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Guidelines

TL;DR — Current guidance converges on multidisciplinary assessment, nutritional restoration, specialist psychotherapy, family treatment for young people, and medication not being used alone. NICE advises against absolute BMI admission thresholds and offers CBT-ED, MANTRA or SSCM to adults, with focal psychodynamic therapy as another option; [unverified] the carried-forward APA summary says to use eating-disorder-focused psychotherapy and weight restoration. Differences often reflect health-system structure and evidence grading rather than opposed facts. Compulsory treatment and severe enduring illness remain major evidence gaps.

Current major guidance

Body	Year/status	Region	AN scope	Source
NICE NG69	2017; updated 2020; 2024 surveillance retained	UK	Recognition, psychological treatment, physical monitoring, settings, compulsory care	NICE NG69, URL verified 2026-09-02
American Psychiatric Association	2023 current	US	Assessment, treatment planning, psychotherapy, nutrition and medical care	Existence and scope verified via the indexed summary article (Crone 2023, PMID 36722117); the guideline's recommendation text could not be retrieved in the 2026-09-02 audit — see the verification note below
RANZCP	2014 guideline	Australia/New Zealand	DSM-5 eating-disorder groups including atypical AN; NHMRC-graded evidence-based recommendations	RANZCP PDF retrieved and read 2026-09-02; Table 7 grades family therapy and individual psychotherapy for AN at NHMRC Level I and antipsychotic medication for weight gain separately. Published version indexed as Hay 2014, PMID 25351912
ANZAED practice and training standards	2020	Australia/New Zealand	Workforce competence: treatment principles, clinical practice standards, discipline-specific standards	PMID 33292546 (general); PMID 33292542 (mental health professionals); PMID 33317617 (dietitians)
AED "Nine Truths About Eating Disorders"	2015; scientific review 2017	International	Public-facing consensus statement, translated into 30+ languages	Evidence review indexed as Schaumberg 2017, PMID 28967161
Society for Adolescent Health and Medicine	2022 position paper	North America/international relevance	Medical management of restrictive EDs in adolescents/young adults	PMID 36058805
Canadian practice guidelines (Couturier)	2020	Canada	Children and adolescents; GRADE-graded recommendations	PMID 32021688
Canadian transitions guideline (Dimitropoulos)	2025	Canada	Paediatric-to-adult transition for eating disorders and mental health conditions; GRADE + modified Delphi	PMID 40722124
German S3 (revised)	2019 revision of 2011 original	Germany	Diagnosis and treatment of eating disorders	Revision described in PMID 30700054

Verification status of the guidance cited here

Audit note, 2026-09-02. NICE NG69 recommendation text and the RANZCP guideline PDF were both retrieved and read directly, and the statements attributed to them below are verified against those documents. The APA 2023 guideline could not be: both psychiatryonline.org URLs returned HTTP 403 to automated requests, and the indexed summary article (Crone 2023, PMID 36722117) carries no abstract. The APA recommendation content on this page is therefore carried forward from the build session unverified, and is marked as such wherever it appears. This is the reason this page remains status: draft while most other pages in this condition were promoted.

NICE NG69, verified against the guideline text

The recommendation text at nice.org.uk/guidance/ng69/chapter/Recommendations was retrieved and read during the independent audit on 2026-09-02; the numbered recommendations below are quoted in substance from that text.

Rec.	Substance
1.2.8	Do not use single measures such as BMI or duration of illness to determine whether to offer treatment for an eating disorder
1.3.4	For adults with anorexia nervosa, consider one of: individual eating-disorder-focused CBT (CBT‑ED), MANTRA, or SSCM — and explain what each involves so the person can choose
1.3.5	CBT‑ED for adults should typically consist of up to 40 sessions over 40 weeks
1.3.8	If CBT‑ED, MANTRA or SSCM is unacceptable, contraindicated or ineffective, consider one of the three not tried before, or eating-disorder-focused focal psychodynamic therapy (FPT)
1.3.10	Consider anorexia-nervosa-focused family therapy (FT‑AN) for children and young people, as single-family therapy or a combination of single- and multi-family therapy
1.3.11	FT‑AN should typically consist of 18 to 20 sessions
1.3.24	Do not offer medication as the sole treatment for anorexia nervosa
1.10.3	Provide acute medical care, including emergency admission, for severe electrolyte imbalance, severe malnutrition, severe dehydration or signs of incipient organ failure
1.11.1	Admit people whose physical health is severely compromised for medical stabilisation and to initiate refeeding, if this cannot be done as an outpatient
1.11.2	Do not use an absolute weight or BMI threshold when deciding whether to admit to day-patient or inpatient care
1.11 (inpatient harms)	Consider that a person may become institutionalised by a long admission, that a lack of change in their condition could indicate inpatient treatment is harmful, and consider an independent second opinion where clinicians disagree about continued inpatient care
1.12.1–1.12.2	Where physical health is at serious risk and the person does not consent, follow the Mental Health Act 1983 framework; for a child or young person lacking capacity, seek parental consent and, if necessary, an appropriate legal framework

Two of these deserve emphasis because they cut against common practice. Recommendation 1.2.8 rules out duration of illness as well as BMI as a gate on treatment — directly relevant to the severe-and-enduring debate, where duration is the usual proxy. And the inpatient-harm recommendation makes NICE one of the few guideline bodies to state in its own text that prolonged inpatient care can itself be harmful and that stasis is a signal to reconsider, not to persist.

Guidance beyond NICE: what carries a grade

Two national guidelines published since NICE state their evidence grading explicitly, which allows the strength of a recommendation to be read alongside its content rather than inferred.

Canada (Couturier 2020, PMID 32021688) developed guidelines for children and adolescents using systematic review, the GRADE system and a national multi-stakeholder panel. The grading is the informative part:

Grade	Recommendation
Strong	Family-Based Treatment
Strong	Use of the least intensive treatment environment
Weak	Multi-Family Therapy
Weak	Cognitive Behavioural Therapy
Weak	Adolescent-Focused Psychotherapy
Weak	Adjunctive yoga
Weak	Atypical antipsychotics

Only two recommendations in the whole adolescent field reached "strong", and one of them is a statement about setting rather than about a therapy. That the same panel graded atypical antipsychotics as a weak positive recommendation is a divergence from NICE, whose 1.3.24 states that medication should not be offered as the sole treatment but which does not endorse antipsychotics adjunctively.

Germany's S3 guideline was revised from its 2011 original; the revision paper reports that most of its treatment recommendations are consistent with existing international guidelines, and that although the evidence base had improved substantially in quality and quantity since 2011, further research remained necessary (Resmark 2019, PMID 30700054).

Canada also now has a dedicated transitions guideline addressing the paediatric-to-adult handover. Built on a scoping review that screened 14,350 records and included 419 studies (199 primary), it issued strong recommendations for integrated, collaborative transition approaches involving young people, families and providers, and for the Transition Readiness Assessment Questionnaire — while reporting that certainty of evidence for specific interventions and tools was generally low, with only three studies contributing key-outcome data (Dimitropoulos 2025, PMID 40722124).

How much do international guidelines actually agree?

A systematic comparison of nine evidence-based eating-disorder guidelines found "notable commonalities and differences", with a specific structure to the agreement: current guidelines "do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent" (Hilbert 2017, PMID 28777107). That is the pattern this page's comparison table reproduces — convergence on the core (nutrition, specialist psychotherapy, family therapy for young people, no stand-alone medication), divergence on almost everything peripheral, which is where most clinical decisions actually live. The same review notes that people with eating disorders frequently do not receive an evidence-based treatment at all, so guideline concordance is not the binding constraint on care quality.

RANZCP 2014, now indexed and readable

The Australian and New Zealand guideline was developed under NHMRC methodology, drawing on prior RANZCP reviews to 2009 updated by a systematic review covering 2008–2013, followed by expert, community and stakeholder consultation. For AN it recommends treatment as an outpatient or day patient in most instances — explicitly framed as the least restrictive environment — with hospital admission for those at risk of medical or psychological compromise; a multi-axial, collaborative approach covering nutritional, medical and psychological aspects; family-based therapies in younger people; specialist therapist-led manualized psychological therapies in all age groups, with longer-term follow-up; and a harm-minimization approach in chronic AN (Hay 2014, PMID 25351912). Two points distinguish it from NICE. It names harm minimization for chronic illness as a guideline position rather than leaving it to the ethics literature — relevant to severe and enduring illness. And it recommends specialist manualized therapy across the whole age range rather than splitting the recommendation by age as NICE does. The same document notes that no specific treatment can be recommended for ARFID because no trials exist to guide practice.

Workforce standards: the layer below guidelines

Guidelines specify what to deliver; they rarely specify who is competent to deliver it. The Australia & New Zealand Academy for Eating Disorders convened an expert group and, through four stages of consultation — expert reviewers, a workshop of roughly 100 clinicians, open online consultation and consultation with professional and consumer/carer organizations — published eight treatment principles and seven general clinical practice standards. The principles are: early intervention is essential; co-ordination of services is fundamental; services must be evidence-based; involvement of significant others is highly desirable; a personalised approach is required; education/psychoeducation is included in all interventions; multidisciplinary care is required; and a skilled workforce is necessary. The practice standards cover diagnosis and assessment, the multidisciplinary team, therapeutic alliance, knowledge of evidence-based treatment, knowledge of levels of care, relapse prevention and professional responsibility (Heruc 2020, PMID 33292546), with separate documents for mental health professionals (Hurst 2020, PMID 33292542) and dietitians (Heruc 2020, PMID 33317617).

These are consensus documents, not evidence syntheses, and they carry no grading. Their significance for this page is structural: the international guidelines converge on what treatment should be offered while the evidence in the table above shows most of those recommendations rest on low-certainty evidence — and no guideline located here specifies the training required to deliver them except this one.

The public-facing consensus

The Academy for Eating Disorders' "Nine Truths About Eating Disorders", crafted in 2015 with international patient, advocacy and parent organizations, has been translated into over 30 languages. A review examining the scientific support for each of the nine statements found that most arise from well-established foundations in the literature, while additional evidence is required to substantiate some of the assertions (Schaumberg 2017, PMID 28967161). It is a public-facing consensus statement rather than a clinical guideline and does not recommend treatment.

Recommendation comparison

Domain	NICE	APA [unverified] / adolescent medical guidance	Shared core
Adults	CBT-ED, MANTRA or SSCM; consider FPT	ED-focused psychotherapy	Specialist psychotherapy plus weight restoration
Youth	AN-focused family therapy	Family-based treatment/caregiver involvement	Developmental and family context
Medication	Do not use as sole treatment	Adjunct only; evidence limited	No stand-alone pharmacotherapy
Admission	Do not use absolute BMI threshold	Physiology, trajectory and context	Risk-based setting decision
Refeeding	Trained multidisciplinary monitoring	Medical monitoring with structured nutrition	Prevent/detect refeeding complications
Atypical AN	Treat closest resembling disorder; risk assessment	Restrictive EDs can be severe at normal/higher weight	Weight alone is insufficient

Evidence behind convergence

The convergence is real, but it rests on thinner evidence than the guidelines' confidence implies, and the certainty belongs next to the recommendation.

Recommendation	Underlying evidence	Certainty as reported by the synthesists
Family therapy for children and young people	Cochrane review, 25 trials: advantage over treatment as usual on post-intervention remission RR 3.50 (95% CI 1.49–8.23) from 2 studies and 81 participants, not maintained at follow-up; no clear advantage over other psychological interventions (RR 1.22, 0.89–1.67; 5 studies, n=252)	Low quality; 68% of studies at high risk of selective reporting bias (Fisher 2019, PMID 31041816)
A menu of adult psychotherapies	Network meta-analysis, 16 RCTs from 14,003 screened reports, 13 in the network, 1,047 patients; none outperformed treatment as usual on BMI or eating-disorder symptoms	Low to very low (Solmi 2021, PMID 33600749)
Medication not as sole treatment	19 acute-phase RCTs, 8 meta-analysed; the 5 reporting BMI showed no significant olanzapine–placebo difference; no significant psychopathology, depression or anxiety effect for any molecule	No evidence demonstrated for any psychotropic in acute-phase AN (Cassioli 2020, PMID 32448045)
No absolute BMI admission threshold	Physiological and contextual admission criteria across restrictive eating disorders at any weight	Position paper, not a graded evidence review (SAHM 2022, PMID 36058805)
Monitored higher-calorie refeeding	StRONG RCT: stability restored earlier (HR 1.67, 95% CI 1.10–2.53), stay 4.0 days shorter, no excess adverse events — but no better remission or rehospitalization at 1 year	Single trial, two US tertiary centres, ≥60% median BMI (Garber 2021, PMID 33074282; Golden 2021, PMID 33753542)

A guideline recommending family therapy for adolescents and a menu for adults is not choosing between strong options; it is distributing weak evidence sensibly. The honest reading of the adult row is that guidelines name specific therapies because clinicians need something to offer, not because the network separates them.

Disagreements and gaps

Question	Current divergence/gap
Exact admission thresholds	Numerical aids differ; NICE rejects a sole absolute BMI rule
Refeeding start/escalation	Older “start low” guidance versus newer monitored higher-calorie evidence; no guidance yet reflects that fixed kcal/day protocols underfeed atypical AN by roughly 25% on a per-kilogram basis (Garber 2024, PMID 38179719)
Severe enduring AN	No validated treatment pathway or terminal threshold
Compulsory feeding	Legal process differs; the only large cohort reports elevated post-compulsion mortality without a comparator pathway, so it cannot guide policy either way (Bager 2026, PMID 42383339)
Bone drugs	No approved agent; fracture excess now established at population scale (osteoporotic-fracture HR 7.50, 95% CI 5.62–10.01) but no trial uses fracture as an endpoint (Cyrenne-Dussault 2026, PMID 41109616)
Atypical AN	Recognition is increasing faster than treatment trials: 64 comparative publications by 2026, still no course or outcome cohort (Lee 2026, PMID 42557659)

NICE’s 2024 exceptional surveillance found little direct evidence for severe enduring AN and did not update NG69; this is an evidence-gap decision, not proof that existing recommendations are optimal (NICE surveillance page, verified 2026-09-02).

Open questions

• Can common outcome definitions make future guideline comparisons quantitative?
• Which newer refeeding evidence should change recommendations for extreme malnutrition? None of it applies: the only randomized trial excluded patients below 60% median BMI (Garber 2021, PMID 33074282; Garber 2016, PMID 26661289).
• Should refeeding guidance be re-expressed in kcal/kg rather than kcal/day, given that fixed-calorie protocols systematically underfeed heavier patients with atypical AN (Garber 2024, PMID 38179719)?
• How should lived-experience evidence be graded alongside trials in coercion policy?
• Why do national panels grade antipsychotics differently — a weak positive recommendation in Canada against NICE's silence on adjunctive use — from substantially the same trial evidence (Couturier 2020, PMID 32021688; Cassioli 2020, PMID 32448045)?
• How should other guideline bodies address paediatric-to-adult transition, given the generally low certainty reported by the dedicated Canadian guideline (Dimitropoulos 2025, PMID 40722124)?
• Is the inconsistency in peripheral recommendations across nine international guidelines a reflection of local health systems or of unstated differences in evidence appraisal (Hilbert 2017, PMID 28777107)?
• Should harm minimization in chronic AN be a guideline recommendation, as RANZCP states, rather than an ethics-literature question (Hay 2014, PMID 25351912)?
• Should guidelines specify workforce competence as well as treatment content? Only one located document does, and it carries no evidence grading (Heruc 2020, PMID 33292546).
• Which of the widely circulated "Nine Truths" statements are firmly evidenced and which are not, and does the distinction reach the audiences that read them (Schaumberg 2017, PMID 28967161)?

Related pages

• Treatment in adolescents — family approaches.
• Treatment in adults — psychotherapy menu.
• Red flags and safety concerns — medical thresholds.

References

1. Society for Adolescent Health and Medicine. Medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2022. PMID 36058805.
2. Fisher CA, et al. Family therapy approaches for anorexia nervosa. Cochrane Database Syst Rev. 2019. PMID 31041816.
3. Solmi M, et al. Comparative efficacy and acceptability of psychological interventions for adult outpatients with anorexia nervosa. Lancet Psychiatry. 2021. PMID 33600749.
4. Cassioli E, et al. Pharmacological treatment of acute-phase anorexia nervosa. J Psychopharmacol. 2020. PMID 32448045.
5. Garber AK, et al. Short-term outcomes of higher- versus lower-calorie refeeding. JAMA Pediatr. 2021. PMID 33074282.
6. American Psychiatric Association. Practice guideline for treatment of patients with eating disorders. Am J Psychiatry. 2023. URL verified 2026-09-02.
7. National Institute for Health and Care Excellence. Eating disorders: recognition and treatment, NG69. 2017, updated 2020. URL verified 2026-09-02.
8. Golden NH, et al. Higher-calorie refeeding in anorexia nervosa: 1-year outcomes from a randomized controlled trial. Pediatrics. 2021;147:e2020037135. PMID 33753542.
9. Garber AK, et al. Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa. Int J Eat Disord. 2024;57:859-868. PMID 38179719.
10. Lee V, Hagan KE. An invited updated systematic review and meta-analysis comparing atypical anorexia nervosa and anorexia nervosa. Int J Eat Disord. 2026. PMID 42557659.
11. Bager L, et al. Excess mortality among patients with anorexia nervosa treated involuntarily. Int J Eat Disord. 2026. PMID 42383339.
12. Cyrenne-Dussault M, et al. Anorexia nervosa and risk of fractures: a matched cohort study of 80,000 men and women. Am J Med. 2026;139:333-340. PMID 41109616.
13. Couturier J, et al. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord. 2020;8:4. PMID 32021688.
14. Dimitropoulos G, et al. Transitions for youth and young adults with eating disorders and/or other mental health conditions: a Canadian guideline. J Eat Disord. 2025;13:158. PMID 40722124.
15. Resmark G, et al. Treatment of anorexia nervosa — new evidence-based guidelines. J Clin Med. 2019;8:153. PMID 30700054.
16. Hilbert A, et al. Evidence-based clinical guidelines for eating disorders: international comparison. Curr Opin Psychiatry. 2017;30:423-437. PMID 28777107.
17. Hay P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014;48:977-1008. PMID 25351912.
18. Heruc G, et al. ANZAED eating disorder treatment principles and general clinical practice and training standards. J Eat Disord. 2020;8:63. PMID 33292546.
19. Hurst K, et al. ANZAED practice and training standards for mental health professionals providing eating disorder treatment. J Eat Disord. 2020;8:58. PMID 33292542.
20. Heruc G, et al. ANZAED practice and training standards for dietitians providing eating disorder treatment. J Eat Disord. 2020;8:77. PMID 33317617.
21. Schaumberg K, et al. The science behind the Academy for Eating Disorders' Nine Truths About Eating Disorders. Eur Eat Disord Rev. 2017;25:432-450. PMID 28967161.
22. Garber AK, et al. A systematic review of approaches to refeeding in patients with anorexia nervosa. Int J Eat Disord. 2016;49:293-310. PMID 26661289.
23. Crone C, et al. The American Psychiatric Association practice guideline for the treatment of patients with eating disorders. Am J Psychiatry. 2023;180:167-171. Summary article; no abstract indexed. PMID 36722117.