special personnel.

Basic Rules

• An eating disorder refers to states in which food and nourishment have an instrumental and manipulative role: food has become a way to regulate the appearance of the body.
• The spectrum of eating disorders is vast. The most common disorders are anorexia nervosa and bulimia nervosa. In addition incomplete clinical pictures and simple binge eating have become more general.
• Recently the international trend has been to put more emphasis on early reaction to the symptoms.
• Even small children can have different kinds of eating disorders that relate to difficulties in the relationships between the child and his/her caretaker.

Aetiology

• Currently eating disorders are considered to be multifarious. Genetic and sociocultural factors and also individual dynamics all affect eating disorders.
• The typical age of onset is adolescence when the body changes and grows.
• Anorexia nervosa typically emerges between 14 and 16 years of age or around the age of 18 years. Bulimia appears typically at the age of 19-20 years.
• Eating disorders are 10-15 times more common among girls than boys.
• Every 150th girl between the ages of 14 and 16 years suffers from anorexia nervosa.
• There is no epidemiological data on the occurrence of bulimia but it is considered to be more common than anorexia nervosa.

Diagnostic Criteria for Anorexia Nervosa

• The patient does not want to maintain his or her normal body weight.
• The patient's weight is at least 15% below that expected for age and height.
• The patient's body image is distorted.
• The patient is afraid of gaining weight.
• There is no other sickness that would explain the loss of weight.

Diagnostic Criteria of Bulimia Nervosa

• Desire to be thin phobic fear of gaining weight
• Persistent preoccupation with eating and an irresistible urge or compulsive need to eat.
• Episodes of binge eating (at least twice a week); control over eating is lost.
• After the episode of binge eating the person attempts to eliminate the ingested food (e.g. by self-induced vomiting and by abuse of purgatives and diuretics).

Symptoms

• Anorexia nervosa generally starts gradually.
• Losing weight can either be very rapid or very slow. Generally the patients continue to go to school; they go on with their hobbies and feel great about themselves. Therefore the families are usually surprised to find that their child suffers from malnutrition.
• A screening questionnaire is helpful in the assessment of patients with suspected eating disorder (each positive answer gives one point; 2 or more points suggest an eating disorder).
  1. Do you try to vomit if you feel unpleasantly satiated?
  2. Are you anxious with the thought that you cannot control the amount of food you eat?
  3. Have you lost more than 6 kg of weight during the last 3 months?
  4. Do you consider yourself obese although others say you are underweight?
  5. Does food/thinking of food dominate your life?
• Anorectic adolescents deny their symptoms and it takes time and patience to motivate them to accept treatment.
• Somatic symptoms include:
  • Disappearance of menstruation
  • The slowing of metabolism constipation
  • Slow pulse low blood pressure
  • Flushed and cold limbs
  • Reduction of subcutaneous fat
• Bulimic adolescents are aware that their eating habits are not normal but the habit causes so much guilt and shame that seeking treatment is not easy.
• Bulimia also causes physical symptoms
  • Disturbances of menstruation
  • Disturbances in electrolyte and acid-alkali balances created by frequent vomiting and damage of the enamel of teeth (see the Finnish Medical Society Duodecim guideline "Dental Caries and Other Diseases of the Hard Tissues of the Teeth and Dental Pulp")

Laboratory Findings

• In anorexia nervosa
  • Slight anaemia
  • Blood glucose levels on the lower border of normal
• In bulimia
  • Hypokalaemia
  • Increased serum amylase

Differential Diagnosis

• Severe somatic diseases for example brain tumours
• Psychiatric diseases--severe depression psychosis use of drugs

Treatment

• If the symptoms correspond to the diagnostic criteria of anorexia nervosa the situation should be discussed with the family before treatment is arranged.
• The adolescent and his or her family should be made aware of the seriousness of the disorder.
• Sometimes it takes time to motivate the patient to participate in the treatment.
• The treatment is divided into
  • Restoring the state of nutrition
  • Psychotherapeutic treatment
• If the state of malnutrition is life threatening the patient is first treated in a somatic ward and thereafter the adolescent is guided into therapy if possible.
• The forms of psychotherapy vary: both individual and family therapy have brought results; in cases of bulimia cognitive therapy and medication (Lewandowski et al. 1997; Whittal Agras & Gould 1999) [C] have been successful.
• With adolescents between the ages of 14 and 16 years positive results have been obtained by treating the entire family because the adolescent's symptoms are often connected with difficulties to "cut loose" from the family.
• With older patients individual supportive and long-lasting treatment has been the best way to promote recovery.
• A prolonged state of malnutrition and insufficient outpatient care are reasons to direct a patient into forced treatment.

Medical Treatment

• A specialist should start all drug treatment.
• Different psychopharmaceuticals for example neuroleptics and antidepressants have been tried in the treatment of anorexia nervosa. Controlled studies have proved them indisputably useful only if the disorder is linked to clear depression.
• Most research on the medical treatment of bulimia has concentrated on antidepressants (Bacaltchuk & Hay 2003) [A] particularly fluoxetine which has been found to decrease binge eating and vomiting for about two-thirds of bulimic patients.

Prognosis

• Early intervention improves prognosis.
• Eating disorders comprise a severe group of diseases that are difficult to treat. The prognosis for the near future of anorectic patients is good but for the long term the prognosis is worse. The percentage of mortality is still 5 to 16%.
• Not enough follow-up research has been carried out on the prognosis of bulimia but the disease is thought to last years.
• Bulimia can be associated with depression self-destructiveness abuse of alcohol or drugs and other psychological problems.

Related Resources

Cochrane Reviews

• A combination of antidepressants and psychotherapy may be more effective than psychotherapy alone but psychotherapy appeared to be more acceptable to subjects. There was a non-significant trend favouring single psychotherapy over single antidepressants (Bacaltchuk Hay & Trefiglio 2001) [C].
• Antidepressants appear to be ineffective in the treatment of anorexia nervosa (Claudino et al 2006; Walsh et al. 2006; Treasure & Schmid 2005) [B].

Other Evidence Summaries

• There is no evidence from controlled trials to assess whether early intervention is beneficial in anorexia nervosa (Shoemaker 1997) [D].
• Evidence on inpatient versus outpatient care for eating disorders is insufficient for firm conclusions (Meads et al. 1999) [D].

Definitions:

Levels of Evidence

1. Quality of Evidence: High

   Further research is very unlikely to change confidence in the estimate of effect

   • Several high-quality studies with consistent results
   • In special cases: one large high-quality multi-centre trial

2. Quality of Evidence: Moderate

   Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

   • One high-quality study
   • Several studies with some limitations

3. Quality of Evidence: Low

   Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

   • One or more studies with severe limitations

4. Quality of Evidence: Very Low

   Any estimate of effect is very uncertain.

   • Expert opinion
   • No direct research evidence
   • One or more studies with very severe limitations

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Bacaltchuk J Hay P Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Syst Rev 2001;(4):CD003385.



• Bacaltchuk J Hay P. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database Syst Rev 2003;(4):CD003391.



• Claudino AM Hay P Lima MS Bacaltchuk J Schmidt U Treasure J. Antidepressants for anorexia nervosa. Cochrane Database Syst Rev 2006;(1):CD004365. [129 references] PubMed



• Lewandowski LM Gebing TA Anthony JL O'Brien WH. Meta-analysis of cognitive-behavioral treatment studies for bulimia. Clin Psychol Rev 1997 Nov;17(7):703-18. PubMed



• Meads C Burls A Gold L Jobanputra P. In-patient versus out-patient care for eating disorders. Birmingham United Kingdom: Development and Evaluation Service Department of Public Health and Epidemiology University of Birmingham; 1999 Sep. 58 p. (West Midlands DES reports; no. 17).



• Schoemaker C. Does early intervention improve the prognosis in anorexia nervosa? A systematic review of the treatment-outcome literature. Int J Eat Disord 1997 Jan;21(1):1-15. [90 references] PubMed



• Treasure J Schmid U. What are the effects of treatments in anorexia nervosa. Clin Evid 2005;13:1151-2.



• Walsh BT Kaplan AS Attia E Olmsted M Parides M Carter JC Pike KM Devlin MJ Woodside B Roberto CA Rockert W. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA 2006 Jun 14;295(22):2605-12. PubMed



• Whittal MC Agras WS Gould RA. Bulimia nervosa: a meta-analysis of psychosocial and pharmacological treatments. Behav Ther 1999;30(1):117-35.

Type of Evidence supporting the Recommendations

Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are. The type of supporting evidence is identified and graded for select recommendations (see the "Major Recommendations" field).

Potential Benefits

• Appropriate diagnosis and treatment of eating disorders among children and adolescents
• Early intervention improves prognosis.

Potential Harms

Not stated

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness

Bibliographic Source(s)

• Finnish Medical Society Duodecim. Eating disorders among children and adolescents. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2007 Mar 28 [Various].

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Finnish Medical Society Duodecim

Guideline Committee

Editorial Team of EBM Guidelines

Composition of Group that Authored the Guideline

Primary Author: Päivi Rantanen

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Eating disorders among children and adolescents. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2005 Feb 8 [Various].

Guideline Availability

This guideline is included in a CD-ROM titled "EBM Guidelines. Evidence-Based Medicine" available from Duodecim Medical Publications Ltd PO Box 713 00101 Helsinki Finland; e-mail: info@ebm-guidelines.com; Web site: www.ebm-guidelines.com.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on August 29 2005. This NGC summary was updated by ECRI on December 22 2006 and December 31 2007.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

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