Time to recognise the risks to patients after an eating disorder diagnosis

The chronic and complex nature of eating disorders are underscored by the increased risks of adverse outcomes after diagnosis

Eating disorders affect millions of individuals worldwide, yet their consequences are under-recognised. Previous studies have reported that individuals with eating disorders experience significantly higher risks of physical illness, psychiatric comorbidity, and death from unnatural causes.^{1 2} A linked cohort study by Morgan and colleagues (doi:10.1136/bmjmed-2025-001438) in BMJ Medicine provides comprehensive evidence on these associated risks to patients from a primary care perspective.³ Drawing on data from more than 24 000 patients aged 10-44 years in the Clinical Practice Research Datalink, the study shows that a multitude of adverse health outcomes appear quickly in patients after receiving a diagnosis of an eating disorder and persist for years afterwards.

The authors used a diverse range of healthcare data—namely, primary care and linked inpatient hospital records—to follow patients with a diagnosis of an eating disorder longitudinally for up to 10 years after diagnosis. These individuals were found to be at increased risk of renal failure, liver disease, diabetes, osteoporosis, and psychiatric disorders (eg, personality disorder and depression). Crucially, vulnerability to these outcomes was particularly high within the first 12 months after diagnosis. During this time, people with eating disorders had more than a fourfold higher risk of mortality than their matched peers (those without a diagnosis of an eating disorder) and had more than a fivefold higher risk of death from an unnatural cause, such as suicide. These patterns were consistent across diagnostic groups, including patients with anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding and eating disorders (OSFED).

Importantly, this study captures the breadth of eating disorder presentations seen in primary care, as opposed to those seen in the population treated within specialist clinics. This is illustrated by the high proportion of patients with OSFED diagnoses in this study, representing a real world clinical picture in which most individuals cannot be easily categorised into traditional diagnostic categories of anorexia nervosa or bulimia nervosa. While the study suggests that patients with OSFED face risks comparable to those faced by individuals with other types of eating disorders, they may be less likely to receive focused monitoring or referral, reinforcing the need for a transdiagnostic approach in detection and treatment.

The strengths of this study lie in its scope and design: the authors used data from a large health administrative database, as well as linked electronic health records from primary and inpatient care, which allowed the examination of a broad range of outcomes across various mental and physical health domains, and levels of care. Their use of controls matched by age, sex, and practice ensures that the associated risk of comorbidity is unlikely to be explained by background population differences. However, the findings of the study must be interpreted cautiously, within the context of the constraints inherent in health administrative data. The analyses rely on accurate diagnostic coding by primary care providers and cannot capture the patient’s illness severity, treatment adherence, or psychosocial background. Moreover, it is difficult to ascertain whether the increased psychiatric and physical risks observed in the exposure group were attributable specifically to an eating disorder, or whether the increased risks may reflect other comorbid factors absent from the comparator group at baseline.

Morgan and colleagues'³ findings have important educational and clinical implications. Earlier studies have illustrated the limited education given during medical training on the topic of eating disorders,^{4 5} and the current study emphasises the importance of disseminating this knowledge to all healthcare professionals. Medical education should place greater emphasis on the recognition and management of eating disorders, to equip primary care providers, specialists, and allied health professionals with the tools to identify early warning signs and monitor ongoing risks associated with eating disorders.

Additionally, the study's findings suggest the approach medical guidelines should take to improve the care of people with eating disorders. Clear care pathways that promote shared responsibility between primary care providers, psychiatrists, and relevant medical specialists (such as endocrinologists, nephrologists, and cardiologists) are needed. Enhanced diagnostic coding and linking electronic health systems would further enable population level surveillance and guide resource allocation. Lastly, the development and implementation of early, evidence based interventions, particularly in primary care environments, is needed to reduce the significant comorbidity experienced by individuals with eating disorders. Nonetheless, implementing new interventions in primary care would require careful consideration of the practical challenges faced by clinicians, for example, time constraints and variable levels of training in management of individuals with an eating disorder.

In summary, Morgan and colleagues³ have illustrated the chronic and complex nature of eating disorders, showing the clinical implications across healthcare settings and the need for the diverse expertise of healthcare professionals in many different specialties. Multiple organ systems are affected by eating disorders, which then requires an integration of care to adequately treat patients. This situation places primary care providers in an ideal position for leading and coordinating the care of individuals with an eating disorder, and suggests that primary care settings would be apt for early and ongoing intervention. Efforts to improve medical education in the area of eating disorders for primary care providers, as well as specialists, are needed in order to improve patient outcomes.