Tips for feeding or eating disorders in adults

• Death can be due to suicide (20% rate has been recorded in anorexia nervosa).
• Death can also result from:
  • arrythmias of the heart/abnormal heart rhythm
  • low potassium levels which cause abnormal heart rhythm
  • infections that may take hold as a consequence of long-term illness
  • severe malnutrition

Prompt review of results and associated clinical decision making are very important.

• See our “Tip Sheet 3 What Medical Investigations?” for physical investigations to consider.

• Anyone can experience a FED: they affect people regardless of age, sex, gender identity, sexuality, ethnicity, culture, education and socioeconomic status.
• Prior to the Covid-19 pandemic, around 6% of adults in the UK were estimated to experience a FED at any point in time, with around 15% experiencing an eating disorder over their lifetime.
• Rates appear to be increasing after the Covid-19 pandemic, so these prevalence rates may now be higher.
• Whilst FEDs can affect anyone, certain groups are at greater risk. In the UK, adolescent and young adult females have the highest rates of FEDs and 41% have been found to report some form of disordered eating behaviour (fasting, purging or binge eating).
• Autistic young people are at greater risk for avoidant restrictive food intake disorder (ARFID) and anorexia nervosa (AN).
• LGBTQ+ and transgender or gender non-binary individuals are also at greater risk for eating disorders.
• There is a strong genetic component to FEDs, with heritability estimates being in the region of 50-75% for AN, bulimia nervosa (BN) and ARFID. Estimates for binge eating disorder (BED) are around 40-45%. FEDs show genetic correlations with other psychiatric disorders (particularly anxiety disorders) but also metabolic disorders.

Prevalence for specific FEDs:

• Lifetime prevalence for AN has recently been estimated at 1.4% for women and 0.2% for men
• For BN, 1.9% for women and 0.6% for men
• For BED, 2.8% for women and 1.0% for men
• ARFID is more evenly distributed between males and females but with uncertain prevalence
• 'Other’ or ‘atypical’ presentations (OSFED or the older diagnostic category of ‘eating disorder not otherwise specified’ in DSM-IV) have been estimated to affect 4.3% of women and 3.6% of men

• People with FEDs may not acknowledge or recognise that they have a problem:
  • They may be in denial about the fact that they have an eating disorder and will go to great lengths to hide symptoms. Use your own clinical observations to alert you and take into consideration reports from family members or close others.
• Traits to look out for:
  • Out-of-control eating and/or purging
  • Mealtime conflict or eating alone
  • May exercise obsessively and/or compulsively, e.g. despite injury or will get very upset if prevented from doing it
  • Lots of rules about eating
  • Heightened anxiety around eating
  • Weight loss, weight gain or weight fluctuations
  • Complex volatile relationships
  • Social withdrawal
  • May struggle with mixed impulsive and obsessive, anxious and/or perfectionist traits
• Mental anguish: need for control of past, present or anticipated events, stress or traumas which can all be linked to disordered eating behaviours.
• Note that in binge eating disorder, overeating is linked with a loss of control and feelings of shame and guilt, but no other compensatory behaviours to lose weight.
• Avoidant restrictive food intake disorder (ARFID) is characterised by eating an insufficient quantity or variety of food, sometimes both, there may be avoidance of certain foods and food groups.
• Relationships suffer because of eating disorders.

People may ask for support with weight management, gastrointestinal problems, reproductive concerns (for women) and/or depression or anxiety prior to disclosing an eating disorder.

Know the seven types of feeding or eating disorders (FEDs) so you can spot them: in each there are mind-body-behaviour-relationship features:

• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Avoidant Restrictive Food Intake Disorder (ARFID)
• Binge Eating Disorder (BED)
• Rumination-regurgitation disorder (RD)
• Pica
• Other Specified Feeding or Eating Disorders (OSFED)
• An eighth category in ICD11 is for ‘Unspecified Feeding or Eating disorders (UFED)

AN is diagnosed based on:

• Restriction of food intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health. Usually this is defined as a BMI <18.5 in adults.
• Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with gaining weight.
• A disturbance in the way body weight or shape are experienced (e.g. seeing oneself as fat despite being underweight); undue influence of body weight or shape on self-evaluation; or denial of the seriousness of low body weight. There are two subtypes of AN: restricting type and binge eating/purging type. Exercise is common in both sub-types.
• What the person might think: “all carbs, sugars, fats are unhealthy, and I should not eat them”, “I should count calories and make sure I don’t eat over a certain amount”, “my body is much larger than others see or think”. They may have feelings of needing to be the ‘best’ at something, perfectionism and a need for control.
• Where the person’s body weight might be: weight is low and may be falling, basic physiology starts to suffer, all body organs impacted - note weight alone is not a reliable indicator. If there is a rapid weight loss, symptoms of starvation may be present even if weight is in a healthy range. This can occur in ‘atypical anorexia’ when someone meets all criteria for AN, but despite significant weight loss, weight is not in the underweight range.
• How their relationships might be: withdrawing from relationships, anxious, avoiding meals with people, strains in close relationships.
• What the person’s behaviour might look like: over exercising, secretive behaviours around eating, perfectionistic traits, obsessive traits like restriction of diet or omitting certain food groups. Excuses such as not feeling hungry. Note that people with AN do usually eat, but their eating is highly controlled and insufficient to meet their energy needs. Some people will eat a range of foods in limited quantities; others will cut out complete food groups.

Individuals with AN may use substances like caffeine, tobacco or recreational drugs to try and suppress appetite. Energy drinks and diet soft drinks may also be consumed in large volumes.

• AN usually starts in adolescence with a median age of onset at 17 years, but can develop earlier and later than this.
• Sufferers from AN have difficulty recognising that they have a problem and there may be a delay of many years between onset and someone seeking help.           

• Look for these physical consequences of anorexia nervosa

  • Chronic tiredness
  • Dizziness - can be due to altered blood biochemistry, drops in blood pressure on standing
  • Epileptic fits due to water loading to falsify weight
  • Hair loss, dry itchy skin, growth of new thin hair on the body, brittle nails - due to malnutrition and stress
  • Cold hands and feet
  • Low body temperature (core temperature below 35^oC)
  • Muscle wasting and weakness – may have difficulties standing up without support
  • Reduced heart rate/bradycardia
  • Reduced white blood cell count - due to malnutrition and increasing risk of infection
  • Amenorrhea or irregular menstrual periods in women
  • AN can be fatal, as can all the other FEDs

BN is diagnosed based on:

• Recurrent binge-eating, characterised by eating an unusually large amount of food in a relatively short period of time, while feeling out of control of one’s eating (i.e. feeling unable to stop eating or control what is eaten).
• Recurrent inappropriate compensatory behaviours to avoid weight gain, such as self-induced vomiting or misuse of laxatives, diuretics or other medications (including insulin in those with diabetes), or fasting, or excessive exercise.
• Binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
• Self-evaluation is unduly influenced by body weight and shape.

Note that recurrent binge eating and inappropriate compensatory behaviours at a very low weight (BMI <18.5) would be diagnosed as AN, not BN.

• What the person might think: “my eating is out of control – I have to do better at limiting what I eat”, “I must cut out all carbs, sugars, fats”, “my body is disgusting and I have to lose weight”, “I’m a failure for not losing weight”. They may be highly ashamed of their eating routines and have low self-worth.
• Where the person’s body weight might be: this may be within the healthy or overweight ranges; sometimes slightly low but not significantly underweight. Weight may fluctuate rapidly or by large amounts of time.
• How their relationships might be: volatile relationships, strained relationships, avoiding meals with people, may be sociable but also sensitive to any perceived criticism or rejection.
• What the person’s behaviour might look like: over-exercising, secretive behaviours around eating, dieting or omitting certain food groups, may be mixed impulsive and obsessive personality traits, perfectionism.
• BN usually starts in late adolescence, with a median age of onset of 18 years, but can develop earlier and later than this.
• Suffers from BN often know they have a problem but may not think it is severe enough to seek help, or they may be too ashamed to seek help, or they may not feel ready to make changes. There may be a delay of many years between onset and someone seeking help.

Restriction, binge eating and compensatory behaviours can form a vicious cycle in BN:

As in anorexia nervosa, Individuals with BN may use substances like caffeine, tobacco or recreational drugs to try and suppress appetite and/or manage urges to binge eat. Energy drinks and diet soft drinks may also be consumed in large volumes.

Look for these physical consequences of BN

• Chronic tiredness
• Dizziness - can be due to altered blood biochemistry, drops in blood pressure on standing
• Tooth decay, loss of enamel and hypersensitivity - due to stomach acid from vomit fluids
• Blood in vomit - due to repetitive microtrauma of the windpipe, rupture of small blood vessels or ulcers
• Scabs on knuckles of index finger - due to sticking finger down the throat
• Two-sided parotid gland enlargements showing as facial shape changes - due to vomiting
• Hair loss, dry itchy skin, growth of new thin hair on the body, brittle nails - due to malnutrition and stress
• Epileptic fits – rare; caused by electrolyte changes resulting from vomiting and/or laxative misuse
• Irregular heartbeat - due to low blood potassium (this can cause cardiac arrest and/or other biochemical changes due to loss of body fluids by purging/vomit)
• Kidney damage - due to dehydration
• Lower bowel problems, bloating, including constipation, loss of normal bowel movements worsens constipation - can become very severe
• Wider gastrointestinal problems - due to dehydration, loss of electrolytes (chloride, calcium, bicarbonate, potassium) which leads to suppression of movement of the intestines (decreased peristalsis)
• BN can be fatal, as can all the other FEDs

BED is diagnosed based on:

• Recurrent binge-eating, characterised by eating an unusually large amount of food in a relatively short period of time, while feeling out of control of one’s eating (i.e. feeling unable to stop eating or control what is eaten).
• Binge eating occurs, on average, at least once a week for three months.
• Binge eating episodes are associated with at least three of the following: eating much more rapidly than usual; eating until uncomfortably full; eating large amounts of food when not physically hungry; eating alone because of feeling embarrassed by how much one is eating; feeling disgusted, depressed or very guilty after eating; marked distress about binge eating.
• Unlike bulimia nervosa (BN), there is no self-induced vomiting or other purging or other inappropriate compensatory behaviours to try and lose weight. In addition, binge eating is not accompanied by significantly low weight, as is seen in anorexia nervosa (AN).
• What the person might think: “my eating is out of control – I have to do better at limiting what I eat”, “I can’t eat in front of others or they will judge me”, “Eating is the only thing that provides me with comfort”. They may be highly ashamed of their eating routines and have low self-worth.
• Where the person’s body weight might be: about two thirds of those with BED are overweight or obese (although conversely, only a small proportion of those who are overweight/obese have BED)
• How their relationships might be: volatile relationships, strained relationships, avoiding meals. with people, may be sociable but also sensitive to any perceived criticism or rejection.
• What the person’s behaviour might look like: binges often involve ‘forbidden foods’ such as sweets or highly calorific and processed foods. Secretive behaviours around eating, dieting or omitting certain food groups, may be impulsive personality traits, low mood, anxiety.
• After a binge, the person can feel very guilty and ashamed and may try to diet or restrain their eating as a means of compensating for the binge (although as above, this does not reach the extreme levels seen in bulimia nervosa).
• Follows a cycle of restriction, thinking about food and feeling deprived, overeating, shame and guilt repeat.
• May have history of AN or BN.
• Binge eating may be an attempt to manage emotional distress, which can lead to ‘feeling zoned out’
• This can impact education and work attainment and relationships.
• Further traits to look out for: low mood and or anxious, out of control eating, isolated or avoidant in relationships.

Table of some distinguishing features of anorexia nervosa, bulimia nervosa and binge eating disorder                         

An umbrella term encompassing a range of presentations previously referred to by multiple descriptive terms (including selective eating, food phobia, food avoidance emotional disorder, functional dysphagia, among others) and typically previously diagnosed as an atypical or not otherwise specified eating disorder, or feeding disorder of infancy or early childhood.

ARFID is diagnosed based on:

• An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following:
  • Significant weight loss
  • Significant nutritional deficiency
  • Dependence on enteral feeding or oral nutritional supplements
  • Marked interference with psychosocial functioning
• The eating disturbance is not better explained by lack of available food (which is particularly important to consider in situations of food insecurity) or by a culturally sanctioned practice or by anorexia nervosa (AN) or bulimia nervosa (BN).
• Unlike in AN and BN, there is no disturbance in how body weight or shape are experienced nor is there a focus on thinness. Binge eating, purging and compulsive exercise are not prominent presenting features.
• What the person might think: “certain foods are scary”, “If I eat that, I will be sick”, “I can’t stand the texture of some foods”, “I am not hungry and not interested in food”.
• Where the person’s body weight might be: often underweight but may be in the healthy weight range or overweight/obese. Note that even if weight is average or high, nutritional deficiencies may be present.
• How their relationships might be: strained relationships, avoiding meals with people, social eating can be highly stressful or impossible.
• What the person’s behaviour might look like: avoidance of social eating, anxiety, low mood. Meals may be skipped or certain foods or food groups avoided.
• Dislike/refusal of certain foods can be related to heightened sensitivity to aspects of some foods such as texture, smell, appearance, taste, temperature. This is typically exacerbated by anxiety or over arousal and may be particularly common in autistic people.
• This is sometimes confused with developmentally normal picky eating, however in ARFID this selectivity is present in a more extreme form leading to nutritional deficiencies and/or associated with significant psychosocial impairment.
• Onset may be trigged by a traumatic incident or aversive experience, such as choking, vomiting, abdominal pain, leading to avoidance and extreme caution.
• Restricted intake can also be related to low interest in eating or poor recognition of hunger cues.
• Limited intake can result from poor internal body awareness and be present in those with high arousal levels (e.g. those with poor emotion regulation as well as those with high distractibility from external stimuli).
• Some groups appear particularly vulnerable to the development of ARFID, i.e. those who are on the autism spectrum, or who have ADHD, anxiety disorders, obsessive-compulsive disorder (OCD) and a range of medical conditions.

• Do not fit the exact diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), rumination-regurgitation disorder, Pica or avoidant restrictive food intake disorder, but share some features.
• Just as serious as other specified feeding or eating disorders, and in the Diagnostic and Statistical Manual of Mental Disorders - fifth edition (DSM- 5) includes Purging Disorder – regularly misusing laxatives, diuretics, insulin (amongst diabetics) or self-induced vomiting in the absence of binging. Atypical anorexia involves all features of AN except that despite significant weight loss, weight is not yet very underweight. Atypical or sub-threshold bulimia or binge eating disorder involves all features of BN/BED, but binges and/or inappropriate compensatory behaviours occur less than once a week, on average, or for less than 3 months.
• May be the most common group of all eating disorders and can progress from one diagnosis into another. As OSFED is an umbrella term, people diagnosed with it may experience very different symptoms.
• ‘Orthorexia’: This is an obsession with healthy or ‘clean’ eating. It can be part of a FED but on its own is not currently considered to be an eating disorder.

Difficulties with eating can be part of other psychological conditions e.g. phobia of vomiting associated with a fear that certain food can make person sick (emetophobia), loss of appetite in a mood disorder, fears around contamination in obsessive-compulsive disorder, altered eating behaviour in psychotic disorders, and avoiding eating due to medically unexplained somatic gastrointestinal symptoms. These difficulties are not diagnosed as feeding or eating disorders.

However, if the eating difficulties reach a clinically significant level (e.g. associated with significant weight loss, and other physical consequences of starvation and malnutrition) a FED diagnosis should be considered. It is also possible for a FED to develop alongside other difficulties and so careful assessment may be needed to determine the most appropriate diagnosis or diagnoses.

In older adults, under-eating and weight loss may occur in the context of depressive symptoms or cognitive decline. Again, careful assessment is important to identify the most appropriate diagnosis or diagnoses and associated support needs.

• BEAT Tips Poster
• BEAT leaftlet: Seeking treatment for an eating disorder? The first step is a GP appointment.
• BEAT carers booklet: Eating disorders: a guide for friends and family
• Type 1 diabetes with an eating disorder: more information
• BEAT elearning for nurses (for all ages, not child and young person specific - Each of the 3 sessions will take around 30 to 60 minutes to complete and includes additional learning resources for those looking to further increase their knowledge. To access the elearning in the elfh Hub directly, please visit the links below.
  • Screening and Assessments
  • The Impact of Starvation
  • Sensitive Communication

• Medical Emergencies in Eating Disorders (MEED). Guidance on recognition and management. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Annexe 1: Summary sheets for assessing and managing patients with severe eating disorders. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Medical Emergencies in Eating Disorders. Annexe 2: What our National Survey found about local implementation of MARSIPAN recommendations. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Annexe 3: Type 1 diabetes and eating disorders (TIDE). RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)

• Eating Disorders: Recognition and Treatment NICE Guideline (NG69) 2020
• Eating Disorders Quality Standard (QS175) 2018
• Adult eating disorders: Community, inpatient and intensive day patient care. Guidance for commissioners and providers

• Ignoring the alarms: How NHS eating disorder services are failing patients. Presented to Parliament pursuant to Section 14(4) of the Health Service Commissioners Act 1993, Ordered by the House of Commons to be printed on 6 December 2017.

• Eating Disorders from the Inside Out: Laura Hill at TEDxColumbus

From MindEd session Eating Disorders: Further Information for Professionals:

• Talk ED
• Beat (beating eating disorders)
• Centre for Clinical Interventions
• Faculty of Eating Disorders Royal College of Psychiatrists
• F.E.A.S.T. (Families Empowered and Supporting Treatment of Eating Disorders)
• Men Get Eating Disorders Too (MGEDT)
• National Institute for Health and Care Excellence guidance for Eating disorders: recognition and treatment

1. Bulik CM, Coleman JRI, Hardaway JA et al. Genetics and neurobiology of eating disorders. Nat Neurosci, 25, 543-554. doi: 10.1038/s41593-022-01071-z. 
2. Galmiche M, Déchelotte P, Lambert G, & Tavalacci MP. Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. Am J Clin Nutri, 109, 1402-1413 (2019).  
3. McClelland, J., Simic, M., Schmidt, U., Koskina, A., & Stewart, C. (2020). Defining and predicting service utilisation in young adulthood following childhood treatment of an eating disorder. BJPsych Open, 6(3), E37
4. Neale J, Pais SMA, Nicholls D, Chapman S, Hudson LD. What Are the Effects of Restrictive Eating Disorders on Growth and Puberty and Are Effects Permanent? A Systematic Review and Meta-Analysis.J Adolesc Health. 2019 Nov 23. doi: 10.1016/j.jadohealth.2019.08.032.
5. NICE guideline (NG69) 2017. Eating Disorders; recognition and treatments. 
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8. Smink FRE, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Curr Opin Psychiatry, 26, 543-548 (2013). doi: 10.1097/YCO.0b013e328365a24f.
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Eating disorders training for health and care staff

This suite of training was developed in response to the Parliamentary and Health Service Ombudsman (PHSO) investigation into avoidable deaths from eating disorders, as outlined in recommendations from the report titled Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients(PHSO, 2017).

It is designed to ensure that health and care staff are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. It is the result of collaboration between eating disorder charity Beat and Health Education England with key partners.

Eating disorders training for medical students and foundation doctors

This eating disorders training is designed for medical students and foundation doctors. The two sessions will take around 20-30 minutes to complete and includes additional learning resources for those looking to further increase their knowledge. The sessions also provide good preparation for those who go on to participate in medical simulation training on eating disorders.

• Signs, Symptoms and Causes
• Practical Requirements

Eating disorders training for nurses

This eating disorders training is designed for the nursing workforce. Each of the 3 sessions will take around 30 to 60 minutes to complete and includes additional learning resources for those looking to further increase their knowledge.

• Screening and Assessments
• The Impact of Starvation
• Sensitive Communication

Eating disorders training for GPs and Primary care workforce

This eating disorders learning package is designed for GPs and other Primary Care clinicians. The two sessions will take around 30-40 minutes each to complete and includes additional learning resources for those looking to further increase their knowledge. 

• GPs and Primary Care: Understanding Eating Disorders
• GPs and Primary Care: Assessing for Eating Disorders

Medical Monitoring in Eating Disorders learning for all healthcare staff who are involved in the physical assessment and monitoring of eating disorders

The eating disorders learning package for Medical Monitoring is designed for primary care teams, eating disorder teams or other teams who are monitoring the physical parameters of a person with an eating disorder. The session will take around 30 minutes to complete and includes additional learning resources for those looking to further increase their knowledge.

• Medical Monitoring in Eating Disorders