The International Classification of Diseases (ICD) was first established in the late 1800s, in an effort to help diagnostic classification standards for clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, with each assigned a unique identifier code.

In this article, we’re covering new and notable changes to be expected to the ICD-11 by nutrition professionals including:

• Changes in the ICD-11 classification system to support nutrition professionals
• An overview of what nutrition conditions are included in both the “Nutrition Disorders” section and the “Feeding and Eating Disorders group”
• What new conditions have been added to the ICD-11
• What updates to existing conditions have been made, and the clinical relevance of such updates

About the ICD-11 Release by WHO

The World Health Organization is responsible for maintaining and updating the ICD. Releasing a new update to the ICD takes more than a decade of development. The newest ICD product, ICD-11, was released in 2018 for State Members to implement and will be ready to go into effect on January 1, 2022.

The ICD-11 release will have a widespread impact and implications across the healthcare industry. For nutrition and wellness professionals working in private practice, it will most notably impact those seeking insurance reimbursement, as insurance payers are dependent on ICD coding. National health program managers also need to be attuned to the coding updates, as well as anyone in a role that impacts the allocation of health resources based on diagnosis codes.

Per a WHO press release, the goal of the ICD-11 revisions is to help “simplify the coding structure and electronic tooling.” The new release demonstrates improved usability, updated scientific content, and provides more details for nutrition professionals and dietitians.

In the United States, a group that advises the Secretary of Health and Human Services has given an expected implementation year of 2025, but if a clinical modification is determined to be needed (similar to the ICD-10-CM), ICD-11 implementation might not begin until 2027.

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What Nutrition Professionals Can Expect from ICD-11

ICD-11 is set to improve classifications relevant to nutrition professionals by adding some missing disorders, more clarity on the transition to new terminology, links to other classifications, and actions to address the disorders.

In efforts to make navigating the ICD-11 easier, the coding structure has been updated to group conditions. The ICD-11 will include a Nutritional Disorders (ND) section within the ‘Endocrine, nutritional and metabolic diseases’ that has been developed by a topic advisory group for nutrition.

The section includes the full range of nutritional disorders, from undernutrition to overweight and obesity, throughout the life cycle. An outline of the new Nutritional Disorders section in the ICD-11 is below. The relevant conditions/diagnoses and ICD codes are organized underneath each of these main categories.

• Undernutrition
• Overweight, obesity, or specific nutrient excess – Including section LD29 for syndromes with obesity as a major feature  
• Nutritional or toxic disorders of the nervous system
• Metabolic Disorders
• Postprocedural endocrine or metabolic disorders
• Symptoms, signs, or clinical findings of endocrine, nutritional, or metabolic disease
• Other Nutrition Conditions

New ICD Grouping of Feeding and Eating Disorders

Another notable section within ICD-11 for nutrition professionals includes the grouping of “feeding and eating disorders.” This new section groups together feeding issues most notable in childhood along with eating disorders, speaking to the connection of these conditions across the lifespan. Furthermore, to align with the latest DSM, ICD-11 updates also include the new diagnoses of binge eating disorder and ARFID, expanding upon ICD‐10 feeding disorder of infancy and childhood. Make tracking all of these codes simpler with Healthie. Healthie reduces the administrative time of corporate wellness professionals by over 40%, and enables real-time communication within an organization and with clients.

An overview of the “feeding and eating disorders” included diagnoses is below:

• 6B80 Anorexia nervosa
• 6B81 Bulimia nervosa
• 6B82 Binge eating disorder
• 6B83 Avoidant-restrictive food intake disorder
• 6B84 Pica
• 6B85 Rumination-regurgitation disorder
• 6B8Y Other specified feeding or eating disorders
• 6B8Z Feeding or eating disorders, unspecified

Description of Binge Eating Disorder (BED) in ICD-11

To align with the DSM classification of BED, ICD-11 also includes the condition as an eating disorder. Binge eating disorder is characterized by frequent, recurrent episodes of binge eating (ie. once a week or more over a period of several months). A binge eating episode is a distinct period of time during which the individual experiences a subjective loss of control over eating, eating notably more or differently than usual, and feels unable to stop eating or limit the type or amount of food eaten. Binge eating is experienced as very distressing and is often accompanied by negative emotions such as guilt or disgust. However, unlike in Bulimia Nervosa, binge eating episodes are not regularly followed by inappropriate compensatory behaviors aimed at preventing weight gain (ie. self-induced vomiting, misuse of laxatives or enemas, strenuous exercise).

Exclusions to the diagnosis of BED under ICD-11 include:

• Anorexia Nervosa (6B80)

Description and updates to Avoidant/Restrictive Intake Disorder (ARFID) in ICD-11

Avoidant-restrictive food intake disorder (ARFID) is characterized by abnormal eating or feeding behaviors that result in the intake of an insufficient quantity or variety of food to meet adequate energy or nutritional requirements. The pattern of restricted eating has caused significant weight loss, failure to gain weight as expected in childhood or pregnancy, clinically significant nutritional deficiencies, dependence on oral nutritional supplements or tube feeding, or has otherwise negatively affected the health of the individual or resulted in significant functional impairment. The pattern of eating behavior does not reflect concerns about body weight or shape. Restricted food intake and its effects on weight, other aspects of health, or functioning are not better accounted for by lack of food availability, the effects of a medication or substance, or another health condition.

ARFID is distinguished from anorexia nervosa by the absence of concerns about body weight or shape.

Exclusions to the diagnosis of ARFID under ICD-11 include:

• Anorexia Nervosa (6B80)
• Feeding problem of infant (MG43.30)
• Feeding problems of newborn (KD32)

Description and updates to Anorexia nervosa in ICD-11

In addition, updates to the descriptions of anorexia nervosa and bulimia nervosa incorporate more recent evidence, which clarifies diagnoses. This better classification eliminates the need for “atypical” categories that previously existed under ICD-10.

Anorexia nervosa in the ICD‐11 eliminates the ICD‐10 requirement for the presence of a “widespread endocrine disorder,” as cases without endocrine disorder were largely responsible for atypical anorexia diagnosis. A large change in the diagnostic criteria for anorexia, is “significantly low body weight” in ICD‐11 has increased from 17.5 kg/m2 to 18 kg/m2. However, guidelines accommodate situations in which the body mass index may not adequately reflect a worsening clinical picture. Anorexia nervosa no longer requires “fat phobia” as in the ICD‐10, to allow for the full spectrum of culturally diverse rationales for food refusal and expressions of body preoccupation. Further qualifiers can also be added for describing the pattern of associated behaviors, such as restricting pattern, binge‐purge pattern.

Under ICD-11, there is the option to “add detail” to an anorexia nervosa, with the suggestion of additional codes to be utilized. These codes help to connect anorexia across the lifecycle, and in conjunction with malnutrition.

• 5B50 Underweight in infants, children, or adolescents
• 5B51 Wasting in infants, children, or adolescents
• 5B52 Acute malnutrition in infants, children, or adolescents
• 5B53 Stunting in infants, children, or adolescents
• 5B54 Underweight in adults

Description and updates to Bulimia nervosa in ICD-11

Bulimia Nervosa is characterized by frequent, recurrent episodes of binge eating (ie. once a week or more over a period of at least one month). A binge eating episode is a distinct period of time during which the individual experiences a subjective loss of control over eating, eating notably more or differently than usual, and feels unable to stop eating or limit the type or amount of food eaten. Binge eating is accompanied by repeated inappropriate compensatory behaviors aimed at preventing weight gain (ie. self-induced vomiting, misuse of laxatives or enemas, strenuous exercise). The individual is preoccupied with body shape or weight, which strongly influences self-evaluation. The individual is not significantly underweight and therefore does not meet the diagnostic requirements of Anorexia Nervosa.

Updates to Bulimia nervosa in the ICD‐11, indicate that a diagnosis can now be made regardless of the current weight of the individual, as long as the body mass index is not so low as to meet definitional requirements for anorexia nervosa. There are also no longer specific minimal binge frequencies, as this requirement was little supported by scientific evidence. ICD‐11 provides more flexible guidance when determining binge frequency. A bulimia nervosa diagnosis does not require “objective” binges and can be diagnosed on the basis of “subjective” binges, in which the individual eats more or differently than usual and experiences a loss of control over eating accompanied by distress, regardless of the amount of food actually eaten.

Exclusions to the diagnosis of Bulimia under ICD-11 include:

• Binge eating disorder (6B82)

You can read more about ICD-11 and browse the released version here.

Resources:

Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland.

Reed, Geoffrey M et al. “Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders.” World psychiatry : official journal of the World Psychiatric Association (WPA) vol. 18,1 (2019): 3-19. doi:10.1002/wps.20611

de Onis, Mercedes et al. “Nutritional disorders in the proposed 11th revision of the International Classification of Diseases: feedback from a survey of stakeholders.” Public health nutrition vol. 19,17 (2016): 3135-3141. doi:10.1017/S1368980016001427