Overview of eating disorders

Last updated: August 22, 2023

Summarytoggle arrow icon

Eating disorders are complex, multifactorial conditions characterized by disordered eating and/or weight control behaviors. They are associated with serious negative physical and psychological outcomes, including mortality. Conditions include anorexia nervosa, bulimia nervosa, binge eating disorder, pica, avoidant-restrictive food intake disorder, and rumination disorder. Although any individual can develop an eating disorder, adolescents, athletes, and individuals with comorbid psychiatric conditions and/or a history of trauma are most commonly affected, and these individuals may benefit from routine screening. Individuals with a suspected eating disorder require a comprehensive clinical and laboratory evaluation. The diagnosis is confirmed if the relevant DSM-5 diagnostic criteria for eating disorders are fulfilled. Most patients can be successfully managed in an outpatient setting, however, intermediate care settings such as partial hospitalization programs and residential care may be more appropriate for some patients. Those with red flag features of eating disorders require inpatient medical or psychiatric hospitalization. Management should involve a multidisciplinary team and consists of nutrition support and education, including weight restoration if necessary; psychotherapy (e.g., family-based therapy for adolescents, cognitive behavioral therapy for adults); and, for some patients, pharmacotherapy (e.g., SSRIs for bulimia nervosa, lisdexamfetamine for binge eating disorder). Although complete recovery is possible, a chronic, relapsing course with progressive deterioration is common.

Anorexia nervosa, bulimia nervosa, binge eating disorder, and pica are further detailed separately.

Overviewtoggle arrow icon

See the respective articles for details.

Binge eating disorder [1][2][3][4]

Most common eating disorder in adults in the US

Weight compensatory behaviors are seen in anorexia nervosa and bulimia nervosa but not in binge eating disorder. [1]

Anorexia nervosa and bulimia nervosa

Overview of anorexia nervosa and bulimia nervosa [1][2][3][5][6]
Anorexia nervosa [7] Bulimia nervosa
Risk factors
  • Multifactorial and not fully understood
  • Associated with the following: [9]
  • Underweight [1][10][11]
    • > 20 years of age: BMI < 18.5 kg/m2
    • ≤ 20 years of age: BMI < 5th percentile for sex and age
  • Healthy weight or slightly elevated [1]
    • > 20 years of age: BMI ≥ 18.5 kg/m2
    • ≤ 20 years of age: BMI ≥ 5th percentile for sex and age
Key features
Management Psychotherapy
Nutrition support
  • Support healthy eating habits.
  • Provide nutritional education.
  • Additionally, in individuals with anorexia nervosa:
    • Monitor weight gain.
    • If BMI is < 15 kg/m2: hospitalization

Avoidant restrictive food intake disorder (ARFID) [2][3]

Key features (all must be present)


Complications of ARFID can be similar to the associated features of severe malnutrition in anorexia nervosa. [13]

Rumination disorder [5][14]

  • A syndrome characterized by recurrent postprandial food regurgitation, without preceding retching [14]
  • Considered both a functional gastrointestinal disorder and an eating disorder

Pica [15][16]

Key features

  • Persistent ingestion of nonnutritive nonfood substances
  • Complications (e.g., dental damage, GI symptoms) may be present depending on the substance consumed.
  • See also “DSM-5 diagnostic criteria for pica.”


Clinical featurestoggle arrow icon

Relative energy deficiency in sport (RED-S; previously known as female athlete triad) is not itself an eating disorder, but can occur concurrently with or lead to the development of an eating disorder. Ensure all athletes are screened for eating disorders. [18]

Screeningtoggle arrow icon

Indications [2][3][5][19]

Consider screening the following individuals at increased risk:

  • Preteens and adolescents [2][5][19]
  • Athletes (at annual preparticipation screens) [20]
  • Sexual minority, transgender, and gender diverse youth
  • Patients with a: [2]
    • History of sexual abuse, childhood adversity, or trauma (including bullying)
    • Chronic disease requiring dietary management
    • Psychiatric disorder and those undergoing an initial psychiatric evaluation

Any individual may be affected by an eating disorder, regardless of race, gender, socioeconomic status, or weight. [5][13][21]

Screen for eating disorders in overweight or obese individuals who are losing weight to ensure they are not practicing unhealthy eating and/or exercise patterns. [3]

Modalities [2][3]

A positive screening must be confirmed with a clinical evaluation for eating disorders. [2][19]

Clinical history and examination [2][5]

  • Assessment of:
    • Eating and exercise behaviors
    • Weight and body image concerns
  • Evaluation of weight, height, and BMI trends

SCOFF questionnaire [2][19][22]

  • The most widely used screening modality for eating disorders
  • It is a 5-item questionnaire
  • Important consideration: May not perform equally well in all populations (e.g., inadequate evidence of its accuracy in men)
  • Clinicians may consider supplementing the SCOFF questionnaire with the question, “During the past 3 months, have you had any episodes of excessive eating?”

Other screening modalities [2]

These tools may be more sensitive than SCOFF for identifying eating disorders but have not been studied as extensively. [2]

  • Eating Disorder Diagnostic Scale [23]
  • Eating Disorder Screen for Primary Care [24]
  • Screen for Disordered Eating [25]

Initial evaluationtoggle arrow icon

Approach [2][3][5]

Clinical evaluationtoggle arrow icon

History [2][3][5][17]

Perform a detailed review of systems (see “Clinical features”). Obtain collateral history (e.g., from family members, teachers) if possible, especially for adolescents.

Current attitudes and behaviors

Past history

  • Weight trends including highest and lowest weights
  • Prior eating disorders and management

Family history

  • History of eating disorders and/or weight-related issues
  • Physical and mental health conditions
  • Special diets
  • Attitudes toward exercise and physical appearance

Psychosocial history

  • Current stressors (e.g., family, school)
  • History of bullying, abuse, or other trauma
  • Mood, suicidality, and other psychiatric symptoms or comorbidities
  • Substance use

Physical examination [2][3][5][17]

Do not assume that bradycardia and/or low blood pressure is due to physical conditioning in athletes with a possible eating disorder. [5]

Anthropometric measurements

  • Weigh patients while they are wearing a gown and facing away from the scale. [5]
  • Assess malnutrition severity.
    • Patients 2–20 years of age: Refer to the CDC longitudinal growth charts. [13]
    • Adolescents and young adults (< 26 years of age): Severity can be determined using the anthropometric measures detailed in the table below. [13][26][27]
Malnutrition severity in adolescents and young adults with eating disorders [13]
BMI Total % body mass loss Rate of % body mass loss
  • 5% regardless of timespan
  • 7.5%
  • 30 days: 5%
  • 3 months: 7.5%
  • 6 months: 10%
  • 12 months: 20%
  • 10%
  • 30 days: > 5%
  • 3 months: > 7.5%
  • 6 months: > 10%
  • 12 months: > 20%
Presence of ≥ 1 criterion confirms the severity.

Malnutrition can be present in patients with a normal weight and BMI. In adolescents and young adults, preferred measurements of malnutrition include percent median BMI, BMI z-score, and degree of weight loss. [5][13]

Diagnosticstoggle arrow icon

DSM-5 diagnostic criteria for eating disorders [1]

Evaluation for complications

Laboratory studies [2][3][5][17]

Routine studies

Additional studies

Individuals with recent rapid weight loss, frequent purging, and severe illness are likely to have laboratory abnormalities, regardless of their body weight. Laboratory findings typically normalize following adequate management. [2][28]

Characteristic laboratory abnormalities in eating disorders [2][17]

Possible findings
Serum electrolytes [29][30]
Renal function tests
Liver function tests
Lipid panel

Hypokalemia can lower the seizure threshold and increase the risk of cardiac arrhythmia.

Normal laboratory study results do not rule out an eating disorder. [2]

ECG [2][3]

Bone densitometry [2]

Exclusion of organic causes [2][3][5][17]

Based on clinical suspicion, evaluate for organic causes of weight changes and eating behaviors, e.g.,

Dispositiontoggle arrow icon

General principles [2][5][13]

  • Determination of treatment settings should be based on shared decision-making including the patient, family members, and the care team. [2]
  • Outpatient care is preferred for most patients, if possible.
  • Consider the following factors when choosing an initial care setting:
    • Red flag features of eating disorders
    • Laboratory study abnormalities in eating disorders
    • The patient's motivation to change
    • The patient's level of control over disordered behaviors
    • Psychosocial and cultural factors (e.g., presence of social support)
    • Logistical factors (e.g., availability of transportation, insurance barriers)
  • Periodically reassess the need for transfer to a higher level of care, e.g., based on :
    • Worsening in any of the above factors
    • Minimal symptom improvement after ≥ 6 weeks of outpatient care (e.g., < 50% reduction in purging behaviors) [2]

Most eating disorders can be managed in an outpatient setting. [2][33]

The decision to transfer a patient to another care setting should not be based on weight or BMI alone. [2]

Red flags supporting hospitalization

The presence of any of the following indicates severe disease and may suggest the need for hospitalization.

Red flag features of eating disorders [2][3][5][13]
Adolescents and adults < 26 years of age Adults ≥ 26 years of age
  • Acute food refusal
  • Frequent, severe compensatory behaviors [13]
  • Uncontrolled binge eating
  • < 15 kg/m2
Weight loss
  • > 10% weight loss in 6 months
  • > 20% weight loss in 1 year
Unstable vital signs Hypothermia
  • Body temperature : < 36°C (< 96.8° F)
  • Blood pressure < 90/45 mm Hg
  • Blood pressure < 90/60 mm Hg
Orthostatic changes
Metabolic abnormalities
ECG abnormalities
Acute complications
  • Arrested physical development [3][5]
  • Comorbidities that may inhibit outpatient management
  • No or minimal improvement with outpatient management

Treatment settings

Inpatient care [2][3][5]

  • Candidates include patients:
  • Care is provided in either a psychiatric or medical unit, depending on the patient's primary needs.
  • Programs with specialized eating disorder care are preferred, if available.

Intermediate care [2][3][5]

Candidates include medically stable patients who require intensive guided management by a care team.

  • Partial hospitalization
    • Patient lives at home but attends a clinic or hospital facility for ≥ 5 hours per day on ≥ 5 days/week. [2]
    • Care team monitors most daily meals.
  • Residential treatment
    • Full-time residence at a facility
    • Nursing on-site 24/7 (typically) and a physician on-call 24/7 [2]
    • Care team monitors all daily meals.

Outpatient care [2][3][5]

Candidates include medically stable patients with motivation to change and good social support.

  • Standard outpatient care
    • Intermittent psychotherapy visits (e.g., 1–2 visits/week) [2]
    • Meals monitored by caregivers
    • Does not interrupt daily living (e.g., school)
  • Intensive outpatient care
    • Partial day psychotherapy visits (e.g., ≥ 3 visits/week for ≥ 3 hours/visit) [2]
    • Care team may monitor meals (e.g., one meal daily). [2]
    • Minimal interruption to daily living

Outpatients must have weekly weight monitoring, and patients with purging behavior also require regular monitoring of electrolyte levels. [2]

Treatmenttoggle arrow icon

Goals [2][3][5]

Components [2][3][5]

Complicationstoggle arrow icon

Oral cavity disorders [29][34]

These may result from repeated self-induced vomiting.

Poor dentition

Sialadenosis [29]

Lower extremity edema [29]

Gastrointestinal dysmotility [2][3][29]

If metoclopramide is used, monitor for extrapyramidal symptoms. [2]

Consider the use of stimulant laxatives only for severe constipation refractory to other treatments; monitor use closely. [2]

Decreased bone density [2][3]

Combined oral contraceptives do not improve bone density and should not be used for the exclusive treatment of amenorrhea in patients with eating disorders. [21]

Bisphosphonates may have teratogenic effects; use with caution in women of childbearing age. [2]

Refeeding syndrome [2][17]

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

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