Clinical Practice Guideline



Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists


Overview:The hallmark of the eating disorders is a significant disturbance in eating behavior.Three eating disorder diagnoses are recognized: anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified.


Anorexia nervosa patients refuse to eat enough to maintain a minimally normal body weight.This disorder is characterized by disturbances in perception of body weight and interpersonal relationships.The prevalence of anorexia nervosa is ten-fold higher in women than men; 0.3 to 1 percent in women.8The age of onset is bimodal, with peak at 14 and 18 years of age; however, patients may present from late childhood through adulthood.9Less than 50% of anorexics recover within 10 years, 25% become chronic, and mortality can reach 25%.2The standardized mortality ratio (SMR) for anorexia nervosa is 10.5 (95% confidence interval [CI] = 5.5-15.5).3


DSM-IV diagnostic criteria for anorexia nervosa.1

         Refusal to maintain body weight at or above a minimally normal weight for age and height (i.e., weight loss or failure to gain weight leading to body weight less than 85 percent of that expected for age and height).

         Intense fear of gaining weight or becoming fat, even though underweight.

         Disturbed experience of one's body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

         In postmenarcheal females, amenorrhea (i.e., absence of three or more consecutive anticipated menstrual cycles).Menstruation induced by hormonal treatment is excluded.


Bulimia nervosa individuals engage in repeated eating binges followed by compensatory behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise.The prevalence of bulimia nervosa among adolescent and young adult females is 1-1.5%, with the prevalence among males being about one-third.9Similar to anorexia nervosa, bulimia nervosa is also characterized by disturbances in perception of body weight and interpersonal relationships, as well as associated with alcohol abuse.4Prognosis for bulimics is better than anorexics; however, fewer than 70% recover within 10 years, while 30% continue to binge eat and purge.10


DSM-IV diagnostic criteria for bulimia nervosa.1

  • Recurrent episodes of binge eating.An episode of binge eating is characterized by both of the following:
    • Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
  • Recurrent inappropriate compensatory behavior to prevent weight gain such as: self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercising.
  • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.
  • Self-evaluation is unduly influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of anorexia nervosa.
  • Specify type:
    • Purging type:the person regularly engages in self-induced vomiting or the misuse of laxatives or diuretics.
    • Nonpurging type:the person uses other inappropriate compensatory behaviors, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or the misuse of laxatives or diuretics.


Eating disorder not otherwise specified (ED-NOS), is used for those eating disorders that do not fully meet the diagnostic criteria for anorexia nervosa or bulimia nervosa.For example, individuals who regularly purge but who do not binge eat, individuals who meet criteria for anorexia nervosa but continue to menstruate, and individuals who meet criteria for bulimia nervosa, but binge eat less than twice weekly, all meet criteria for ED-NOS.1The prevalence of ED-NOS is 3 to 5 percent of women aged 15 to 30 in Western countries.14


Pathology associated with anorexia nervosa includes osteopenia, mitral valve prolapse, prolonged QT interval, arrhythmias, heart failure, amenorrhea,12 and nutritional emphysema.5 Eating disorders are associated with anxiety, depression and suicidal ideation.11Common skin changes include dry scaly skin, fine, dark, downy hair on back, abdomen and forearms, and acrocyanosis.In bulimia nervosa, the Russellís sign (presence of scar/callus formation over the dorsal surface of the hand, as the hand is used to stimulate the gag reflex to induce vomiting), dental erosions and enlarged salivary glands are seen.Many individuals with bulimia maintain a normal weight despite active symptoms.


Cognitive behavioral therapy (CBT) is the psychotherapy of choice for bulimia nervosa.Individuals with bulimia nervosa may also benefit from pharmacological therapy, antidepressants with selective serotonin reuptake inhibitor, fluoxetine, as best studied.13The goal for treatment of anorexia nervosa is weight restoration and reintegration of the individual into a normal family and social life.13To accomplish this a team approach is usually required: dietitian for nutritional aspects, medical provider for managing medical concerns and mental health provider for CBT and interpersonal therapy.


Aeromedical Concerns:A significant concern is the co-morbidity of physical and emotional difficulties that lower the personís stamina for managing the high stress of military flying.For example, eating disorders can cause life-threatening metabolic alkalosis, hypokalemia, dehydration, and hypotension which impact readiness, mission completion, and flying safety.Anxiety and depression are comorbidities highly associated with eating disorders, and there exists an increased risk of suicide.Another area of concern is the level of interpersonal hypersensitivity that often exists within a person with an eating disorder.Such interpersonal reactivity may interfere with crew resource management and other aspects of crew relations essential to successful flying.The common aviator characteristics of lack of insight, use of denial and unreliable history are hallmarks of these disorders and are likely to be present in these individuals.Further, the course and outcome of these disorders is highly variable and marked by relapse with periods of remission alternating with recurrences.As a result, the psychological disposition of a person with an eating disorder is incompatible with aviation duties.


Medical Work-up: See above discussion.


Aeromedical Disposition (military):Air Force:If the DSM-IV-TR diagnostic criteria for anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified are met, then aviators should be placed DNIF and evaluated by a qualified mental health professional.Once the disorder has resolved for one year, a trained aviator may apply for FC II and FC III waivers.For untrained individuals, a minimum of two years remission is required before being considered for a FC I/IA, FC II or FC III waiver.


The initial aeromedical summary should include the following:

††††††††††† A.History - Address pertinent negatives and positives such as symptoms of amenorrhea, constipation, abdominal pain, cold intolerance, lethargy and excess energy (activity level), and any social, occupational, administrative or legal problems associated with the case.Comment regarding stability of patientís weight.

††††††††††† B.Physical - height and weight, blood pressure, skin, cardiovascular, abdominal and neurologic.

††††††††††† C.Lab work including:complete blood count (CBC), chemistry 16 (electrolytes, glucose, calcium, magnesium, phosphorous, blood urea nitrogen (BUN) and creatinine), urine analysis, and ECG.

††††††††††† D.Psychiatric evaluation and treatment summary.

††††††††††† E.Dental evaluation for bulimia nervosa and ED-NOS that purge.

††††††††††† F.Medical evaluation board (MEB) reports if applicable.

††††††††††† G.Input from the individualís commander/supervisor regarding the aviatorís current status.


The renewal aeromedical summary should include the following:

A.History - assessment for recurrences.Comment regarding stability of patientís weight.

B.Physical exam:height and weight, blood pressure, skin, cardiovascular, abdominal, and neurologic.

C.Psychiatric evaluation for first renewal and if clinically indicated on subsequent renewals.


Navy:Eating disorders are considered disqualifying for aviation duties.Waivers may be considered on a case-by-case basis if the patient is off medication, asymptomatic, and out of active treatment for one year.A psychiatric evaluation is required prior to waiver consideration, and these patients must meet minimum Navy aviation weight standards15.


Army:Eating disorders are considered disqualifying for aviation duties.Waivers may be considered on a case-by-case basis if the patient is off medication, asymptomatic, and fully functional in an alternate duty assignment for one year. These patients must meet the minimum aviation weight standards.A psychiatric evaluation is required prior to waiver consideration, and follow-up psychiatric care is at the discretion of the treating mental health provider; however it should involve at least monthly follow-up during the first year of treatment16.


Aeromedical Disposition (civilian): ††No antidepressants, antipsychotic or anxiolytics are presently permitted in civil aviation.Eating disorders are granted medical certification once they have resolved.Depending on the length of time medication was used, the airman may be asked to discontinue all psychotropic medications for 90 days before consideration for return to flying.A current status of the medical condition is required at that time.


Waiver Experience (military): A review of the Air Force database through March 2008 revealed 19 cases of eating disorders.Of the 19 cases, 11 (58%) were disqualified and 8 (42%) were granted waivers.A review of 19 waivers (8 approvals/11 disqualified) revealed that five were disqualified due to associated comorbidities (suicide, suicidal gestures, and depression), four were disqualified due to inadequate control; and two were disqualified based on other non-related medical conditions. Of the approved waivers the minimal time of remission was 1 year.


Waiver Experience (civilian): There is no single pathology code for eating disorders in the FAAís Aeromedical Certification system so civil aviation experience with this condition cannot be determined at this time.




1.American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, Text Revision.Washington, DC 2000. p. 589.


2.Bergh C, Brodin U, Lindberg G, So® dersten P.Randomized controlled trial of a treatment for anorexia and bulimia nervosa.Proc Natl Acad Sci USA.2002 Jul 9; 99(14):9486-91.


3.Birmingham CL, Su J, Hlynsky JA, Goldner EM, Gao M.The mortality rate from anorexia nervosa.Int J Eat Disord.2005 Sep; 38(2):143-6.


4.Bulik, C M., Klump, KL., Thornton, L., et al., Alcohol use disorder comorbidity in eating disorders: a multicenter study. J Clin Psychiatry. 2004 Jul;65(7):1000-6.


5.Coxson HO, Chan IH, Mayo JR, et al.Early emphysema in patients with anorexia nervosa.Am J Respir Crit Care Med.2004; 170:748.


6.Forman SF.Eating disorders:epidemiology, pathogenesis, and clinical features.UpToDate.Online version 16.1; January 31, 2008.


7.Forman SF.Eating disorders:treatment and outcomes.UpToDate.Online version 16.1; January 31, 2008.


8.Hoek HW, van Hoeken D.†† Review of the prevalence and incidence of eating disorders.Int J Eat Disord.2003; 34:383.


9.Hudson JI, Hiripi E, Pope HG Jr, Kessler RC.The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.Biol Psychiatry.2007; 61:348-58.


10.Keel PK, Mitchell JE, Miller KB, Davis TL, Crow SJ.Long-term Outcome of Bulimia Nervosa.Arch Gen Psychiatry.1999; 56:63-69.


11.Miller KK, Grinspoon SK, Ciampa J, et al. Medical findings in outpatients with anorexia nervosa.Ach Intern Med.2005; 165:561-6.


12.Mitchell JE, Crow S.Medical complications of anorexia nervosa and bulimia nervosa.Curr Opin Psychiatry.2006; 19:438-443.


13.Moore DP, Jefferson JW.Chapter 109 Ė Anorexia Nervosa and Chapter 110 Ė Bulimia Nervosa.Handbook of Medical Psychiatry, 2nd ed.Mosby; Philadelphia: 2004.


14.Putukian M.The female triad - eating disorders, amenorrhea and osteoporosis.Med Clin North Am.1994; 78:345.


15.Navy.Aeromedical Reference and Waiver Guide.Adjustment Disorder, Update March 2007.


16.USA.Aeromedical Policy Letters, Eating Disorders, revised Jun. 2005.



July 22, 2008