Incidence, prevalence and mortality of anorexia nervosa and other eating disorders.
ABSTRACT The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders.
General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population.
The incidence of anorexia nervosa is around eight per 100,000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15-24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.
- SourceAvailable from: Marianne Martinsen[Show abstract] [Hide abstract]
ABSTRACT: Many athletes struggle with disordered eating or eating disorders (ED) as they attempt to conform to demands or competition regulations that might be ill-suited to their physique. In this situation, participation in sports may lead to an array of health concerns that may adversely affect the athlete’s short and long-term health at a variety of performance levels and sports. The peak onset of ED is adolescence, when most athletic participation and competition takes place and athletes begin to focus on a particularly sport. For athletes, the biological changes occurring during adolescence might affect not only attitudes toward weight and shape, but also performance. To prevent the medical and psychological consequences related to ED, early intervention and identification is important. Aims: The overall aim of this thesis was to examine the effect of a one-year school-based intervention program to prevent the development of new cases of ED and symptoms associated with ED among adolescent male and female elite athletes (Paper II). An educational program was developed for coaches and included as a separate part of the intervention program. In Paper III, we examine the effect of the education program on the coaches’ knowledge about nutrition, weight regulation, and ED. In Paper I, we investigate the prevalence of ED among adolescent elite athletes compared to non-athletic controls. Finally, we wanted to design and validate a brief screening questionnaire with the ability to discriminate between athletes with and without an ED (Paper IV). Methods: First-year students (athletes) and their coaches at all the Norwegian Elite Sport High Schools (n=16) and first-year students (controls) at two randomly selected regular high schools participated in the three school year project period (2008 to 2011). In phase I (pretest) of the study all the schools were included and the students were screened for symptoms associated with ED and ED. In phase II, the Elite Sport High Schools were stratified (by size) and randomized to the intervention (n=9) or control group (n=7). The intervention group received the intervention program. Data from the athletes and their coaches at phase I and II, and data from the controls at phase I are included in this thesis. Paper I: In this cross-sectional study we used a two-tiered approach: self-reported questionnaire (part I) and clinical interview (part II). The questionnaire, including the Eating Disorder Inventory 2 (EDI-2) and questions related to ED, was completed by 611 athletes (90%) and 355 controls (84%). Subjects reporting symptoms associated with ED were classified as “at risk” for ED. In part II, all at-risk athletes (n=153), a random sample not at risk for ED (n=153), and a random sample of 50% of the controls classified as at risk (n=91) and not at risk (n=88) were invited to the clinical interview (Eating Disorder Examination) to screen for ED. Paper II: The 611 athletes participating in Paper I formed the basis of this randomized controlled trial (RCT). After the pretest (Paper I) all athletes (and coaches, Paper III) from each school were randomized to the same treatment arm (intervention or control). A final sample of 465 (93.8%) athletes was followed during high school. The athletes completed the questionnaire screening at pretest (Paper I), pottest 1 (after the intervention) and posttest 2 (9-months after intervention). Clinical interviews were conducted after pretest and at posttest 2 (one-year after intervention). Paper III: In this part of the RCT 76 coaches (93.8%) employed at and working with the first-year students at the Elite Sport High Schools were followed during the project period. At pretest and posttest (9-months after intervention) the coaches completed a questionnaire including questions concerning nutrition, weight-regulation, and ED. Paper IV: We conducted this prospective cross-sectional study in three phases. Phase I consist of data from the screening at pretest among the female athletes (Paper I). Based on the questionnaire screening we extracted items with good predictive abilities for an ED-diagnosis to the Brief ED in Athletes Questionnaire (BEDA-Q) version 1 and version 2. Version 1 consisted of 7-items from the EDI-Body dissatisfaction, EDI-Drive for thinness, and questions regarding dieting. In version 2, two items from the EDI-Perfectionism subscale were added. In phase II, the external predictive validity of version 1 was tested involving 54 age-matched elite athletes from an external dataset. In phase III, the predictive ability of posttest assessments was determined among athletes with no ED at pretest (n=53, 100%). Main results: 1) No new cases of ED in athletes at the intervention schools one-year after the intervention program, while 13% of the females and one male at the control schools developed ED. 2) Coaches at the intervention schools had higher scores on total knowledge, weight-regulation and ED compared to coaches at the control schools after intervention. The intervention also showed positive effects on the coaches’ subjective evaluation of their ED knowledge. 3) Higher prevalence of ED in adolescent elite athletes than controls (although more controls than athletes reported symptoms associated with ED. 4) BEDA-Q version 2 showed higher discriminative accuracy than version 1 in distinguishing athletes with and without an ED, and higher diagnostic accuracy in predicting new cases of ED than version 1. Conclusions: A one-year school-based intervention program can prevent new cases of ED and symptoms associated with ED in adolescent female elite athletes. The intervention part targeting the coaches with strategies of identification, management and prevention of ED produced significant effect of at least 9-months. It is confirmed that the prevalence of ED is higher among adolescent elite athletes than controls and higher in female than male adolescent elite athletes. Finally, BEDA-Q containing 9-items reveal promising psychometric and predictive features to distinguish between adolescent female elite athletes with and without ED. Key words: athletes, coaches, eating disorders, prevalence, prevention, screening, instrument, intervention02/2015, Degree: PhD
- Psychological Inquiry 08/2014; 25(3-4):394-413. · 4.73 Impact Factor
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ABSTRACT: Anorexia nervosa is a serious condition associated with high mortality. Incidence is highest for female adolescents, and prevalence data highlight a pressing unmet need for treatment. While there is evidence that adolescent-onset anorexia has relatively high rates of eventual recovery, the illness is often protracted, and even after recovery from the eating disorder there is an ongoing vulnerability to psychosocial problems in later life. Family therapy for anorexia in adolescence has evolved from a generic systemic treatment into an eating disorder-specific format (family therapy for anorexia nervosa), and this approach has been evidenced as an effective treatment. Individual treatments, including cognitive behavioral therapy, also have some evidence of effectiveness. Most adolescents can be effectively and safely managed as outpatients. Day-patient treatment holds promise as an alternative to inpatient treatment or as an intensive program following a brief medical admission. Evidence is emerging of advantages in detecting and treating adolescent anorexia nervosa in specialist community-based child and adolescent eating-disorder services accessible directly from primary care. Limitations and future directions for modern treatment are considered.Adolescent Health, Medicine and Therapeutics 01/2015; 6:9-16.
Incidence, prevalence and mortality of anorexia nervosa and
other eating disorders
Hans Wijbrand Hoeka,b,c
Purpose of review
with eating disorders.
General-practice studies show that the overall incidence
compared with the 1980s. Some evidence suggests that
the occurrence of bulimia nervosa is decreasing. Anorexia
nervosa is a common disorder among young white females,
but is extremely rare among black females. Recent studies
confirmprevious findingsofthehigh mortalityratewithinthe
anorexia nervosa population.
The incidence of anorexia nervosa is around eight per
100 000 persons per year. An upward trend has been
observed in the incidence of anorexia nervosa in the past
century till the 1970s. The most substantial increase was
among females aged 15–24 years, for whom a significant
increase was observed from 1935 to 1999. The average
prevalence rates for anorexia nervosa and bulimia nervosa
among young females are 0.3 and 1%, respectively. Only a
minority of people with eating disorders, especially with
bulimia nervosa, are treated in mental healthcare.
anorexia nervosa, eating disorder, epidemiology, mortality
Curr Opin Psychiatry 19:389–394. ? 2006 Lippincott Williams & Wilkins.
aParnassia Psychiatric Institute, The Hague, The Netherlands,bDepartment of
Epidemiology, Columbia University, New York, USA andcDepartment of Psychiatry,
University Medical Center Groningen, University of Groningen, Groningen, The
Correspondence to Professor Hans Wijbrand Hoek MD PhD, Parnassia Psychiatric
Institute, Mangostraat 15, 2552 KS The Hague, The Netherlands
Tel: +31 70 391 7344; fax: +31 70 391 7088; e-mail: email@example.com
Current Opinion in Psychiatry 2006, 19:389–394
crude mortality rate
Diagnostic and Statistical Manual of Mental Disorders
Eating Disorder Not Otherwise Specified
standardized mortality rate
? 2006 Lippincott Williams & Wilkins
Incidence and prevalence rates are the basic measures of
disease frequency. Incidence is the number of new cases
in the population over a specified period. The incidence
of eating disorders is commonly expressed in terms of per
differences between groups are better clues to the etiol-
ogy than are prevalence rate differences because they
relate to fairly new cases of an eating disorder.
Prevalence is the total number of cases in the population.
The point prevalence is the prevalence at a specific point
of time. The 1-year period prevalence rate is the point
prevalence rate plus the annual incidence rate. The
prevalence rate is the most useful rate for planning
facilities as it indicates the demand for care.
Mortality rates are often used as an indicator of the
severity of anorexia nervosa. In a meta-analysis of excess
mortality in the 1990s, anorexia nervosa was associated
with the highest rate of mortality among all mental
disorders . The standard measures for mortality are
the crude mortality rate (CMR) and the standardized
mortality rate (SMR). The CMR is the proportion of
deaths within the study population. The SMR is the
fraction of the observed mortality rate (CMR) compared
with the expected mortality rate in the population of
origin, for example, all young females.
This article is based on a selection from the literature,
of eating disorders and updates and incorporates our
previous reviews [2–4].
The validity of many epidemiological studies of eating
disorders is called into question because of a number of
methodological problems related to the selection of
populations under study and the identification of cases
[3,5]. Problems that are specific to eating disorders are
their low prevalence in the general population and the
tendency of the people with eating disorders to conceal
their illness and to avoid professional help.
Most incidence studies of anorexia nervosa have used
psychiatric case registers or medical records of hospitals
in a circumscribed area. All record-based studies will
grossly underestimate the incidence in the community
because not all cases will be referred to (mental) health-
care or become hospitalized. Therefore, it is unclear
whether the reported increase in the number of cases
in healthcare facilities reflects an actual increase in the
incidence in the community; the increase might also be
due to improved methods of case detection or the wider
availability of services. Findings from case registers and
hospital records are of restricted value for generating
hypotheses on the etiology of the disease because there
is no direct access to the patients and the additional
information that is available is usually limited and of a
demographic nature only.
At present, a two-stage screening approach is the most
widely accepted procedure for the identification of preva-
lent cases. First, a large population is screened for the
likelihood of an eating disorder by means of a screening
questionnaire that identifies an at-risk population (first
stage). Then definite cases are established on the basis of
a personal interview of both the persons from this at-risk
population and those from a randomly selected sample of
people not at risk (second stage). Methodological pro-
rates, sensitivity and specificity of the screening instru-
ment and often the restricted size of the groups inter-
viewed, particularly of those not at risk.
Incidence of anorexia nervosa
The highest reported age-adjusted and sex-adjusted
incidence rate of anorexia nervosa was 8.3 per 100 000
person years in Rochester, MN, USA, during 1935–1989
. Lucas and colleagues used an extensive case-finding
method, which included all medical records of healthcare
providers, general practitioners and specialists in the
community of Rochester. They screened records that
mentioned diagnostic terms that could refer to nonde-
tected cases. They included probable as well as possible
cases, and definite cases constituted only 39% (82 out of
208) of all incident cases identified during 1935–1989.
Incidence rates derived from general practices gener-
ally represent eating disorders that started more
recently than those based on other medical records.
Two recent studies of this type examined the inci-
dence of anorexia nervosa in primary care in the UK
and the Netherlands during the second half of the
1990s. Currin and colleagues [7??] searched the General
Practice Research Database in the UK for new cases of
anorexia nervosa between 1994 and 2000. They com-
pared their data with the findings of a similar study for
1988–1993 . The incidence of anorexia nervosa
remained remarkably consistent over the two study
periods. The age-adjusted and sex-adjusted incidence
rate of anorexia nervosa in 2000 was 4.7 [95% confidence
interval (CI): 3.6–5.8] compared with 4.2 (95% CI: 3.4–
5.0) per 100 000 persons in 1993.
In two studies in the Netherlands [9,10], general prac-
titioners studied the incidence of eating disorders in a
large representative sample of the Dutch population.
The overall incidence of anorexia nervosa was 7.7
(95% CI: 5.9–10.0) per 100 000 persons per year during
1995–1999. It was comparable to the rate of 7.4 during
1985–1989 . Incidence rates for anorexia nervosa
are highest for females aged 15–19 years. They con-
stitute approximately 40% of all identified cases . In
Rochester, MN, USA, the incidence rate was 74 per
100 000 person years for 15–19-year-old females during
1935–1989 . In Switzerland the incidence rate of
cases admitted for anorexia nervosa was 20 per 100 000
person years for females between 12 and 25 years of
age during 1993–1995 .
The question of whether the incidence of anorexia ner-
vosa is on the rise has been considerably debated. Long-
term epidemiological studies are sensitive to minor
changes in the absolute incidence numbers and in the
methods used, for example, variations in registration
policy, demographic differences between the popu-
lations, faulty inclusion of readmissions, the specific
methods of detection used or the availability of services
In a meta-analysis  of the incidence of anorexia ner-
vosa in mental healthcare, various studies in northern
east Scotland, 1960–1969 ; and the Netherlands,
1970–1999 [9,10,16] (Fig. 1). Until the 1970s, there
was an increase of the registered incidence of anorexia
nervosa in Europe.Since 1970, the incidence of anorexia
nervosa in Europe seems to have been rather stable .
Only two studies have used the same methods during a
prolonged study period, inthe United States from 1935 to
1989  and in Switzerland from 1956 to 1995 . In
Rochester, MN, USA the age-adjusted incidence rates of
Services research and outcomes
Figure 1 Registered yearly incidence of anorexia nervosa in
mental healthcare in northern Europe in the 20th century
per 100 000 population
Hospital records, Sweden;
mental healthcare, the Netherlands.
case register, north-east Scotland;
anorexia nervosa showed a significant linear increasing
trend only in females aged 15–24 years from 1935 to
1989. This increase in young females continued pro-
bably during the 1990s according to the findings in the
Netherlands (G.E. van Son, D. van Hoeken, A.I.M.
Bartelds et al., unpublished data).
In Switzerland, the development of the incidence of
severe anorexia nervosa was studied in a geographically
defined region by means of five sampling periods and the
same methodology from 1956 to 1995. The medical
records of all hospitals of the canton of Zurich were
screened for first-time hospitalizations of female anorexia
nervosa patients. The incidence of severe anorexia ner-
vosa in the canton of Zurich rose significantly during the
1960s and 1970s. Since then the incidence of severe
anorexia nervosa appears to have reached a plateau of
around 1.2 per 100 000 persons per year .
Although anorexia nervosa occurs in males as well as in
females, few studies report incidence rates for males.
From incidence studies that report on males, one can
conclude that the incidence of anorexia nervosa among
males is below 1.0 per 100 000 persons per year
Prevalence of anorexia nervosa
The current standard for the assessment of the preva-
lence of eating disorders is the process employing a two-
stage selection of cases. Prevalence rates of anorexia
nervosa varied between 0 and 0.9%, with an average
point prevalence rate of 0.29% in young females, accord-
ing to Diagnostic and Statistical Manual of Mental Dis-
orders, Fourth Edition (DSM-IV) criteria . Most
studies found higher prevalence rates for partial syn-
dromes of anorexia nervosa.
In a recent nationwide study in Portugal, the point
prevalence of anorexia nervosa among adolescent girls
was 0.39% .
In Sweden, the lifetime prevalence was 1.2% for rigor-
of women from the 1935–1958 birth cohorts [18??]. In an
Australian study of female twins, aged 28–39 years, the
lifetime prevalence of anorexia nervosa was 1.9% with an
additional 2.4% for partial anorexia nervosa (absence of
amenorrhea) [19?]. The lifetime prevalence was 2.2% for
anorexia nervosa according to DSM-IV criteria in a large
sample of women from the 1975–1979 birth cohorts of
In a meta-analysis , the 1-year prevalence rates per
100 000 young females were computed by point preva-
lence plus annual incidence rate at different levels of care
(Table 1).Usingtwo-stage studies ofcommunity samples
and estimates of theincidence, the 1-year prevalence rate
of anorexia nervosa in the community was calculated as
370 per 100 000 young females. One can conclude from
Table 1 that the majority of the patients with anorexia
nervosa in the community do not enter the mental
Mortality associated with anorexia nervosa
The few very long-term follow-up studies indicate a high
mortality associated with anorexia nervosa. In an oldest
long-term follow-up study in Sweden, a CMR of 18% was
found among 94 patients with anorexia nervosa, 24 years
after onset . In a meta-analysis in 1995 of 42 pub-
lished studies , the CMR was 5.9% (178 deaths in
3006 patients), translating into 0.56% per year or 5.6% per
decade. In the studies specifying the cause of death, 54%
of the patients died as a result of eating-disorder com-
plications, 27% committed suicide and the remaining
19% died of unknown or other causes. In a meta-analysis
of SMRs in 2001, the overall aggregate SMR of anorexia
nervosa in studies with 6–12 years of follow-up was 9.6
(95% CI: 7.8–11.5) and in studies with 20–40 years of
follow-up 3.7 (95% CI: 2.8–4.7) . Only one study
suggested that the overall mortality of anorexia nervosa
was not increased among the spectrum of cases repre-
208 patients with anorexia nervosa in Rochester from
1935 to 1989 did not differ from the expected rate .
Recent studies confirm the high mortality rate within the
anorexia nervosa population, for example, in Canada
[25??], northeast Scotland [26??] and Germany [27?]. In
Canada, 326 patients diagnosed with anorexia nervosa
completed an assessment over a 20-year period; the SMR
was 10.5 (95% CI: 5.5–15.5) [25??]. In northeast Scotland,
23 of 524 patients with anorexia nervosa seen in specialist
services died; the median length of time between diag-
nosis and death was 11 years [26??]. The CMR in this
study was 4.4% and the SMR 3.3 (95% CI: 2.2–4.9). In
only one-third of the cases, anorexia nervosa was men-
tioned in the death certificate, but an eating disorder or
other psychiatric pathology probably contributed to sev-
eral of the other deaths. In a 12-year follow-up study of
103 patients with anorexia nervosa in Germany, the CMR
was 7.7% and another 40% had a poor outcome [27?].
Anorexia nervosa and other eating disorders Hoek 391
Table 1 One-year period prevalence rates per 100 000 young
females at different levels of care
Level of morbidity
Anorexia nervosa in Blacks and Asians
Hardly any epidemiological studies of anorexia nervosa
were conducted outside Western countries. Transcul-
tural studies conducted in the 1970s and 1980s showed
that anorexia nervosa was rare in non-Western countries
that anorexia nervosa does occur in non-Western
countries [32,33]. Abnormal eating attitudes and beha-
vior do occur frequently in traditional as well as in
Blacks and Asians [34–38,39?–41?].
In a recent comprehensive study [42??] conducted on the
Caribbean island Curac ¸ao, the full spectrum of com-
munity health and service providers was contacted.
Persons constituting probable incident cases were
interviewed. The overall incidence of anorexia nervosa
of 1.82 (95% CI: 0.74–2.89) per 100 000 persons per year
on Curac ¸ao is much lower than in the United States and
Western Europe. No cases were found among the
majority black population. The incidence of 9.1 (95%
CI: 3.71–14.45) among the minority mixed and white
population on Curac ¸ao, however, was similar to the
incidence in the Netherlands and the United States.
The results obtained on Curac ¸ao are consistent with
findings in a US prevalence study, in which anorexia
nervosa was not found in black women, in contrast to a
lifetime prevalence rate of 1.5% for anorexia nervosa
among white women. Bulimia nervosa and binge-eating
disorder (BED) occur frequently among black women,
but might be also more common among white women
Epidemiology of other eating disorders
Bulimia nervosa was first distinguished as a disorder
separate from anorexia nervosa by Russell in 1979 
and Diagnostic and Statistical Manual of Mental Dis-
orders, Third Edition (DSM-III) in 1980. Before 1980,
the term ‘bulimia’ in medical records denoted symptoms
of heterogeneous conditions manifested by overeating,
but not the syndrome as it is known today. Only a few
incidence studies of bulimia nervosa have been con-
ducted. An annual incidence of bulimia nervosa of 13.5
per 100 000 person years was found in Rochester, MN,
USA, during 1980–1990  and of 11.5 in the Nether-
lands during 1985–1989 . In a study of the General
Practice Research Database in the UK for new cases of
bulimia nervosa, the age-adjusted and sex-adjusted inci-
dence of bulimia nervosa decreased during the second
half of the 1990s to 6.6 per 100 000 persons in 2000 (95%
CI: 5.3–7.9) [7??]. This possible decrease in the occur-
rence of bulimia nervosa is supported by some recent
evidence provided by a US study, suggesting that the
prevalence of bulimia nervosa has decreased during
1982–2002 [46?]. The generally accepted prevalence rate
of bulimia nervosa from two-stage studies is about 1%
among young females [3,47]. Table 1 shows a meta-
analysis of the 1-year prevalence rates of bulimia nervosa
per 100 000 young females at different levels of care .
One can conclude from this table that only a very small
minority (6%) of the patients with bulimia nervosa in
the community enters the mental healthcare system.
Mortality associated with bulimia nervosa is considerably
lower than that associated with anorexia nervosa  but
has been less examined. A meta-analysis encompassing
43 follow-up studies of bulimia nervosa cohorts gave an
overall aggregate SMR of 1.6 (95% CI: 0.8–2.7) for
bulimia nervosa .
Nowadays the majority of cases suffering from an eating
disorder can only be classified in the DSM-IV category
Eating Disorder Not Otherwise Specified (EDNOS),
including partial syndromes of anorexia nervosa or buli-
mia nervosa and BED, a proposed new category in DSM-
IV for research purposes. BED is often seen in obese
individuals, but in a recent study [50?], BED aggregated
strongly in families independently of obesity. Using
DSM-IV criteria, the prevalence of BED was 1% in a
large general population sample in Australia; using a
broader definition, the prevalence was estimated to be
2.5% . In the United States, a rate of 2.6% was found
among a large sample of 18–40-year-old white women for
recurrent binge eating (two episodes per week during the
previous 3 months) and a higher rate of 4.5% in black
women of the same age group [52,53].
In outpatient settings, EDNOS cases account for an
average of 60% of all cases, compared with 14.5% for
anorexia nervosa and 25.5% for bulimia nervosa [54?].
Although these patients are characterized by similar core
cognitive psychopathology, they represent the least
studied group of patients with eating disorders.
The registered incidence rates of anorexia nervosa and
bulimia nervosa are up to 8 per 100 000 persons per year
and 13 per 100 000 persons per year, respectively. It must
be assumed that even the studies with the most complete
case-finding methods yield an underestimate of the true
larly in females 15–24 years old, increased during the past
in the general population, they are relatively common
among adolescent girls and young women. For anorexia
nervosa and bulimia nervosa average prevalence rates of
0.3 and 1%, respectively were found for young females.
One-third of the people who meet stringent diagnostic
criteria for anorexia nervosa and only 6% of those with
bulimia nervosa are treated in mental healthcare.
Future epidemiological research should move toward
Services research and outcomes
characteristics of negative self-evaluation and perfection-
. As in the case of other psychiatric disorders, genetic
stances [57,58??] are probably important in the develop-
make an effort to control them.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 453–454).
of special interest
of outstanding interest
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