Three in Four: Eating Disorder Referral Gaps in Primary Care

In a study of 35,404 adults in England and Northern Ireland — all of them with an eating disorder diagnosis recorded by their GP — 26,822 had no record of a referral to specialist services.

Three in four. Not undiagnosed. Diagnosed, coded, and then nothing.

A fair question at this point is who made those diagnoses. The data comes from GP records, and the diagnoses are the ones GPs themselves recorded. The study’s senior author, Professor Ulrike Schmidt, notes that the referral pattern “may point to GPs not always having the training, the diagnostic tools and the time to diagnose eating disorders accurately in primary care.”

The pattern underneath

The same study looked at what predicted whether a referral happened, and the answer is uncomfortable.

Being underweight raised the odds of referral more than fourfold for patients with anorexia nervosa. For patients with bulimia nervosa, being underweight lowered the odds of referral. Same for other specified feeding and eating disorders — atypical anorexia nervosa, purging disorder, binge eating disorder of low frequency — and for generic eating disorder diagnoses.

Read that again, because it’s the whole argument: the system responds to thinness, and it responds to thinness in the one diagnosis where thinness is already expected. Everywhere else, it doesn’t know what to do with it.

That’s not a decision anyone made. It’s what happens when referral pathways are built around a number rather than around a condition.

A note on language. We use the diagnostic terms the research uses, but “atypical anorexia nervosa” is a term we struggle with. Anorexia occurs in bodies of every size. A label that marks a presentation as atypical because of what the person weighs is part of the same pattern this study describes.

The same bias shows up in time

A systematic review pooling 14 studies across seven countries measured how long eating disorders go untreated. Anorexia nervosa: 29.9 months. Bulimia nervosa: 53.0 months. Binge eating disorder: 67.4 months.

Two and a half years, four and a half years, five and a half years. The delay is longest for exactly the disorders least associated with low weight.

The same review found that a shorter time to treatment is associated with a greater likelihood of recovery. So the delay isn’t neutral. It changes outcomes.

And that’s only the people who got diagnosed at all

In a Finnish population-based cohort, researchers interviewed young adults and identified 142 with a lifetime eating disorder. (“Lifetime” here means they met criteria for an eating disorder at some point in their life — not that the illness lasted a lifetime.) Only 45 of them — 32% — had ever had it detected by a health professional.

Two in three had never been picked up by anyone. Detection was highest for anorexia nervosa at 57%, and fell steadily from there: bulimia 50%, atypical anorexia 44%, binge eating disorder 33%, other specified disorders 12%.

The further a presentation sits from the mental image of what an eating disorder looks like, the less likely it is that anyone names it.

They are not hard to reach

In a matched cohort of 46,473 adults in England, the people who eventually reached specialist eating disorder services had been consulting their GP at roughly double the background rate for the two years beforehand.

The same study found lower odds of referral for Asian patients and for Black patients — roughly half the odds, in the case of Black patients, compared with White patients.

The contact is happening. The recognition isn’t keeping pace with it.

The people doing the work say the same thing

In our own #EDinformed survey, we asked 29 professionals working in Ireland and the UK whether they thought eating disorder services here were adequate. One said yes.

What they described was structural: “Public sector care is almost non-existent.” “Rising cases and lack of treatment in inpatient beds mean people aren’t being treated in a timely manner, worsening their condition.” And one that captures the referral problem exactly: “I have met clients treated in their teens who seem traumatised by their care, only to fall through the net and have no supports as adults.”

But the answer that has stayed with us came from a psychotherapist asked what training they wanted:

“I would like to know about risk assessment, thresholds for serious concern, and what practical supports and real-time help is available if I refer.”

That is not someone who can’t recognise an eating disorder. That is someone who can, and doesn’t know what happens next. Which is the gap this whole month is about.

What this is and isn’t

None of this is a story about individual clinicians being careless. Every number above describes a system-level pattern: referral criteria built around BMI, training that never covered this, and pathways that work well for one presentation and poorly for the rest.

But system-level patterns are made of individual consultations. And the one thing that reliably shifts them is more clinicians being able to recognise what they’re looking at.

You don’t have to be a specialist. You do need training — and we can help with that.

The training

Eating Disorders: What Every Professional Needs to Know is a one-day training for clinicians, therapists, dietitians and allied health professionals who don’t work in eating disorders and don’t intend to — but who want to recognise one when it’s in front of them, and know how to support a client who presents with signs and symptoms.

Saturday 28 November 2026, 10:00–16:00, at the Carmelite Centre, Dublin 2. Six hours, six CPD points (PSI). €169, or €139 for students. It runs on a Saturday, so it doesn’t cost you clinic time.

See the full programme → Eating Disorders: What Every Professional Needs to Know

Frequently Asked Questions

How many people with an eating disorder are referred to specialist services?

In a study of 35,404 adults in England and Northern Ireland with an eating disorder diagnosis recorded by their GP, 75.8% had no record of a referral to specialist eating disorder services.

Does body weight affect whether someone is referred for eating disorder treatment?

Yes. In the same study, being underweight raised the odds of referral more than fourfold for patients with anorexia nervosa, but lowered the odds of referral for patients with bulimia nervosa, other specified feeding and eating disorders, and generic eating disorder diagnoses.

How many eating disorders are never detected at all?

In a Finnish population-based cohort, only 32% of people identified as having a lifetime eating disorder had ever had it detected by a health professional. Detection rates ranged from 57% for anorexia nervosa down to 12% for other specified feeding and eating disorders.

How long do eating disorders go untreated?

A systematic review of 14 studies across seven countries found average durations of untreated illness of 29.9 months for anorexia nervosa, 53.0 months for bulimia nervosa and 67.4 months for binge eating disorder.

Are there differences in referral rates between ethnic groups?

Yes. In a cohort of 46,473 adults in England, Asian patients and Black patients had lower odds of referral than White patients, with Black patients having roughly half the odds.

Sources

• Gao et al. (2026), The Lancet Primary Care 2(7):100179. DOI: 10.1016/j.lanprc.2026.100179

• Silén et al. (2021), European Eating Disorders Review 29(5):720–732. DOI: 10.1002/erv.2838

• Wilkins et al. (2026), BMJ Open 16(6):e119143. DOI: 10.1136/bmjopen-2026-119143

• Austin et al. (2021), European Eating Disorders Review 29(3):329–345. DOI: 10.1002/erv.2745