Written by Babatunde Carew
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This review covers eating disorder epidemiology, diagnosis, and treatment; guidelines exist only for bulimia nervosa and binge-eating disorder, with high mortality and limited medication data in anorexia and avoidant/restrictive food intake disorder (ARFID).
Eating disorders – patients aren’t eating, but guidelines are out to lunch
In the US, the spectrum of eating disorders – which includes anorexia nervosa, bulimia nervosa, binge-eating disorder, and ARFID – impacts over 2 million adults and carries an estimated economic burden of $64.7 billion annually, disproportionately affecting young women.
Anorexia nervosa
- Definition: severe caloric restriction leading to low body weight (BMI < 18.5)
- Characteristics: rigid rules around food, excessive exercise, preoccupation with weight/body shape
- Types: restrictive subtype (solely restricting food intake) and binge/purge subtype (engaging in binge eating and purging behaviors).
- Complications: bradycardia, hypotension, amenorrhea, electrolyte imbalances, anemia, osteopenia/osteoporosis, and prolonged QTc. Most improve with weight gain, but bone density may not recover.
- Risk: high mortality rate among psychiatric disorders with substantial risk of suicide
- Treatment: nutritional rehabilitation, psychotherapy, and family-based treatment for adolescents. True refeeding syndrome during recovery is rare.
- Guidelines: no consensus for treatment
Bulimia nervosa
- Definition: recurrent binge eating and purging (vomiting, laxative misuse, excessive exercise) occurring at least once per week for ≥ 3 months.
- Characteristics: normal or above-normal body weight, though preoccupied with weight/body shape.
- Complications: dental erosion, parotid gland hypertrophy, fluid and electrolyte imbalances, and Mallory-Weiss tears in rare cases.
- Treatment: Cognitive behavioral therapy (CBT) is the most effective treatment, and fluoxetine (60 mg/day) is FDA-approved to reduce binge/purge episodes.
Binge-eating disorder
- Definition: binging at least once per week for ≥ 3 months without purging behavior.
- Characteristics: overweight or obesity, associated with food insecurity
- Complications: T2DM, HTN, HLD
- Treatment: CBT, interpersonal therapy, antidepressants, and lisdexamfetamine – the only FDA-approved medication for this disorder.
Avoidant/restrictive food intake disorder (ARFID)
- Definition: restrictive eating not driven by body image concerns, rather due to sensory sensitivities, low appetite, or fear of adverse eating experiences (e.g. choking, vomiting).
- Characteristics: develops more frequently in youth with neurodevelopmental disorders (e.g. autism spectrum disorder) and psychiatric conditions such as anxiety.
- Complications: nutritional deficiencies, weight loss, delayed growth or puberty, amenorrhea, weakened bones and muscles, and psychosocial impairment.
- Treatment: limited data, but typically includes a behavioral approach to expand food intake and nutritional adequacy.
Source
Eating Disorders: A Review. JAMA. 2025 Apr 8;333(14):1242-1252. doi: 10.1001/jama.2025.0132. PMID: 40048192
