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 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.
See the respective articles for details.
Binge eating disorder 
Most common eating disorder in adults in the US
- Recurrent binge eating episodes that are not associated with inappropriate weight compensatory behaviors
- Pronounced obesity at a young age is common; BMI may also be normal.
- See also “DSM-5 diagnostic criteria for binge eating disorder.”
|Overview of anorexia nervosa and bulimia nervosa |
|Anorexia nervosa ||Bulimia nervosa|
|Risk factors|| |
|Key features|| |
Avoidant restrictive food intake disorder (ARFID) 
Key features (all must be present)
- Avoidance or restriction of food
- ≥ 1 of the following:
- Features are not explained by body image disturbance, cultural practice, food insecurity, or another medical (e.g., gastrointestinal disease) or psychiatric (e.g., anorexia nervosa) condition.
- See “Initial evaluation of individuals with a suspected eating disorder.”
- Nutritional rehabilitation: similar principles as those used for . 
- Prevent refeeding syndrome.
Complications of ARFID can be similar to the associated features of severe malnutrition in anorexia nervosa. 
Rumination disorder 
- A syndrome characterized by recurrent postprandial food regurgitation, without preceding retching 
- Considered both a functional gastrointestinal disorder and an eating disorder
- 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 history 
- Body image disturbance: distorted perception of one's body and associated dissatisfaction with one's appearance
- Fear of weight gain
- Changes in eating and/or exercise patterns
- Social stressors related to appearance or weight
- Weight fluctuation (e.g., weight loss, inadequate weight gain for height, rapid weight gain) 
Signs of malnutrition 
- Neurological: seizures, weakness, dizziness, headaches
- Cardiovascular: palpitations, cardiac arrhythmias, orthostatic hypotension
- Metabolic: secondary osteoporosis, stress fractures, euthyroid sick syndrome, hypothermia
- Secondary amenorrhea, oligomenorrhea, delayed puberty
- Hair loss; brittle nails and hair
- Muscle wasting
- Poor wound healing
- Signs of recurrent vomiting 
- Gastrointestinal symptoms 
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 . 
Consider screening the following individuals at increased risk:
- Preteens and adolescents 
- At annual adolescent health visits
- Evaluation of weight loss
- Athletes (at annual preparticipation screens) 
- Sexual minority, transgender, and gender diverse youth
- Patients with a: 
- 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. 
A positive screening must be confirmed with a . 
Clinical history and examination 
- Assessment of:
- Eating and exercise behaviors
- Weight and body image concerns
- Evaluation of weight, height, and BMI trends
SCOFF questionnaire 
- 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 
These tools may be more sensitive than SCOFF for identifying eating disorders but have not been studied as extensively. 
- Eating Disorder Diagnostic Scale 
- Eating Disorder Screen for Primary Care 
- Screen for Disordered Eating 
- Perform a clinical evaluation in patients with any of the following:
- Confirm the diagnosis.
- Further evaluation
Current attitudes and behaviors
- Body image and weight
- Food and eating (e.g., eating habits, types of food consumed, dietary restrictions, bingeing)
- Presence and frequency of inappropriate weight compensatory behaviors
- Weight trends including highest and lowest weights
- Prior eating disorders and management
- History of eating disorders and/or weight-related issues
- Physical and mental health conditions
- Special diets
- Attitudes toward exercise and physical appearance
- 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 
Vital signs, including:
- Anthropometric measurements, including BMI
- Comprehensive physical exam to assess for signs of malnutrition and/or purging (see “Clinical features”)
- Weigh patients while they are wearing a gown and facing away from the scale. 
- Assess malnutrition severity.
- Patients 2–20 years of age: Refer to the . 
- Adolescents and young adults (< 26 years of age): Severity can be determined using the anthropometric measures detailed in the table below. 
|Malnutrition severity in adolescents and young adults with eating disorders |
|BMI||Total % body mass loss||Rate of % body mass loss|
| || |
| || |
|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. 
DSM-5 diagnostic criteria for eating disorders 
Evaluation for complications
Laboratory studies 
- Malnutrition and/or significant weight loss
- Self-induced vomiting: alpha-amylase
- Dehydration: urinalysis (for urine specific gravity) 
- Pancreatitis: lipase
- Oligomenorrhea, amenorrhea, delayed puberty, and/or long-standing eating disorder 
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. 
Characteristic laboratory abnormalities in eating disorders 
|Serum electrolytes || |
|Renal function tests|
|Liver function tests|
Normal laboratory study results do not rule out an eating disorder. 
- Possible findings 
- Possible findings: osteopenia, osteoporosis 
Exclusion of organic causes 
Based on clinical suspicion, evaluate for organic causes of weight changes and eating behaviors, e.g.,
General principles 
- Determination of treatment settings should be based on shared decision-making including the patient, family members, and the care team. 
- Outpatient care is preferred for most patients, if possible.
- Consider the following factors when choosing an initial care setting:
- 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) 
Most eating disorders can be managed in an outpatient setting. 
The decision to transfer a patient to another care setting should not be based on weight or BMI alone. 
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 |
|Adolescents and adults < 26 years of age||Adults ≥ 26 years of age|
|BMI|| || |
|Weight loss|| |
|Unstable vital signs||Hypothermia|| |
|Hypotension|| || |
|Orthostatic changes|| |
| || |
|ECG abnormalities|| |
Inpatient care 
- Candidates include patients:
- With red flag features of eating disorders who require continuous medical monitoring and/or intensive management
- Who require treatment over objection
- 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 
Candidates include medically stable patients who require intensive guided management by a care team.
- Patient lives at home but attends a clinic or hospital facility for ≥ 5 hours per day on ≥ 5 days/week. 
- Care team monitors most daily meals.
- Full-time residence at a facility
- Nursing on-site 24/7 (typically) and a physician on-call 24/7 
- Care team monitors all daily meals.
Outpatient care 
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) 
- 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) 
- Care team may monitor meals (e.g., one meal daily). 
- Minimal interruption to daily living
- Normalize behaviors around eating and weight, e.g.:
- Increase self-acceptance and reduce disordered thoughts and beliefs about body weight, size, and shape, and about food.
- Establish an individualized and multidisciplinary treatment plan, including a goal weight if necessary.
- Comanage nutritional support with a dietitian.
- Refer all patients for psychotherapy, e.g., family-based therapy for adolescents and young adults, and cognitive behavioral therapy for adults. 
- Consider adjunctive pharmacotherapy as needed.
- Identify and manage complications of eating disorders. 
- See respective articles for details:
Oral cavity disorders 
These may result from repeated self-induced vomiting.
- Clinical features
- Clinical features: enlarged parotid (most common), sublingual, and submandibular glands
Lower extremity edema 
- Etiology: may occur after cessation of purging behaviors
Gastrointestinal dysmotility 
If metoclopramide is used, monitor for . 
Decreased bone density 
- Etiology: starvation → hormonal derangements → decreased bone mass density 
- Clinical features: See “Clinical features of osteoporosis.”
- Weight restoration is the primary means of treatment.
- Address micronutrient deficiencies.
- Consider pharmacotherapy in select patients.
- Adolescents with bone age ≥ 15 years and bone mineral density z-score < -2.0 who cannot sustain weight gain: transdermal estradiol (off-label) PLUS cyclic oral progesterone (e.g., off-label use of medroxyprogesterone ). 
- Adults with osteoporosis (especially those with a previous fracture): See “Bisphosphonates for osteoporosis.” 
Refeeding syndrome 
- Refeeding syndrome is a syndrome of metabolic derangements and organ dysfunction caused by the reintroduction of nutrition in chronically malnourished individuals. 
- For details and management, see “Refeeding syndrome.”
We list the most important complications. The selection is not exhaustive.