A study of GP records for over 35,000 adults in England and Northern Ireland has found that most people diagnosed with an eating disorder are never referred on to specialist NHS treatment, and that body weight plays a large part in who gets seen and who doesn’t.
Using anonymised primary care data from the Clinical Practice Research Datalink (CPRD Aurum), covering records from 2010 to 2023, researchers identified 35,404 adults aged 18 to 80 with at least one eating disorder diagnosis, of whom 26,822, or 75.8%, had no record of referral to specialist services. The study, published in Lancet Primary Care, was led by Chloe Gao and Jessica Wilkins at the Centre for Research in Eating and Weight Disorders, IoPPN, King’s College London, with colleagues at the University of British Columbia and South London and Maudsley NHS Foundation Trust.
Interaction between weight and referral
The interaction between weight status and diagnosis type worked in opposite directions depending on diagnosis. Underweight sharply increased referral odds for anorexia nervosa, but reduced them for bulimia nervosa, other specified feeding or eating disorder, and generic eating disorder diagnoses. For avoidant restrictive food intake disorder and binge eating disorder, the link wasn’t statistically significant, though the researchers note the sample sizes here were smaller.
"Three in four people in our study who had an eating disorder diagnosis recorded by their GP were not referred for specialist treatment. Being underweight made a real difference for anorexia nervosa, but it worked the opposite way for diagnoses like bulimia nervosa and other specified feeding or eating disorder. That tells us something about how clinicians are trained to spot risk, and it's a pattern worth GPs and services paying close attention to, especially given how much this varied across diagnostic categories."
Chloe GaoJoint first author and Researcher in the Institute of Psychiatry, Psychology & Neuroscience, at King’s College London
Across every model in the study, women had substantially higher odds of referral than men, and referral rates varied by region, with the south east and north west showing higher odds of referral than the north east, south west, and West Midlands.
Joint first author and PhD candidate in the Institute of Psychiatry, Psychology & Neuroscience, at King’s College London Jessica Wilkins said: “Eating disorders present with a range of symptoms, in people of all shapes and sizes, and our data suggest that referral decisions may still be shaped by a person’s weight rather than by their symptoms. We also saw women referred at almost double the rate of men, and real differences by region, which points to inconsistency both in how eating disorders are picked up and access to available treatment across the country. We hope this evidence supports a wider conversation about how eating disorders are recognised in general practice, across the full range of diagnoses.”
"Being underweight isn't compatible with a current diagnosis of bulimia nervosa, so this pattern may point to GPs not always having the training, the diagnostic tools and the time to diagnose eating disorders accurately in primary care. We need referral pathways that recognise eating disorders regardless of a person's body weight, and specialist services that are appropriately resourced to provide effective treatment and care to all who need it."
Ulrike SchmidtEating Disorders and Obesity theme lead, NIHR BRC: Maudsley, and Professor of Eating Disorders at King's IoPPN
Methodology: the study used generalised estimating equation models on CPRD Aurum electronic health records, adjusting for age, sex, region, and area-level deprivation. Underweight was defined per WHO guidelines as a BMI below 18.5 kg/m². Full statistical outputs and confidence intervals are available in the paper.
Funding: Medical Research Council, Arts and Humanities Research Council, Economic and Social Research Council, and the National Institute for Health and Care Research (NIHR).
