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Epidemiology of eating disorders: An update

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Abstract

Objectives of review. To summarize the recent advances in the descrip- tive epidemiology of eating disorders, emphasizing studies published between 2005 and 2006. Summary of recent findings. During their lifetime, 0.9-2.2% of women and 0.2-0.3% of men suffer from anorexia nervosa (AN). Its overall incidence in the population has remained stable during the 1990s com- pared with the 1980s, but has increased among adolescent girls. Most recent studies confirm previous findings of high mortality associated with AN. Bulimia nervosa (BN) affects 1.5-2% of women and 0.5% of men, and its occurrence may be decreasing. Atypical eating disorder cases account for the majority of all clinical and community eating disorder cases, and only a minority receive specialized treatment. Future directions. The incidence and prevalence of AN and BN have been extensively quantified in European and North American settings. How- ever, non-Western populations and atypical manifestations of eating dis- orders remain a challenge for future studies.
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4
Epidemiology of eating disorders: an
update
Anna Keski-Rahkonen, Anu Raevuori and Hans W Hoek
Abstract
Objectives of review. To summarize the recent advances in the descrip-
tive epidemiology of eating disorders, emphasizing studies published
between 2005 and 2006.
Summary of recent findings. During their lifetime, 0.9–2.2% of women
and 0.2–0.3% of men suffer from anorexia nervosa (AN). Its overall
incidence in the population has remained stable during the 1990s com-
pared with the 1980s, but has increased among adolescent girls. Most
recent studies confirm previous findings of high mortality associated with
AN. Bulimia nervosa (BN) affects 1.5–2% of women and 0.5% of men, and
its occurrence may be decreasing. Atypical eating disorder cases account
for the majority of all clinical and community eating disorder cases, and
only a minority receive specialized treatment.
Future directions. The incidence and prevalence of AN and BN have been
extensively quantified in European and North American settings. How-
ever, non-Western populations and atypical manifestations of eating dis-
orders remain a challenge for future studies.
Introduction
Descriptive epidemiological studies provide information about the occurrence
of disease and trends in the frequency of disease over time. The most commonly
used descriptive measures in epidemiology are incidence, prevalence and
mortality.
Incidence relates the number of new cases to the total number of individuals at
risk during the specified period. The incidence of eating disorders is usually
expressed as the number of new cases per 100 000 person-years of observation
time.
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Prevalence is the total number of cases as a proportion of the total population
at a specific point in time or during a specified period (e.g. one year or a
lifetime).
Mortality rates are often used as an indicator of illness severity. The crude
mortality rate (CMR) is the proportion of deaths within the study population.
The standardized mortality rate (SMR) is the ratio of deaths observed compared
with the expected mortality rate in the population of origin (e.g. all young
females).
Mortality rates are by their nature distal outcome measures. More proximal
measures of both disease processes and outcomes within the population are
often necessary for predicting the course of illness and estimating disease burden.
Despite various propositions, definitions of outcome, such as criteria for remis-
sion and recovery, remain contentious (Couturier and Lock 2006).
The validity and generalizability of results from epidemiological studies are
influenced by the selection of target populations and methods of case detection
(Hsu 1996; Hoek and van Hoeken 2003). Because eating disorders are relatively
rare among the general population, medical records or case registers of a specific
catchment area are often used to obtain a sufficient number of cases. Yet because
only a fraction of cases will seek professional help or receive a referral to
specialized healthcare services, studies limited to clinical settings may grossly
underestimate the occurrence of eating disorders in the community. Differential
availability of services and variable methods of case detection may be inter-
preted as changes in occurrence. Findings based on clinical case registers may
also lead to biased conclusions about mortality and other disease outcomes,
because clinical samples are often biased towards cases with longer duration
and greater severity of illness. Large population-based studies are more rep-
resentative of the source population and less biased in their conclusions,
although they are often extremely expensive and time-consuming to conduct.
Our aim was to summarize recent advances in the descriptive epidemiology
of eating disorders, updating previous reviews of the same topic (Hoek and van
Hoeken 2003; Hoek 2006). We identified articles through MEDLINE using the
search terms ‘epidemiology’, ‘incidence’, ‘prevalence’, ‘mortality’ or ‘outcome’
in combination with ‘eating disorders’, ‘anorexia nervosa’, ‘bulimia nervosa’,
‘binge eating disorder’ or ‘EDNOS’. Community or population-based studies
published in 2005 and 2006 were emphasized.
Literature review
Anorexia nervosa
Incidence
Incidence rates derived from primary care represent eating disorders at the
earliest stage of detection. In the UK, new cases of anorexia nervosa (AN)
recorded in the General Practice Research Database between 1994 and 2000 (Currin
et al. 2005) were compared to similar data from 1988–1993 (Turnbull et al. 1996).
Epidemiology of eating disorders: an update 59
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The age- and sex-adjusted incidence of AN remained remarkably consistent
over the two study periods. In 2000, it was 4.7 (95% confidence interval [CI]: 3.6–
5.8) per 100 000 person-years, compared with 4.2 (95% CI: 3.4–5.0) per 100 000
person-years in 1993.
The incidence of AN ascertained by general practitioners in a large represen-
tative sample of the Dutch population was 7.7 (95% CI: 5.9–10.0) per 100 000
person-years during 1995–1999 (van Son et al. 2006a), practically the same as the
rate of 7.4 per 100 000 person-years during 1985–1989. Incidence rates for AN
were considerably higher for females aged 15–19 years, accounting for 40% of all
identified cases resulting in an incidence of 109 per 100 000 in this age group
(Hoek and van Hoeken 2003).
In Switzerland, the incidence rate of cases admitted for AN was 20 per 100 000
person-years for females between 12 and 25 years of age during 1993–1995
(Milos et al. 2004).
The sole recent effort known to us to quantify rates of AN directly in the
general population yielded an incidence of 270 per 100 000 person-years among
15–19 year old Finnish female twins during the period 1990–1998 (Keski-
Rahkonen et al. 2007). This community rate is much higher than the rate of
109 per 100 000 15–19 year old females in general practice in the Netherlands
during 1995–1999 (van Son et al. 2006a), probably because the Finnish study was
conducted in the community rather than through primary health care. If we
combine the Finnish incidence rate in the community with the Dutch rate in
general practice, only 43% (109/270) of all community cases have been detected.
This percentage is similar to the finding of 40% reported in a meta-analysis by
Hoek (2006).
Prevalence
The lifetime prevalence of AN diagnosed according to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) was 1.2% among
women in the 1935–1958 birth cohorts of Swedish twins (Bulik et al. 2006). The
lifetime prevalence of broad DSM-IV AN, defined as DSM-IV AN excluding
amenorrhea, in the same study was an additional 1.2%. In an Australian study
of female twins aged 28–39 years, the lifetime prevalence of AN was 1.9%, with
an additional 2.4% for partial AN (i.e. anorexia in the absence of amenorrhea)
(Wade et al. 2006). The lifetime prevalence of DSM-IV AN was 2.2% in a large
sample of women from the 1975–1979 birth cohorts of Finnish twins (Keski-
Rahkonen et al. 2007), and an additional 2% of women fulfilled the criteria for
ICD-10 atypical anorexia. In a nationally representative survey of the US
household population, the lifetime prevalence of DSM-IV AN was found to
be 0.9% among adult females (Hudson et al. 2007). Thus, according to various
methodologically sound, large-scale, nationally representative surveys, 0.9–2.2% of
women in Western countries suffer from DSM-IV AN during their lifetime.
Forms of AN that fall below the diagnostic threshold appear to be about twice as
common.
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In a recent nationwide study conducted in Portugal among adolescent girls
aged 12–23 years, the point prevalence of DSM-IV AN was 0.39% (Machado et al.
2006). An Austrian community-based questionnaire survey (Mangweth-Matzek
et al. 2006) assessed AN among women aged 50–60 years. AN was rare among
the elderly only one participant met the DSM-IV criteria for AN, yielding a
point prevalence of 0.2%.
Time trends
The registered incidence of AN increased in Europe until the 1970s, but seems to
have remained relatively stable thereafter (Hoek 2006). The study of Swedish
twins born during the period 1935–1958 (Bulik et al. 2006) documented a clear
increase in the prevalence of DSM-IV AN in both sexes among participants born
after 1945. In the Netherlands, the overall incidence of AN has been otherwise
stable, but increased significantly (from 56.4 to 109.2 per 100 000) among 15–19
year old females from 1985–1989 to 1995–1999 (van Son et al. 2006a). In
Switzerland, the changes in incidence of first-time hospitalization of females
with AN were studied in a geographically defined region using the same
medical-record-based methodology from 1956 to 1995. The incidence of severe
AN increased significantly during the 1960s and 1970s, but appears to have
reached a plateau of around 1.2 per 100 000 person-years thereafter (Milos et al.
2004).
Mortality
In the 1990s, AN was associated with the highest rate of mortality of all mental
disorders (Harris and Barraclough 1998). Recent studies have confirmed the
high mortality rate within the AN patient population. In Canada, 326 patients
diagnosed with AN completed an assessment over a 20-year period, and the
SMR was 10.5 (95% CI: 5.5–15.5) (Birmingham et al. 2005). In northeast Scotland,
23 out of 524 patients with AN who were seen by specialist services died, and
the median length of time between diagnosis and death was 11 years (Millar et al.
2005). The CMR in this study was 4.4% and the SMR was 3.3 (95% CI: 2.2–4.9).
AN was only mentioned on the death certificate in one-third of the cases, but
eating disorders or other psychiatric pathology probably contributed to several
of the other deaths. In a 12-year follow-up study of 103 patients with AN in
Germany, the CMR was 7.7%, and a further 40% of patients had a poor outcome
(Fichter et al. 2006).
In a recent Swedish study (Lindblad et al. 2006), a significantly higher
mortality rate (4.4% vs. 1.2%) was found among female patients hospitalized
due to AN in 1977–1981 compared with those hospitalized in 1987–1991. The
hazard ratio of death for the 1977–1981 cohort relative to the 1987–1991 cohort
was 3.7. Lindblad et al. (2006) argue that this dramatic decrease in the mortality
rate is related to the introduction of specialized care units for patients with
eating disorders.
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However, a Norwegian study based on national patient and cause of death
registers found rates of AN-related deaths to be 6.5 and 9.9 per 100 000 (Reas
et al. 2005). Of the documented deaths, 44% occurred at or above the age of 65
years, implying that many AN patients have a relatively long life expectancy.
An earlier population-based study (Korndorfer et al. 2003) of all patients
presenting with AN in Rochester, Minnesota, in 1935–1989 found an estimated
survival rate of 93% 30 years after the initial diagnosis of AN, which did not
differ significantly from an expected population survival rate of 94%. The SMR
was 0.71 (95% CI: 0.42–1.09).
Finally, in an audit conducted in the UK, death certificates emerged as a
flawed source of information. Both over-reporting and under-reporting of AN
as a cause of death occurred, the latter probably being more common (Muir and
Palmer 2004).
Other illness outcomes
Several new community or population cohort-based epidemiological studies
have focused on outcomes other than mortality in AN. Long-term recovery rates
from AN were relatively good the five-year recovery rate from DSM-IV AN
was 66% (Keski-Rahkonen et al. 2007). Residual symptoms were very frequent
(Wade et al. 2006; Keski-Rahkonen et al. 2007), but appeared to progress to full
recovery over time (Keski-Rahkonen et al. 2007). Although AN is often
perceived as a chronic illness, its mean duration among the general population
is shorter than was previously thought, at 1.7 years in the USA (Hudson et al.
2007) and three years in Finland (Keski-Rahkonen et al. 2007). Only a minority of
cases of AN seek treatment (Hoek 2006; Hudson et al. 2007; Keski-Rahkonen et al.
2007).
Males
Although AN occurs in males as well as in females, only a few studies have
reported its incidence among males. In the Netherlands and the UK, the
incidence of AN among males was less than 1 per 100 000 person-years (Currin
et al. 2005; van Son et al. 2006a). However, according to recent Swedish, Finnish
and American population studies, AN in males appears to be more common. In
a large-scale, population-based study of Swedish twin birth cohorts for the
period 1945–1958 (Bulik et al. 2006), the prevalence of DSM-IV AN in males was
0.11%. No cases of male AN were detected in the birth cohorts for the period
1935–1944. Combining clinical interview data with Swedish Hospital Discharge
Register and National Cause of Death Register data, the lifetime prevalence of
AN in males was found to be 0.29%.
In Finland, a lifetime prevalence of 0.24% for DSM-IV AN was detected
among young men aged 22–27 years (Raevuori et al. 2007). The incidence of
DSM-IV AN among 12–25 year old males was 18 per 100 000 person-years.
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In a nationally representative survey of US households (Hudson et al. 2007),
the lifetime prevalence of DSM-IV AN was found to be 0.3% among men. Based
on figures in these studies, the rough rate ratio of females compared with males
is between four and 10. Thus, many recent community-based studies have
found that AN is more common among males than previously thought. AN may
be even more frequently underdetected in males than in females.
Non-Western countries
Abnormal eating attitudes and behaviors are frequent in developing countries
and among ethnic minorities, particularly among individuals of Asian and
African descent (Becker et al. 2005; Pike and Mizushima 2005; Striegel-Moore
et al. 2005; Tong et al. 2005). Recent studies demonstrate that AN does occur in
non-Western countries (Lee et al. 2005; Uzun et al. 2006). The most comprehen-
sive attempt to quantify eating disorders in non-Western settings took place on
the Caribbean island of Curac¸ao, where the full spectrum of community health
service providers was contacted (Hoek et al. 2005). The overall incidence of AN
was 1.82 (95% CI: 0.74–2.89) per 100 000 person-years, much lower than that in
the USA and Western Europe. No cases were found among the majority black
population. However, among the minority mixed and white population the
incidence resembled that in the Netherlands and the USA.
Bulimia nervosa
Incidence and time trends
In the Netherlands, the nationwide primary care-based study (van Son et al.
2006a) found a statistically non-significant decreasing trend in the incidence of
BN when comparing two five-year periods, namely 1985–1989 (incidence rate
8.6 per 100 000 person-years) and 1995–1999 (incidence rate 6.1 per 100 000
person-years). Compared with rural areas, the incidence of BN was almost 2.5
times higher in urbanized areas and five times higher in large cities (van Son
et al. 2006b).
In the UK, the age-adjusted and sex-adjusted incidence of BN in primary care
decreased during the second half of the 1990s from 12.2 per 100 000 person-years
in 1993 to 6.6 per 100 000 person-years in 2000 (95% CI: 5.3–7.9) (Currin et al.
2005). This possible decrease in the occurrence of BN is also supported by some
recent evidence provided by an American study of college students, which
suggests that the point prevalence of BN among women has significantly
decreased over two decades, from 4.2% in 1982 to 1.3% in 1992 and 1.7% in
2002 (Keel et al. 2006). Based on recent studies, it thus appears that the peak of
the bulimia epidemic was reached by the early 1990s, and that rates of bulimia
have started to decrease since then.
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Prevalence
The generally accepted prevalence rate of BN from two-stage studies is about
1% among young females (Hoek and van Hoeken 2003). The lifetime prevalence
was 2.0% for BN according to DSM-IV criteria in a large sample of women from
the 1975–1979 birth cohorts of Finnish twins (Keski-Rahkonen et al. 2006), and
the point prevalence for DSM-IV BN in the sample was 0.9%. A representative
survey of the US household population (Hudson et al. 2007) found that the
lifetime prevalence of DSM-IV BN was 1.5% in adult females. In adolescent
female populations, the prevalence of BN is often still lower than among adult
women. In a nationwide study in Portugal, the prevalence of DSM-IV BN among
12–23 year old females (mean age 16 years) was only 0.3% (Machado et al. 2006).
In a Spanish study (Rodriguez-Cano et al. 2005) of 13–15 year old adolescents
representing the general population, the prevalence of BN according to ICD-10,
DSM-III-R and DSM-IV criteria was 0.75% among girls. Thus, bulimia affects
1--2% of young women during their lifetime. However, as bulimic symptoms
often have a later onset than anorexic symptoms, the prevalence of bulimia is
generally lower among adolescent women than among young adult women.
Mortality
Few studies have assessed mortality associated with BN. A meta-analysis
encompassing 43 follow-up studies of BN cohorts gave an overall aggregate
SMR of 1.6 (95% CI: 0.8–2.7) for BN (Nielsen 2003).
Males
The lifetime prevalence of DSM-IV BN was found to be 0.5% among adult males
in the USA (Hudson et al. 2007), somewhat higher than expected on the basis of
earlier reports (Hoek and van Hoeken 2003).
Eating disorders not otherwise specified (EDNOS)
Currently, in outpatient settings, 15% of cases present with AN and 25% present
with BN. EDNOS accounts for the remaining 60% of cases (Fairburn and Bohn
2005). The category EDNOS includes partial syndromes of AN and BN. Despite
demonstrating a core cognitive psychopathology similar to other eating dis-
order sufferers, EDNOS patients represent the least studied group of patients
with eating disorders. The prevalence of EDNOS according to DSM-IV criteria
was 2.4% in a nationwide study of Portuguese female students aged 12–23
years. EDNOS accounted for 77% of all diagnosed cases of eating disorders in
the community (Machado et al. 2006). In a Spanish study of 13–15 year old
adolescents from the general population, the prevalence of EDNOS was 4.9% in
females and 0.6% in males (Rodriguez-Cano et al. 2005). An Austrian questionnaire
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survey (Mangweth-Matzek et al. 2006) examined a randomly selected non-
clinical sample of elderly women. In total, 3.8% of the women met the criteria for
eating disorders, and the great majority of them (15/18) were diagnosed with
EDNOS.
Binge-eating disorder (BED)
In a nationally representative study conducted in the USA, the lifetime preva-
lence of DSM-IV BED was 3.5% among adult females and 2.0% among adult
males (Hudson et al. 2007). BED occurs frequently among black women, but
may be even more common among white women (Striegel-Moore et al. 2005).
Although BED has traditionally been associated with obesity, it appears to
aggregate strongly in families independently of obesity (Hudson et al. 2006).
Clinical implications and summary of important
findings
AN is generally considered to be a rare disorder, but recent community studies
suggest that its lifetime prevalence may be higher than previously thought (up
to 2% among women and 0.3% among men). Some recent evidence suggests that
the incidence of BN is decreasing, but atypical forms of eating disorders, such as
BED and EDNOS, appear to be very common in the community. Most indi-
viduals with eating disorders do not seek specialized care. Thus, there is an
ongoing need to train community healthcare providers to improve their detection
of eating disorders.
Recent studies show that the mortality rate of AN is still very high, and
probably the highest of all the mental disorders. The availability of specialized
care for patients with eating disorders may decrease mortality from AN. Yet
studies that focus on individuals receiving clinical care may bias conclusions
about the prognosis of eating disorders. Recent population-based studies of AN
have revealed that recovery rates are relatively favorable, and that the mean
duration of illness may be shorter than was previously thought.
Future directions
Recent large population-based studies of North Americans and Europeans have
extensively quantified the incidence and prevalence of AN and BN using reliable
standardized methods. Yet the incidence and prevalence of eating disorders
appear to be changing rapidly among non-Western populations, where their
documentation remains a challenge.
Although mortality associated with AN has received much attention, the
natural course of eating disorders remains poorly understood. More proximal
outcomes should be systematically assessed and reported.
Epidemiology of eating disorders: an update 65
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The large majority of all eating disorder cases in both outpatient settings and
the community fall into the heterogeneous category EDNOS. As current diag-
nostic classifications have failed to capture adequately the commonest forms of
eating disorders, current diagnostic boundaries may require radical rethinking
and refining in the future.
The scope of this review has been limited to descriptive epidemiology.
However, the future of epidemiological research lies in analytical epidemiology
that is, understanding more fully the risk factors and etiological mechanisms
of eating disorders. Promising areas of inquiry include genetic, epigenetic and
cultural mechanisms in the development of eating disorders.
References
(References included from the targeted review years are preceded by one
asterisk. References preceded by three asterisks are of particular significance.
The significance is explained by a short commentary following the complete
reference.)
*Becker AE, Gilman SE and Burwell RA (2005) Changes in prevalence of overweight and in
body image among Fijian women between 1989 and 1998. Obesity Research, 13: 110–17.
*Birmingham CL, Su J, Hlynsky JA, Goldner EM and Gao M (2005) The mortality rate from
anorexia nervosa. International Journal of Eating Disorders, 38: 143–6.
***Bulik CM, Sullivan PF, Tozzi F, Furberg H, Lichtenstein P and Pedersen NL (2006)
Prevalence, heritability, and prospective risk factors for anorexia nervosa. Archives of
General Psychiatry, 63: 305–12.
This is the largest twin study ever conducted in individuals with rigorously diag-
nosed AN in a population-based sample of Swedish twins born between 1935 and
1958. The prevalence of AN was higher in individuals of both sexes born after 1945.
Prospectively assessed neuroticism was associated with the subsequent development
of AN.
*Couturier J and Lock J (2006) What is recovery in adolescent anorexia nervosa? Inter-
national Journal of Eating Disorders, 39: 550–55.
***Currin L, Schmidt U, Treasure J and Jick H (2005) Time trends in eating disorder
incidence. British Journal of Psychiatry, 186: 132–5.
This study examined time trends in eating disorders at primary care level in the UK
during the years 1994–2000. The incidence of AN remained constant over the period
studied. There was an increase in the incidence of BN, but rates declined after a peak
in 1996.
***Fairburn CG and Bohn K (2005) Eating disorder NOS (EDNOS): an example of the
troublesome ’’not otherwise specified’’ (NOS) category in DSM-IV. Behavior Research and
Therapy, 43: 691–701.
This analysis of four well-diagnosed adult samples of patients with eating disorders
showed that EDNOS is the commonest eating disorder in outpatient settings.
*Fichter MM, Quadflieg N and Hedlund S (2006) Twelve-year course and outcome
predictors of anorexia nervosa. International Journal of Eating Disorders, 39: 87–100.
Harris EC and Barraclough B (1998) Excess mortality of mental disorder. British Journal of
Psychiatry, 173: 11–53.
*Hoek HW (2006) Incidence, prevalence and mortality of anorexia nervosa and other eating
disorders. Current Opinions in Psychiatry, 19: 389–94.
66 Annual Review of Eating Disorders Part 2 – 2008
C
:
/P
os
t
scr
i
p
t/04
_
W
on
d
er
li
c
h2008
_
D
.
3d
8/10/7
12
:
58
[This page: 67]
Hoek HW and van Hoeken D (2003) Review of the prevalence and incidence of eating
disorders. International Journal of Eating Disorders, 34: 383–96.
***Hoek HW, van Harten PN, Hermans KME, Katzman MA, Matroos GE and Susser ES
(2005) The incidence of anorexia nervosa on Curac¸ao. American Journal of Psychiatry, 162:
748–52.
This comprehensive epidemiological study was conducted on a Caribbean island
with a mainly black population. It was found that on Curac¸ao, sociocultural factors
appear to be associated with differential incidence rates of AN.
Hsu LKG (1996) Epidemiology of the eating disorders. Psychiatric Clinics of North America,
19: 681–700.
*Hudson JI, Lalonde JK, Berry JM, Pindyck LJ, Bulik CM, Crow SJ et al. (2006) Binge-eating
disorder as a distinct familial phenotype in obese individuals. Archives of General
Psychiatry, 63: 313–19.
***Hudson JI, Hiripi E, Pope HG Jr. and Kessler RC (2007) The prevalence and correlates of
eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61:
348–58.
This large nationally representative study from the USA documents the 12-month
prevalence of eating disorders and also attempts to quantify comorbidity and
impairment associated with eating disorders.
*Keel PK, Heatherton TF, Dorer DJ, Joiner TE and Zalta AK (2006) Point prevalence of
bulimia nervosa in 1982, 1992 and 2002. Psychological Medicine, 36: 119–27.
*Keski-Rahkonen A, Sihvola E, Raevuori A, Kaukoranta J, Bulik CM, Hoek HW et al. (2006)
Reliability of self-reported eating disorders: optimizing population screening. Inter-
national Journal of Eating Disorders, 39: 754–62.
***Keski-Rahkonen A, Hoek HW, Susser ES, Linna MS, Sihvola E, Raevuori A et al. (2007)
Epidemiology and course of anorexia nervosa in the community. American Journal of
Psychiatry, 164: 1259–65.
This nationwide Finnish twin study of young adult women found a substantially
higher lifetime prevalence and incidence of DSM-IV AN than has previously been
reported. The 5-year clinical recovery rates were better than those in most previous
studies.
Korndorfer SR, Lucas AR, Suman VJ, Crowson CS, Krahn LE and Melton LJ (2003) Long-
term survival of patients with anorexia nervosa: a population-based study in Rochester,
Minn. Mayo Clinic Proceedings, 78: 278–84.
*Lee HY, Lee EL, Pathy P and Chan YH (2005) Anorexia nervosa in Singapore: an eight-year
retrospective study. Singapore Medical Journal, 46: 275–81.
*Lindblad F, Lindberg L and Hjern A (2006) Improved survival in adolescent patients with
anorexia nervosa: a comparison of two Swedish national cohorts of female inpatients.
American Journal of Psychiatry, 163: 1433–5.
*Machado PP, Machado BC, Goncalves S and Hoek HW (2006) The prevalence of eating
disorders not otherwise specified. International Journal of Eating Disorders, 40: 212–17.
*Mangweth-Matzek B, Rupp CI, Hausmann A, Assmayr K, Mariacher E, Kemmler G et al.
(2006) Never too old for eating disorders or body dissatisfaction: a community study of
elderly women. International Journal of Eating Disorders, 39: 583–6.
*Millar HR, Wardell F, Vyvyan JP, Naji SA, Prescott GJ and Eagles JM (2005) Anorexia
nervosa mortality in Northeast Scotland, 1965–1999. American Journal of Psychiatry, 162:
753–7.
Milos G, Spindler A, Schnyder U, Martz J, Hoek HW and Willi J (2004) Incidence of severe
anorexia nervosa in Switzerland: 40 years of development. International Journal of Eating
Disorders, 35: 250–58.
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Muir A and Palmer RL (2004) An audit of a British sample of death certificates in which
anorexia nervosa is listed as a cause of death. International Journal of Eating Disorders, 36:
356–60.
Nielsen S (2003) Standardized mortality ratio in bulimia nervosa. Archives of General
Psychiatry, 60: 851.
*Pike KM and Mizushima H (2005) The clinical presentation of Japanese women with
anorexia nervosa and bulimia nervosa: a study of the Eating Disorders Inventory-2.
International Journal of Eating Disorders, 37: 26–31.
Raevuori A, Hoek HW, Rissanen A, Kaprio J and Keski-Rahkonen A (2007) Incidence and
lifetime prevalence of anorexia nervosa in young men. Paper presented at the International
Conference on Eating Disorders, Baltimore, Maryland, 2–5 May 2007.
*Reas DL, Kjelsas E, Heggestad T, Eriksen L, Nielsen S, Gjertsen F et al. (2005) Character-
istics of anorexia nervosa-related deaths in Norway (1992–2000): data from the National
Patient Register and the Causes of Death Register. International Journal of Eating
Disorders, 37: 181–7.
*Rodriguez-Cano T, Beato-Fernandez L and Belmonte-Llario A (2005) New contributions to
the prevalence of eating disorders in Spanish adolescents: detection of false negatives.
European Psychiatry, 20: 173–8.
*Striegel-Moore RH, Fairburn CG, Wilfley DE, Pike KM, Dohm FA and Kraemer HC (2005)
Toward an understanding of risk factors for binge-eating disorder in black and white
women: a community-based case–control study. Psychological Medicine, 35: 907–17.
*Tong J, Miao SJ, Wang J, Zhang JJ, Wu HM, Li T et al. (2005) Five cases of male eating
disorders in Central China. International Journal of Eating Disorders, 37: 72–5.
Turnbull S, Ward A, Treasure J, Jick H and Derby L (1996) The demand for eating disorder
care. An epidemiological study using the General Practice Research Database. British
Journal of Psychiatry, 169: 705–12.
*Uzun O, Gulec N, Ozsahin A, Doruk A, Ozdemir B and Caliskan U (2006) Screening
disordered eating attitudes and eating disorders in a sample of Turkish female college
students. Comprehensive Psychiatry, 47: 123–6.
***van Son GE, van Hoeken D, Bartelds AI, van Furth EF and Hoek HW (2006a) Time trends
in the incidence of eating disorders: a primary care study in the Netherlands. Inter-
national Journal of Eating Disorders, 39: 565–9.
This Dutch primary care-based study examined changes in the incidence of eating
disorders in the 1990s compared to the 1980s. The increase of incidence of anorexia
nervosa among the high risk group continued to the end of the past century, but the
incidence of bulimia did not rise as expected.
*van Son GE, van Hoeken D, Bartelds AI, van Furth EF and Hoek HW (2006b) Urbanisation
and the incidence of eating disorders. British Journal of Psychiatry, 189: 562–3.
*Wade TD, Bergin JL, Tiggemann M, Bulik CM and Fairburn CG (2006) Prevalence and
long-term course of lifetime eating disorders in an adult Australian twin cohort.
Australian and New Zealand Journal of Psychiatry, 40: 121–8.
68 Annual Review of Eating Disorders Part 2 – 2008
... Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge-eating disorder, are defined by disturbances in eating habits characterized be either excessive or insufficient food intake accompanied by extreme body image concerns. Eating disorders affect between 0.5 and 3% of the population and are associated with several medical, psychological and social complications (Keski-Rahkonen, Raevuori, & Hoek, 2018). The leading evidence-based treatments for eating disorders are psychological in nature, including cognitive-behavioral therapy (CBT), interpersonal psychotherapy, and family-based therapy, all of which aim to address maladaptive processes that account for the persistence of eating disorders (Hilbert, Hoek, & Schmidt, 2017). ...
Article
Knowledge is a relevant concept in internet-based cognitive-behaviour therapy (I-CBT), yet little research has sought to understand the role of knowledge in I-CBT for eating disorders. This study addressed this gap. Data were analysed from 293 participants enrolled in a RCT of I-CBT for eating disorder symptoms. A test assessing knowledge of CBT principles and eating disorders was administered before and after I-CBT. Participants had high knowledge to begin with, correctly answering 72% of items. A significant increase in knowledge scores and knowledge confidence was observed after ICBT. While no relationship between the degree of knowledge gain and the degree of symptom improvement emerged, an increase in confidence in one's knowledge was associated with greater symptom improvement. Higher baseline knowledge levels predicted lower likelihood of drop-out and a higher likelihood of adherence, but was unrelated to symptom-level improvement. Findings suggest that while new knowledge can be acquired through I-CBT, the degree of knowledge gain alone is not sufficient to explain improvement in symptoms. Pre-existing knowledge levels may be an important prognostic indicator of patient progress and compliance to I-CBT. Ensuring that patients can correctly apply the key I-CBT skills may be more important than knowledge gain.
... In girls, the lifetime prevalence of anorexia nervosa ranges from 0.3% to 2.6%, bulimia nervosa from 0% to 2.6%, and binge eating disorder from 1.0% to 3.0%. 3 The age at which difficulties start tends to be lower, impacting on long term prognosis and increasing the need for differential treatments. There has also been some movement within the male/ female ratio, with the number of young men diagnosed with eating disorders increasing. ...
... They are characterized by serious eating disorders, such as extreme reduction of food, excessive nutrition, high stress and concern for their weight or shape, and they all compromise the physical health and social functioning of the individual. EDs are defined by the experts of the Academy of Eating Disorders (2) as "severe mental illness" and represent a constantly growing public health problem, becoming the second leading cause of death, especially among adolescents in Western countries (3,4) . The average age of onset at a global level is between 15 and 24 years, however in recent decades there has been a progressive decrease in the age of onset, with diagnosis before menarche and in some cases even at the age of 8-9 years (5). ...
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According to the World Health Organization, eating disorders are a constantly growing public health problem in industrialized countries with an important stigmatizing impact. The study investigates stigmatizing beliefs and attitudes towards Anorexia nervosa (AN) and Bulimia nervosa (BN). Materials and methods: From October 2018 to November 2019, an online survey was conducted for students of the Degree Courses in Nursing of 2 Italian university centres, using the Italian version of the SAB-BN-ITA, adapted for AN. Results: The sample consists of 517 nursing students, aged between 20 and 23. Male subjects presented higher scores, relative to stigma, both for BN (F =17.5, p <0.001) and for AN (F = 1 9.64, p <0.001). For the sample the main trigger factor of BN is the influence of the media (56.67), the lack of social support (53.19) and parental care (51.84). The association between the stigmatizing views was explored through Spearman's correlation and a linear regression model between the two overall scores (coeff. 0.73; p <0.001: r-squared 0.52). The 'self-regulation' is the stigmatizing opinions for AN (Coeff. 0.0768; p <0.001; r-squared 0.039) and BN (Coeff 0.0684; p <0.001; r-squared 0.030), and the 'social support' is stigmatizing opinions for AN (coeff. -0.0713; p = 0.004; r-squared 0.016). Conclusions: The study shows that the male gender has a higher level of stigma than the female one. Moreover, a large number of students consider media influence to be the main causative factor in the onset of ADs, in addition to the lack of social support.
... Eating disorders (EDs) are among the most serious psychiatric illnesses (Keski-Rahkonen et al., 2018), and despite continuing advances that have improved the understanding of the pathophysiology of EDs, treatment outcomes remain far less than optimal (Linardon et al., 2017;Zipfel et al., 2015). Such evidence indicates a critical need for ongoing study to identify and target underlying mechanisms that contribute to the onset and maintenance of EDs. ...
Article
Existing data suggest that deficits in social cognitive functioning are transdiagnostic phenomena that are observed across various forms of psychopathology. The goal of the present review was to provide an updated systematic review of the literature on social cognitive functioning across eating disorders (EDs), including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Studies that assessed six areas of social cognition were included: theory of mind, social perception, social knowledge, attributional bias, emotion perception, and emotion processing. A systematic search identified 71 studies, the majority of which examined adult women with AN. Research typically focused on alexithymia, theory of mind, empathy, social processing, emotion recognition, or emotion processing. Results suggested some deficits in social cognition in EDs. AN had the most studies with some evidence for deficiencies in social cognition but a fair amount of variability. Research on BN and BED was limited and inconsistent, though there appear to be some deficits in social cognition. Together, the limited coverage across EDs and heterogeneous methodology preclude firm conclusions regarding general or ED-specific deficits, as well as understanding the role of social cognition in ED etiology and maintenance. Therefore, several key questions and future directions are outlined for research moving forward.
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Introduction Second-generation antipsychotics (SGAs) are frequently prescribed for the treatment of resistant anorexia nervosa. However, few clinical trials have been conducted so far and no pharmacological treatment has yet been approved by the Food and Drug Administration. The aim of this paper is to conduct a systematic scoping review exploring the effectiveness and safety of atypical antipsychotics in anorexia nervosa (AN). Method We conducted a systematic scoping review of the effectiveness and tolerability of SGAs in the management of AN. We included articles published from January 1, 2000, through September 12, 2022 from the PubMed and PsycInfo databases and a complementary manual search. We selected articles about adolescents and adults treated for AN by four SGAs (risperidone, quetiapine, aripiprazole or olanzapine). This work complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRIMA-ScR) and was registered in the Open Science Framework (OSF) repository. Results This review included 55 articles: 48 assessing the effectiveness of SGAs in AN and 7 focusing only on their tolerability and safety. Olanzapine is the treatment most frequently prescribed and studied with 7 randomized double-blind controlled trials. Other atypical antipsychotics have been evaluated much less often, such as aripiprazole (no randomized trials), quetiapine (two randomized controlled trials), and risperidone (one randomized controlled trial). These treatments are well tolerated with mild and transient adverse effects in this population at particular somatic risk. Discussion Limitations prevent the studies both from reaching conclusive, reliable, robust, and reproducible results and from concluding whether or not SGAs are effective in anorexia nervosa. Nonetheless, they continue to be regularly prescribed in clinical practice. International guidelines suggest that olanzapine and aripiprazole can be interesting in severe or first-line resistant clinical situations.
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Introduction Eating disorders are a serious problem affecting people of all ages and genders, cultures and origins, affecting not only the physical sphere, but above all the human psyche. In many cases, they are still taboo, as eating disorder issues can often be mistaken for trivialities. Their psychopathology is very complex and it is impossible to pinpoint a single cause. However, it is indisputable that food intake is related to the physiological, but also psychological and social spheres. The core of psychopathology is a distorted perception of the importance of figure, weight, appearance and their constant control. Aim The aim of the study was to determine the scale of eating disorders among students of ANS in Nowy Sącz and the impact of the COVID-19 pandemic on the change in body weight of students. Material and methods The research tool was a questionnaire developed on the basis of the EDE-Q 6.0 and CIA 3.0 questionnaires (Christopher et al., 2008), consisting of open and closed questions regarding the perception of the importance of one's figure, body weight, appearance and their control. Based on the students' answers, the body mass index before and after the pandemic was calculated COVID-19, and also analyzed answers that may indicate problems with nutrition and attitude to your own body. The study was conducted online via the Google Forms online survey platform, in the period from 7 to 21 October 2022, on a representative group of 255 students of the Academy of Applied Sciences in Nowy Sącz. Results The survey participants were mostly young women (average age 21.24), undergraduate full-time students, living in rural areas. There were no significant differences in body mass index (BMI) between men and women before and during the pandemic. In the study group, the question concerning the influence of diet, physical exercise or feelings regarding nutrition, figure and body weight deserve attention, with more than 50% of students indicating the influence of the above-mentioned factors. factors for: critical thinking about yourself, source of nervousness, worry, making you feel guilty, or feeling ashamed of yourself. In the questions regarding the sense of satisfaction with their figure, body weight and appearance, over 50% of students indicated a lack of satisfaction, i.e. a negative perception of themselves in terms of body weight (striving to lose weight, fear of gaining weight, feeling of being fat, limiting amount of food eaten). Conclusion Based on the conducted research, it can be concluded that students of the ANS in Nowy Sącz are at risk of eating disorders. It is therefore worth taking preventive measures aimed at raising awareness of the scale of the problem and popularizing the available forms of psychological support in this area.
Chapter
Anorexia nervosa, one of the most deadly mental disorders, is a pathophysiologically complex mosaic of numerous extensively investigated pathways, and the current state of knowledge cannot provide us with one definite answer regarding its etiopathogenesis. Although classified as a psychiatric disorder, traditionally viewed as a consequence of the psychological features, the model explaining the onset and development of anorexia is multifactorial with growing interest in its metabolic origin. The clinical presentation varies in severity, but ultimately every organ in the diseased body is affected. There are many biological alterations that simply act in accordance with severe malnutrition and weight loss; nevertheless, there is an evident dysfunction in the course of adaptive pathways that induce or at least potentiate those changes. Based on human and animal studies, the most relevant streams in AN pathophysiology seem to point toward a relatively adequate peripheral response that fails to properly stimulate feeding-related neurohormonal brain circuits. This metabolic origin of AN is supported by molecular identifications of specific genetic polymorphisms. Endocrine adaptations involve among others hyperghrelinemia, hypoleptinemia, hypogonadotropic hypogonadism, and CRH hypersecretion. Those hormonal shifts interact not only with appetite-regulating brain regions but also affect energy expenditure, physical activity, behavior, cognition, as well as rewarding/motivational drive. This narrative review aims to present emerging biological concepts underlying anorexia nervosa.
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BACKGROUND AND OBJECTIVES Throughout the COVID-19 pandemic, there has been an increase in hospital admissions for adolescents with eating disorders (EDs). However, there is a paucity of information on how this increase has affected hospitalization courses and disposition planning. We sought to describe the changes in hospitalizations for EDs at our institution during the pandemic. METHODS We reviewed charts of patients admitted to our academic medical center for nutritional restoration from January 1, 2017, to June 30, 2021. We report differences in patient characteristics and hospitalization courses using descriptive statistics and Poisson regression. RESULTS We reviewed charts for 85 patients for 108 hospital admissions. Admissions increased from 1.4 per month prepandemic to 3.6 per month during the pandemic (P < .001). Most patients were female (91%), White (79%), had private insurance, (80%) and had restrictive eating behaviors (97%). During the pandemic, we found (1) an increase in the average length of stay (12.6 days vs. 18.0 days) with younger age associated with longer length of stay (P < .001); (2) more patients requiring psychotropic medication management (11% vs 31%, P = .01); and (3) fewer patients discharged from the hospital with outpatient therapy (43% vs 24%, P = .03). CONCLUSIONS In addition to an increase in hospital admissions for ED management during the pandemic, our study highlights the evolving needs of ED patients during their hospitalizations. The implications of longer admissions with higher acuity at discharge represent areas where appropriate adaptations in inpatient management and disposition planning may improve the quality of care for ED patients.
Chapter
Seit der Veröffentlichung der ersten AWMF-S3-Leitlinie „Diagnostik und Therapie der Essstörungen“ erfolgte 2013 die Veröffentlichung der neuen amerikanischen Psychiatrieleitlinien im Diagnostischen und Statistischen Manual psychischer Störungen DSM-5 (deutsche Ausgabe 2015). Darin wurden (kindliche) Fütterstörungen im Kapitel „Fütter- und Essstörungen“ zu einem Bereich zusammengefasst. Im DSM-5-Manual liegen für folgende Störungen diagnostische Kriterien vor: Pica, Ruminationsstörung, Störung mit Vermeidung oder Einschränkung der Nahrungsaufnahme (alle drei hauptsächlich im Kindesalter vorkommend) sowie Anorexia nervosa (AN), Bulimia nervosa (BN) und Binge-Eating-Störung (BES). Die diagnostischen Kriterien, wie z. B. für AN, BN und BES, wurden auch geändert – sie wurden etwas breiter gefasst. Das hat unmittelbaren Einfluss im Sinne einer mäßigen Erhöhung der Inzidenz- und Prävalenzzahlen. Die Veränderung der diagnostischen Kriterien von DSM-IV auf DSM-5 ist auch aus anderen Gründen relevant: die meisten wissenschaftlichen Arbeiten zu Neuerkrankungsraten und zur Häufigkeit psychischer Erkrankungen wurden auf der Basis der DSM-Kriterien gemacht. In Deutschland sind andererseits klinisch und gegenüber Kassen und Rentenversicherungen die internationalen Diagnosekriterien ICD relevant.
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An epidemiological study of anorexia nervosa and bulimia nervosa in primary care was performed using the General Practice Research Database (GPRD). The GPRD was screened between 1988 and 1994 for newly diagnosed cases of anorexia nervosa and bulimia nervosa. The validity of the computer diagnosis was established by obtaining clinical details from a random sample of the general practitioners (GPs). Incidence rates for detection of cases by GPs in 1993 was 4.2 per 100,000 population for anorexia nervosa, and 12.2 per 100,000 for bulimia nervosa. The relative risks of females to males was 40:1 for anorexia nervosa and 47:1 for bulimia nervosa. A threefold increase in the recording of bulimia nervosa was found from 1988 to 1993. Eighty per cent of anorexia nervosa cases and 60% of bulimia nervosa cases were referred to secondary care. There is a continuing expansion of service need for bulimia nervosa. The majority of cases of eating disorders are referred to secondary services. There is scope for more effective management of bulimia nervosa in primary care.
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The current study described the clinical presentation of anorexia nervosa (AN) and bulimia nervosa (BN) in Japan utilizing the Eating Disorders Inventory-2 (EDI-2) and assessed whether the clinical profile of eating disorder cases in Japan differs significantly from North American data. Statistical comparisons of Japanese AN, BN, and non-eating-disordered (NonED) EDI-2 data were conducted across diagnostic groups and with the North American standardization sample. The Japanese diagnostic groups reported significant between-group differences on all eight EDI-2 subscales. Compared with the standardization sample, all the Japanese groups reported significantly greater maturity fears, the Japanese AN-restricting subtype group (AN-R) reported lower levels of drive for thinness and perfectionism, the Japanese BN group reported lower levels of drive for thinness, and the Japanese NonED Group reported lower levels of drive for thinness and perfectionism but higher rates of ineffectiveness. Differences between the Japanese and North American groups suggest that certain cultural differences exist in eating disorder profiles.
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Although the epidemiology of Eating Disorders (ED) has been highly developed in Spain, further research considering false negatives and also the prevalence of these disorders in males are needed. They were the aims of the present study. One thousand and seventy six adolescents (500 males and 576 females) participated in a two-stage survey. At the age of 13, apart from exploring numerous clinical and psychosocial variables, they were assessed by means of self-administered screening instruments, the eating attitude test (EAT), bulimic investigatory test Edinburgh (BITE), and body shape questionnaire (BSQ). The subjects were interviewed again 2 years later. Afterwards, 159 probable cases and 150 controls were interviewed by means of the structured interview SCAN. Prevalence of ED in adolescents was 3.71% (95% CI 2.58-4.83; 6.4% of females, 0.6% of males): anorexia nervosa 0.1%, bulimia nervosa 0.75%, eating disorder not otherwise specified (EDNOS) = 2.88%. The rate of false negative was 2.6% of the control group and most of them were EDNOS. The prevalence of ED obtained in our study, higher than others found in previous Spanish research, and a relatively high percentage of false negatives both indicate that up to now the prevalence of ED in Spanish adolescents could be underestimated.
Article
Recent studies on the epidemiology of anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders in special populations and in other cultures are reviewed. In addition, studies on the epidemiology of dieting behavior and longitudinal studies of the outcome of dieting behavior are reviewed. It is concluded that anorexia and bulimia nervosa are uncommon disorders but probably have increased in incidence in recent years. However, they are one of the most common psychiatric disorders to affect young women in the west. Dieting behavior is a major risk factor in the pathogenesis of the eating disorders. The prevalence of the eating disorders in a given community is, therefore, correlated with the prevalence of dieting behavior in the community.
Article
We describe the increased risk of premature death from natural and from unnatural causes for the common mental disorders. With a Medline search (1966-1995) we found 152 English language reports on the mortality of mental disorder which met our inclusion criteria. From these reports, covering 27 mental disorder categories and eight treatment categories, we calculated standardised mortality ratios (SMRs) and 95% confidence intervals (CIs) for all causes of death, all natural causes and all unnatural causes; and for most, SMRs for suicide, other violent causes and specific natural causes. Highest risks of premature death, from both natural and unnatural causes, are for substance abuse and eating disorders. Risk of death from unnatural causes is especially high for the functional disorders, particularly schizophrenia and major depression. Deaths from natural causes are markedly increased for organic mental disorders, mental retardation and epilepsy. All mental disorders have an increased risk of premature death.
Article
To estimate long-term survival of unselected patients with anorexia nervosa from Rochester, Minn. In this population-based retrospective cohort study, all 208 Rochester residents who presented with anorexia nervosa (193 women and 15 men) for the first time from 1935 through 1989 were monitored for up to 63 years. Subsequent survival was compared with that expected for Minnesota white residents of similar age and sex, and standardized mortality ratios were determined on the basis of age- and sex-specific death rates for the US population in 1987. Survival was not worse than expected in this cohort (P = .16). The estimated survival 30 years after the initial diagnosis of anorexia nervosa was 93% (95% confidence interval, 88%-97%) compared with an expected 94%. During 5646 person-years of follow-up (median, 22 years per patient), 17 deaths occurred (14 women and 3 men) compared with an expected 23.7 deaths (standardized mortality ratio, 0.71; 95% confidence interval, 0.42-1.09). One woman died of complications of anorexia nervosa, 2 women committed suicide, and 6 patients (5 women and 1 man) died of complications of alcoholism. Other causes of death were not increased. Long-term survival of Rochester patients with anorexia nervosa did not differ from that expected. This finding suggests that overall mortality was not increased among the spectrum of cases representative of the community.
Article
I congratulate the authors on a very fine and much needed study on mortality in eating disorders.¹ I have but one comment. In the "Comment" section, the authors state, "To our knowledge, only one other study has reported an SMR [standardized mortality ratio] for bulimia nervosa." When submitted for publication (November 13, 2001), information from 2 overviews on this topic²,3 should have been available to the authors. One article was published in March/April 1998,² and the other in June 2001.³ I have updated the findings on SMR in bulimia nervosa in Table 1. A simulation exercise based on the observation of a linear relationship between expected mortality and person-years surveyed in the 6 studies in the Table 1, encompassing 43 follow-up studies of bulimia nervosa cohorts, gave an overall aggregate (pseudo) SMR of 1.6 (95% confidence interval, 0.8-2.7; P =.15). Of note is that the 6 studies reporting SMR differed significantly from the 37 other follow-up studies (Zelen exact, P =.002).¹⁰ These 37 studies had an overall (pseudo) SMR of 0.8 (95% confidence interval, 0.25-1.8; P = .73).
Article
The current study examined the development of the incidence of severe anorexia nervosa with five sampling periods covering the years 1956-1995 in a geographically defined region of Switzerland. Applying the same methodology as in the earlier sampling periods, the medical records of all hospitals of the canton of Zurich were screened manually for first-time hospitalizations of female anorexia nervosa patients during the years 1993-1995. Incidence rates were compared with the previous sampling period (1956-1985). The incidence rate of severe anorexia nervosa in the total population and the rate in the population at risk (females 12-25 years old) did not differ significantly from the incidence rates of 1983-1985. The incidence of severe anorexia nervosa in the canton of Zurich rose significantly during the 1960s and 1970s. Since then, the incidence appears to have reached a plateau.
Article
Anorexia nervosa is associated with an increased mortality rate. National mortality statistics based on statutory death certification are potentially an important source of information. However, there are reasons to believe that these statistics may be subject to significant errors. An audit of the quality of information and diagnosis was conducted on death certificates in which anorexia nervosa was mentioned. The current study examined data from death certificates of people who died in England and Wales between 1993 and 1999. There were 230 such deaths, but only 128--just over one half--were rated as likely to be deaths associated with true anorexia nervosa. National mortality statistics derived from death certificates are a flawed source of information on deaths from anorexia nervosa when taken at face value. There may be both underreporting and overreporting. Detailed examination may improve their usefulness by reducing the overerreporting. It seems likely that the association of deaths with anorexia nervosa is systematically underreported.
Article
Despite the recent surge of eating disorders among women in large Asian cities, male eating disorder cases remain rare. The current article described 5 male eating disorder cases that presented within a period of 2 years in Wuhan, a city in central China. The authors described 4 cases of anorexia nervosa (2 restrictive, 2 bulimic) and 1 case of normal weight bulimia nervosa. Fear of fat was reported for all 5 cases, and none of the cases reported homosexuality. Sociocultural changes and westernization most probably accounted for the increasing incidence of eating disorders among male and female youngsters in China today.