ArticlePDF AvailableLiterature Review

Abstract and Figures

Purpose of review: Eating disorders are currently not considered to be limited to Western culture. We systematically reviewed the existing literature on the prevalence of eating disorders in Latin America. Recent findings: Of 1583 records screened, 17 studies from Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela were included in the analysis. Most studies reported point-prevalence rates and only three studies provided lifetime and 12-month prevalence rates. We found a mean point-prevalence rate of 0.1% for anorexia nervosa, 1.16% for bulimia nervosa, and 3.53% for binge-eating disorder (BED) in the general population. Heterogeneity for bulimia nervosa and BED was large. This meta-analysis indicates that the prevalence of anorexia nervosa seems to be lower, whereas the prevalence of bulimia nervosa and especially of BED seems to be higher in Latin America than in Western countries. Summary: Our findings show that eating disorders are common mental disorders in Latin America. However, some facets of Latin American culture might be protective for the development of anorexia nervosa and increase the risk for bulimia nervosa and BED. Further studies investigating the epidemiology of eating disorders and their relation to culture in Latin America are needed. Video abstract: SPANISH ABSTRACT.
Content may be subject to copyright.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
C
URRENT
O
PINION
Epidemiology of eating disorders in Latin America:
a systematic review and meta-analysis
David R. Kolar
a,b
, Dania L. Mejı´a Rodriguez
b,c
, Moises Mebarak Chams
b
,
and Hans W. Hoek
d,e,f
Purpose of review
Eating disorders are currently not considered to be limited to Western culture. We systematically reviewed
the existing literature on the prevalence of eating disorders in Latin America.
Recent findings
Of 1583 records screened, 17 studies from Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela
were included in the analysis. Most studies reported point-prevalence rates and only three studies provided
lifetime and 12-month prevalence rates. We found a mean point-prevalence rate of 0.1% for anorexia
nervosa, 1.16% for bulimia nervosa, and 3.53% for binge-eating disorder (BED) in the general population.
Heterogeneity for bulimia nervosa and BED was large. This meta-analysis indicates that the prevalence of
anorexia nervosa seems to be lower, whereas the prevalence of bulimia nervosa and especially of BED
seems to be higher in Latin America than in Western countries.
Summary
Our findings show that eating disorders are common mental disorders in Latin America. However, some
facets of Latin American culture might be protective for the development of anorexia nervosa and increase
the risk for bulimia nervosa and BED. Further studies investigating the epidemiology of eating disorders and
their relation to culture in Latin America are needed.
Video abstract
http://links.lww.com/YCO/A35
Spanish abstract
http://links.lww.com/YCO/A36
Keywords
anorexia nervosa, binge-eating disorder, bulimia nervosa, epidemiology, Latin America
INTRODUCTION
Historically, eating disorders were perceived as
culture-bound syndromes [1] restricted to the West-
ern culture. Eating disorders were first described in
Caucasian females living in Western Europe and
North America, leading to the presumption that
specific characteristics of their culture must be cru-
cial to the development of an eating disorder. Sev-
eral decades after the emergence of eating disorders
in Western culture, cases of eating disorders have
been identified in all cultures to a varying extent,
mostly with increasing incidence rates but still lower
prevalence rates than in Western countries [2,3].
Recent evidence suggests that the incidence of
bulimia nervosa is decreasing in Western countries,
but remains stable for anorexia nervosa [4,5]. The
point-prevalence for anorexia nervosa in Western
Europe and North America ranges from 0 to 0.9%
a
Department for Child and Adolescent Psychiatry and Psychotherapy,
University Medical Center of the Johannes Gutenberg University, Mainz,
Germany,
b
Departamento de Psicologı´a, Universidad del Norte, Barran-
quilla, Colombia,
c
Departamento de Ciencias Sociales y Humanas,
Universidad Simo
´n Bolı´var, Barranquilla, Colombia,
d
Department of
Epidemiology, Mailman School of Public Health, Columbia University,
New York, New York, USA,
e
Parnassia Psychiatric Institute, The Hague,
The Netherlands and
f
Department of Psychiatry, University Medical
Center Groningen, University of Groningen, Groningen,The Netherlands
Correspondence to David R. Kolar, Department of Child and Adolescent
Psychiatry and Psychotherapy, University Medical Center, Langen-
beckstr., 1 55131 Mainz, Germany. Tel: +49 6131 17 3280; fax: +49
6131 17 5580; e-mail: david.kolar@unimedizin-mainz.de
Curr Opin Psychiatry 2016, 29:363– 371
DOI:10.1097/YCO.0000000000000279
This is an open-access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-NoDerivatives 4.0 License, where
it is permissible to download and share the work provided it is properly
cited. The work cannot be changed in any way or used commercially.
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com
REVIEW
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
with a mean estimate of 0.29% in the high-risk
population of young females [6,7]. For bulimia
nervosa, a general point-prevalence of up to 1%
among young females is widely recognized [79].
Regarding eating disorders in Asia, the prevalence
rates in Japan and China are now considered at par
with European levels of eating disorders [10,11],
whereas eating disorders seem to be at a rise in Arab
countries, but still have lower prevalence rates com-
pared with Western nations [12]. The proceeding
industrialization, globalization and therefore west-
ernization in these regions are suspected as catalysts
for increasing incidence rates of eating disorders
[2,13
&
].Inconsiderationofthecloseproximityof
Latin America to the United States, not only in a
geographical but also economical manner, research
on the epidemiology of eating disorders in these
countries could further confirm the westernization
theory of rising prevalence rates of eating disorders
in developing countries. Recent research suggests
that prevalence rates of eating disorders in urban-
ized regions of Latin America reach similar levels as
in Europe and the United States [14,15], and Latin
American immigrants in Western countries did
not differ from the Caucasian population regarding
diagnoses of eating disorders [16,17]. However,
English language literature on the epidemiology of
eating disorders in Latin America is still rare, as most
studies are published in Spanish or Portuguese.
As a first step to better understanding eating
disorders in Latin America, this study provides
a systematic review of the existing literature
on the epidemiology of eating disorders in the
general population in Latin America. Its focus
is on the prevalence of anorexia nervosa, bulimia
nervosa and binge-eating disorder (BED) in Latin
American countries in continental South and
Central America.
METHODS
The review was conducted in accordance to the
Preferred Reporting Items for Systematic reviews
and Meta-Analyses statement (PRISMA) [18].
This review focuses on the prevalence rates of ano-
rexia nervosa, bulimia nervosa, and BED in Latin
American countries. Latin America is defined as all
American countries in which Romance languages
are spoken. For a more focused review, only
continental American countries were considered.
Therefore, literature on the prevalence of eating
disorders in the following countries was included:
Argentina, Bolivia, Brazil, Chile, Colombia, Costa
Rica, Ecuador, El Salvador, Guatemala, Honduras,
Mexico, Nicaragua, Panama, Paraguay, Peru, Uru-
guay, and Venezuela. Suriname, Guyana, and Belize
were excluded, as their official languages are not
considered Romance. French Guyana was excluded,
as it is not a sovereign state.
Literature search
A systematic literature search was conducted in
January 2015 and was updated in May 2016 for
recently published articles. The following databases
were screened: Medline (via PubMed and DIMDI),
Web of Science, SciELO, LILACS, IBECS, INDPSI,
HISA, and LIS. The search term was a combination
of the disorders of interest (eating disorder, anorexia
nervosa, bulimia nervosa, and BED), ‘South Amer-
ica’ and ‘Latin America’, and all names of the
countries included. Because of the interest in local
literature, SciELO, LILACS, IBECS, INDPSI, HISA,
and LIS were searched in Spanish and Portuguese
in addition to English.
Data extraction and quality assessment
Records identified in the literature search were
evaluated in a two-step approach. A screening of
titles and abstracts of all publications found in the
databases was conducted by two researchers. Articles
fulfilling all of the following eligibility criteria were
considered for full-text review: (1) the article was
written in English, Spanish, or Portuguese; (2) the
article was related to eating disorders; and (3)
the article was related to the epidemiology of
these disorders. Articles considered as relevant were
reviewed in full-text. Articles meeting at least one
exclusion criterion of the following were excluded
during screening and full-text review: (1) editorials,
newspaper articles, literature reviews, study pro-
tocols, theory articles, unpublished manuscripts,
KEY POINTS
Few cases of anorexia nervosa were found in the
epidemiological studies analyzed in this review,
indicating that the Latin American culture might be a
protective factor.
The prevalence rate of bulimia nervosa might be
slightly underestimated in our review and is likely to be
higher than in Western Europe or North America.
Binge-eating disorder appears to have a high
prevalence in Latin America.
The English literature on eating disorders in Latin
America is scarce as most of the studies reviewed were
published in either Spanish or Portuguese language
journals, which decreases the international visibility of
studies on eating disorders in Latin America.
Eating disorders
364 www.co-psychiatry.com Volume 29 Number 6 November 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
dissertations, government reports, books and book
chapters, conference proceedings, meeting
abstracts, and lectures; (2) the article was published
in a journal without peer review; (3) samples with
overall sample age under 10; (4) studies with biased
sample selection; or (5) the article studied a clinical
population. Articles fulfilling the inclusion criteria
as provided in Table 1 were included in a
qualitative analysis.
The screening and full-text review was con-
ducted online using Covidence (Covidence.org,
Alfred Health, Melbourne, Australia). Two research-
ers decided on the inclusion of each article at each
stage of the review. If disagreement occurred, resolv-
ing was conducted by the principal investigator. The
first three authors speak fluent English and Spanish,
and the first author speaks Portuguese as well. In
the case of difficulties understanding Portuguese
language articles, a translation was given by the first
author.
Quality assessment of the articles was conducted
with the Strengthening the Reporting of Observa-
tional Studies in Epidemiology (STROBE) checklist
[19]. Additionally, a methodological scoring system
to rate studies adapted from Loney et al. [20]
was used.
Statistical analyses
As three disorders were analyzed in this review,
separate meta-analyses were conducted for each
disorder. Only two studies reported 12-month
and lifetime prevalence rates, hence quantitative
analyses were conducted for point-prevalence rates
only. In many epidemiological studies, prevalence
rates are assessed by first screening a larger popu-
lation with a screening questionnaire to identify
people at risk for having an eating disorder. Sub-
sequently, the final diagnosis of an eating disorder
is established in a personal interview to which only
the high-risk group is invited. The prevalence rates
of these so-called two-stage studies included in the
meta-analysis were recalculated and based on
participants screened at first stage, as not all studies
provided response rates for the second stage. If,
for example, 2770 patients were included, 2756
participants filled in the screening instrument and
23 cases were detected at the second stage, the preva-
lence rate would be p¼23/2756. Meta-analyses were
conducted with MetaXL 3.0 (epigear.com), which
allows analyzing a quality effects model accounting
for heterogeneous prevalence studies, by taking the
overall quality scores of the studies into account [21].
This model was calculated for each disorder separ-
ately. As recommended by Barendregt et al. [22],
prevalence values were normalized and double arc-
sine transformed to stabilize variance of prevalence
estimates near 0. Finally, forest plots presenting the
overall and study-specific prevalence, 95% confi-
dence intervals and the study weight were computed.
RESULTS
In our literature search, 2199 articles were ident-
ified as shown in the study flow diagram (Fig. 1).
After removal of duplicates, 1583 articles were
Table 1. Inclusion criteria for articles
Inclusion criterion Definition
1 Type of eating disorder
investigated
Only anorexia nervosa, bulimia
nervosa and/or BED
2 Origin of study sample Sample recruited in one of the previous
defined Latin American countries
a
3 Sample size More than 200 subjects screened
3 Type of diagnosis
assessment
Only questionnaires and/or interviews
based on DSM-IV, DSM-V or ICD-10
criteria for anorexia nervosa, bulimia
nervosa and/or BED
4 Reporting of
prevalence
Prevalence rates for at least one of the
diagnoses of interest must be reported
BED, binge-eating disorder.
a
Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El
Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay,
Peru, Uruguay, and Venezuela.
Medline
via PubMed: 791
via DIMDI: 100
ISI web of
knowledge
484
SciELO
328
LILACS
496
2199 records
identified through
database searching
129 records
identified
through other
sources
1583 records
screened after
duplicates removed
1361 records
excluded
222 full-text articles
assessed for
eligibility
205 records excluded:
98 only subclinical
disordered eating
studied
28 clinical population
18 missing prevalence
13 sample age or size
13 sample selection biased
10 no valid instrument
9 other disorders studied
5 no Latin American
sample
4 no peer-review
3 same population
3 study protocol
1 Editorial
17 studies included in
qualitative synthesis
15 studies included in
quantitative syntheses
(meta-analyses)
FIGURE 1. Study flow diagram. IBECS, INDPSI, HISA, and
LIS were searched in combination with LILACS.
Epidemiology of eating disorders in Latin America Kolar et al.
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 365
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Table 2. Sample characteristics, measures, prevalences and quality scores of all studies included
Study and
setting
Sampling
frame
Sample
design
a
(age)
Sample
size (n) Measures
b
Response
rate
Prevalence rates Score
Anorexia
nervosa
c
Bulimia
nervosa
c
BED
c
Angel 2008 [23]
Colombia – urban
Municipal educational
census
Whole population of high school
students (mean age 14.2 years)
2770 2-phase design: 1.
ECA; 2. SCAN
33.5% response
in phase 2
0.11% 0.83% n/a 4
Baader 2014 [24]
Chile – Valdivia
Census of the Universidad
Auto
´noma de Chile;
stratified by subjects and
classes
University students (mean age 21
years)
804 EDDS 97.4% 0.13% 6.13% 2.55% 6
Benjet 2012 [25,26]
Mexico – rural/
urban
National Census; stratified
for seventeen districts
of Mexico
Adolescents (12– 17 years) 3005 WMH-CIDI 71% 0.5%
d
;
0.1%
e
1%
d
; 0.7%
e
1.4%
d
; 0.7%
e
8
Compte 2015 [27
&&
]
Argentina – urban
Randomized selection of 12
universities in Buenos Aires;
six universities participated
All male students (18– 28 years) of
participating classes
475 2-phase design: 1.
EAT-26; 2. EDE interview
99.4% in first
phase, 77.8%
in second
phase
0% 0% 0% 7
Freitas 2008 [28]
Brazil – Rio de
Janeiro
Census (Brazilian Institute of
Geography and Statistics)
Female individuals 35 years 1500 SCID-I/P questions 86.5% n/a n/a 9.78% 6
Herscovici 2005
[29,30] Argentina –
rural and urban
Pediatric primary care
distributed accordingly to
national census
Children and adolescents (10– 19
years)
1971 2-Phase design: 1.
EDE-Q4; 2. EDE
interview
42% response
rate in
second phase
0% 0.05% 6.60% 5
Kessler 2013 [14]
Colombia – urban
community
WHO World Mental Health
(WMH) Survey Initiative;
sample representative for
urbanized areas
(Colombia/Mexico) or one
specific urbanized area
(Sa
˜o Paulo, Brazil)
Adults (18 years) 1217 WMH-CIDI (DSM-V
criteria for BED)
Response rates
range from
45.9 to
87.7% and
average at
68.8%.
n/a 0.4%
d
; 0.2%
e
0.9%
d
; 0.3%
e
5
Brazil – Sa
˜o Paulo
community
2942 n/a 2%
d
; 0.9%
e
4.7%
d
; 1.8%
e
Mexico – urban
community [31]
1236 n/a 0.8%
d
; 0.3%
e
1.6%
d
; 0.5%
e
Mancilla-Diaz 2007
[32] Mexico –
Mexico city
university students
Probabilistic and stratified
sample based on all female
university students in 2002;
not further explained
Female university students 1995
sample: (mean age 19.49 years)
522 2-phase design:
1.EAT-40, BULIT
screening; 2.
IDED – IV
32.9% 0 1.15% n/a 3
2002 sample: (mean age 19.53
years)
880 40.3% 0 1.14% n/a
Mascarenhas 2007
[33,34] Brazil –
Feira da Santana,
BA
Randomized sample, stratified
for subdistricts of Feira da
Santana
Adults (20– 59 years) 2506 PHQ (2 binges per
week for 3 months
criterion)
n/a n/a 1.00% 5.03% 4
Morales 2015 [35
&
]
Venezuela –
urban
Census of all enrolled medical
students at the local
university (UCLA)
Randomized sample of medicine
students (18– 28 years)
497 Questionnaire
based on DSM-V
criteria for BED
n/a 3.20% 5
Pin
˜eros-Ortiz
2010 [36]
Colombia –
urban community
Randomized selection of
education institutes in the
region.
Adolescents (12– 20 years) 937 2-phase design: 1.
EAT-26; 2.
telephone
interview
85.18% in first
phase; 38.3%
in second
phase
0% 0.21% n/a 3
Pivetta 2010 [37]
Brazil – high school
students
Randomized selection of
registered education
institutes, stratified for
public and private.
Adolescents (14– 19 years) 1209 QEWP-R 93.3% n/a 1.90% 1.82% 4
Quintero-Pa
´rraga
2003 [38]
Venezuela –
Maracaibo city
Educational population
reported. Official State
Census
Middle and high school Students (12–
18 years)
1363 The A.B.A checklist 80.86% 0% 1.54% 0.66%; 4
Rueda-Jaimes 2005a
[39] Colombia –
Bucaramanga
Three schools selected at
convenience from different
socio-economic districts of
Bucaramanga
All female school students (10– 19
years)
247 WMH-CIDI 98.4% 1.65% 5.35% n/a 6
Rueda-Jaimes 2005b
[40] Colombia –
Bucaramanga
Six faculties with
predominantly female
students of the Universidad
Auto
´noma de Bucaramanga
Female students in 2nd semester 241 2-phase design:
1. SCOFF; 2.
WMH-CIDI
62.6% 0% 2.08% n/a 5
Rueda-Jaimes 2008
[41] Colombia –
Bucaramanga
Private Bucaramanga
University
University students (16– 35 years) 261 WMH-CIDI 99.61% n/a 1.15% 4.21% 6
Va
´zquez 2005 [42]
Mexico – Mexico
City
Six schools in Mexico City School students (mean age 15.25
years)
525 2-phase design:
1. EAT-40;
Bulit; 2. IDED
n/a 0.38% 0.95% n/a 3
BED, binge-eating disorder; BULIT, bulimia Test; EAT, Eating Attitudes Test; ECA, Encuesta de Comportamento Alimenticio; EDDS, Eating Disorder Diagnostic
Scale; EDE, Eating Disorder Examination; IDED, Interview for Diagnosis of Eating Disorders; PHQ, Patient Health Questionnaire; QEWP-R, Questiona
´rio sobre
Padro
˜es de Alimentac¸a
˜o e Peso – Revisado; SCAN, Cuestionarios para la Evaluacio
´nClı
´nica en Neuropsiquiatrı
´a; WMH-CIDI, World Mental Health Composite
International Diagnostic Interview.
a
Random sample, if not specified.
b
Measurements based on DSM-IV, if not specified.
c
Prevalences are reported as point prevalence, if not specified.
d
Lifetime prevalence.
e
12-month prevalence.
Eating disorders
366 www.co-psychiatry.com Volume 29 Number 6 November 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
screened and 1361 articles removed as irrelevant.
A total of 222 studies were reviewed in full-text,
resulting in an inclusion of 17 studies. Reasons for
the exclusion of studies are given in Fig. 1. Fifteen
of the studies provided point-prevalence rates of
eating disorders and were therefore included in the
meta-analyses.
Table 2 provides sample characteristics,
measures and reported prevalence values of each
study included. Of the studies included, five
were conducted in Colombia, three in Brazil, three
in Mexico, two in Venezuela and one each in
Argentina and Chile. One additional study pro-
vided data from Colombia, Brazil, and Mexico.
Due to the small number of studies, an inter-
national comparison of the results was not
conducted.
Lifetime and 12-month prevalence rates
Only two of the included studies reported lifetime
and 12-month prevalence rates for bulimia nervosa
and BED [14,25], and only one study for anorexia
nervosa [25]. Regarding Mexico, lifetime prevalence
rates for adolescents aged 1217 years were 0.5%
(12 months: 0.1%) for anorexia nervosa, 1.0%
(0.7%) for bulimia nervosa, and 1.4% (0.7%) for
BED [25]. In a study on adults, lifetime prevalence
rates of bulimia nervosa were identified as 0.8% (12
months: 0.3%) in Mexico, 0.4% (0.2%) in Colom-
bia, and 2.0% (0.9%) in Brazil [14]. Regarding BED,
the same study identified the lifetime prevalence
ratesas1.6%(12months:0.5%)forMexico,0.9%
(0.3%) for Colombia, and 4.7% (1.8%) for Brazil
[14]. Lifetime prevalence rates were highest for
bulimia nervosa and BED in Brazil, and lowest in
Colombia [14].
Mean point-prevalence and heterogeneity
testing for anorexia nervosa
In 10 studies providing 11 distinct samples
(N¼10 840) assessing anorexia nervosa, there was
a weighed mean prevalence rate of 0.1%, 95% CI
(0.02, 0.23) for the general population in Latin
America (Fig. 2). The included studies varied
regarding their quality index from three to seven
points. Heterogeneity of the studies was moderate
(I
2
¼51.50). By exclusion of the most extreme
outlier Rueda-Jaimes et al. [39], the heterogeneity
can be reduced to almost 0. There was no real
difference between the mean prevalence in the
general population and that of a meta-analysis with
the female subsample only (0.1%, 95% CI [0.02,
0.35]; N¼6 334). Prevalence rates were comparable
amongst the different countries included.
Mean point-prevalence and heterogeneity
testing for bulimia nervosa
Regarding bulimia nervosa, 14 distinct samples in
13 studies were identified, with an overall sample
size of N¼14 816 participants assessed at first stage.
In the meta-analysis, a weighed mean prevalence
rate of 1.16% (95% CI [0.55, 1.98]) was calculated for
Latin America (Fig. 3). Heterogeneity was large
(I
2
¼92.28), reflecting the different sample settings
and countries included. The highest prevalence rate
was found for Chile, and the lowest for Argentina,
especially in a male sample [27
&&
]. The prevalence
rates for Colombia, Brazil, Venezuela, and Mexico
seem comparable. As the Chilean study was
conducted as a self-report screening, the high preva-
lence rate might be due to the study design. How-
ever, no study could be determined as a main source
of heterogeneity. In consideration of the small
Study Prev LCL UCL Weight %
Angel 2008
Baader 2014
Compte 2015
Herscovici 2005
Mancilla-Diaz 2007a
Mancilla-Diaz 2007b
Piñeros-Ortiz 2010
Quintero-Párraga 2003
Rueda-Jaimes 2005a
Rueda-Jaimes 2005b
Vázquez 2005
Overall
0.11
0.13
0.00
0.00
0.00
0.00
0.00
0.00
1.65
0.00
0.38
0.10 0.02 0.23 100.00
0.01
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.35
0.00
0.01
0.28
0.55
0.36
0.09
0.33
0.20
0.18
0.13
3.71
0.45
1.15
17.71
10.96
9.92
16.96
4.45
5.87
6.09
10.37
6.69
6.51
4.46
0.0 0.5 1.0
Prevalence
1.5 2.0
FIGURE 2. Forest plot of the meta-analysis of the anorexia nervosa point-prevalence rates. LCL, lower confidence level; Prev:
prevalence rate; UCL, upper confidence level.
Epidemiology of eating disorders in Latin America Kolar et al.
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 367
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
number of studies included, no moderator analysis
for heterogeneity was conducted.
Mean point-prevalence and heterogeneity
testing for binge-eating disorder
Within nine studies analyzing point-prevalence
rates for BED, N¼10 363 persons were screened at
first stage. A weighed mean prevalence rate of 3.53%
(95% CI [1.60, 6.13]) was identified (Fig. 4). Hetero-
geneity was large (I
2
¼97.00). Regarding potential
sources of heterogeneity, one study was identified
assessing the occurrence of two binges per week for
the shorter time range of 3 instead of 6 months as
proposed by the DSM-IV criteria for this disorder [33].
However, exclusion of this study did not reduce
heterogeneity meaningfully. Possible moderator vari-
ables for heterogeneity were age and sex, as studies
differed notably regarding age ranges. Due to the
restricted number of studies included, no moderator
analysis was conducted. Regarding country differ-
ences, no conclusion could be drawn as the preva-
lence rates varied strongly depending on the study.
DISCUSSION
The present systematic review and meta-analysis
evaluated the epidemiology of anorexia nervosa,
bulimia nervosa, and BED in Latin America, by
assessing not only English literature published
in international journals, but also by considering
high-quality studies published in Spanish or Portu-
guese in Latin American journals. We computed
mean point-prevalence rates for the specific
disorders and compared the prevalence rates of
the different countries.
Study
Angel 2008 0.83 0.53
4.55
0.00
0.00
0.38
0.53
0.64
0.00
1.20
0.95
2.83
0.85
0.14
0.27
0.55
1.21
7.93
0.36
0.22
2.28
1.96
1.43
0.64
2.76
2.27
8.58
3.78
2.89
2.00
1.98
13.14
8.29
7.58
12.64
3.39
4.43
12.17
4.59
7.17
7.77
5.17
4.99
5.27
3.40
100.00
6.13
0.05
0.00
1.15
1.14
1.00
0.21
1.90
1.54
5.35
2.08
1.15
0.95
1.16
Baader 2014
Compte 2015
Herscovici 2005
Mancilla-Diaz 2007a
Mancilla-Diaz 2007b
Mascarenhas 2007
Piñeros-Ortiz 2010
Pivetta 2010
Quintero-Párraga 2003
Rueda-Jaimes 2005a
Rueda-Jaimes 2005b
Rueda-Jaimes 2008
Vázquez 2005
Overall
Prev LCL UCL We igh t %
012345
Prevalence
67
FIGURE 3. Forest plot of the meta-analysis of the bulimia nervosa point-prevalence rates. LCL, lower confidence level; Prev,
prevalence rate; UCL, upper confidence level.
Study Prev LCL UCL Weight %
Baader 2014 2.55
0.00
9.78
6.60
5.03
3.22
1.82
0.66
4.21
1.55
0.00
8.23
5.54
4.21
1.83
1.13
0.29
2.07
3.79
0.36
11.46
7.74
5.92
4.97
2.66
1.17
7.04
10.44
9.18
14.70
16.89
16.46
6.73
9.31
10.16
6.13
Compte 2015
Freitas 2008
Herscovici 2005
Mascarenhas 2007
Morales 2015
Pivetta 2010
Quintero-Párraga 2003
Rueda-Jaimes 2008
Overall 3.53 1.60 6.13 100.00
012345
Prevalence
678910
FIGURE 4. Forest plot of the meta-analysis of the binge-eating disorder point-prevalence rates. LCL, lower confidence level;
Prev, prevalence rate; UCL, upper confidence level.
Eating disorders
368 www.co-psychiatry.com Volume 29 Number 6 November 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Epidemiology of anorexia nervosa in Latin
America
Our findings demonstrate that the prevalence rates
for anorexia nervosa are comparable among the
different countries in Latin America, and signifi-
cantly lower compared to European or North Amer-
ican samples [4,69]. Similar prevalence rates were
found in Hispanic immigrants in the United States
[43]. This might be due to the different body ideal of
Latinas and Latinos compared to other ethnicities,
which idealizes a ‘curvier’ shape and higher weight
of the body than in Western countries [44
&&
,45,46],
and might be a protective factor in adolescence. As
recent research highlights the influence of other
etiological factors besides culture contributing to
the development and maintenance of anorexia
nervosa, genetic variations [47], or emotion dysre-
gulation [48] might play an important part in the
observed cases of anorexia nervosa in Latin America.
Epidemiology of bulimia nervosa in Latin
America
The point-prevalence of bulimia nervosa is mostly
reported as 1% in two-stage studies of young females
[7]. In this meta-analysis, the heterogeneity of the
studies was large. However, most of the studies
found prevalence rates of at least the same range
or higher than in Western Europe, but assessed
eating disorders of both genders. Additionally, half
of the samples were younger than 20 years of age. As
the peak incidence rate of bulimia nervosa is slightly
later than that of anorexia nervosa and females are
at a higher risk for developing any eating disorder,
this indicates that the general point-prevalence rate
in Latin America is most likely underestimated in
our study. This is in line with cross-cultural studies
conducted in the United States, indicating that the
prevalence rate of bulimia nervosa is at least in the
same range or even slightly higher in Hispanic
immigrants than in Caucasian residents [43,49].
Epidemiology of binge-eating disorder in
Latin America
We identified a higher BED point-prevalence in Latin
America than previous studies in Western popu-
lations [50,51]. Recent studies comparing eating
disorder prevalence rates of ethnic minorities with
Caucasian habitants identified higher prevalence
rates of Hispanic females in the United States
[43,49,52]. A possible explanation might be that food
has a high emotional value in many Latin American
cultures which reflects in the language (e.g., ‘Las
penas con pan duelen menos’, – the sorrows with
bread hurt less, ‘barriga llena, corazo
´n contento’ – a
full belly is a pleased heart), and addressing the
cultural assumptions regarding food is of importance
in nutritional interventions for Latinas [53
&&
].
Additionally, BED occurs more often in overweight
and obese individuals [54,55]. As most of the Latin
American countries have higher prevalence rates of
obesity and overweight than Western European
countries especially in females [56], a high prevalence
of BED might be a concomitant phenomenon of the
obesity epidemic in these countries.
Limitations of the study
One of the main difficulties in reviewing the liter-
ature regarding Latin American studies on eating
disorders is the wide range of instruments used to
assess the prevalence rates. The studies included
varied heavily regarding the study design (self-
administered questionnaire to two-phase designs)
and the instruments used. Hence, heterogeneity was
large and the mean prevalence rates of the meta-
analyses remain difficult to interpret. Furthermore,
the studies included were conducted during a time
span of 13 years. Because only few studies were from
Argentina, Chile, and Venezuela, we did not con-
duct cultural comparisons within Latin America and
the influence of specific countries on the prevalence
rates remains unexplored.
CONCLUSION
Eating disorders are common in Latin America, with
a lower prevalence rate for anorexia nervosa and a
higher rate for bulimia nervosa and BED, when
compared to Western Europe or the United States.
These findings might reflect a stronger cultural bond
of anorexia nervosa to a Western lifestyle than of
bulimia nervosa and BED. However, we could not
analyze cultural differences within Latin America as
most of the studies included were conducted either
in Brazil, Mexico, or Colombia. Therefore, further
research assessing the epidemiology and cultural
factors of eating disorders in developing countries
such as Ecuador, Suriname, or Guyana are needed to
draw conclusions regarding the cultural factors of
eating disorders in Latin America.
Acknowledgements
We are thankful to Jochem Ko
¨nig and Ekkehart Jenetzky
for their valuable comments on the methodology of this
study. Patricia Meinhardt conducted proof-reading of the
manuscript.
Financial support and sponsorship
None.
Epidemiology of eating disorders in Latin America Kolar et al.
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 369
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
&of special interest
&& of outstanding interest
1. Prince R. The concept of culture-bound syndromes: anorexia nervosa and
brain-fag. Soc Sci Med 1985; 21:197– 203.
2. Pike KM, Hoek HW, Dunne PE. Cultural trends and eating disorders. Curr
Opin Psychiatry 2014; 27:436–442.
3. Hoek HW. Epidemiology of eating disorders in persons other than the high-
risk group of young Western females. Curr Opin Psychiatry 2014; 27:423
425.
4. Smink FR, van Hoeken D, Donker GA, et al. Three decades of eating disorders
in Dutch primary care: decreasing incidence of bulimia nervosa but not of
anorexia nervosa. Psychol Med 2016; 46:1189 –1196.
5. Nagl M, Jacobi C, Paul M, et al. Prevalence, incidence, and natural course of
anorexia and bulimia nervosa among adolescents and young adults. Eur Child
Adolesc Psychiatry 2016; 25:903–918.
6. Hammerle F, Huss M, Ernst V, Bu
¨rger A. Thinking dimensional: prevalence of
DSM-5 early adolescent full syndrome, partial and subthreshold eating
disorders in a cross-sectional survey in German schools. BMJ Open
2016; 6:e010843.
7. Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other
eating disorders. Curr Opin Psychiatry 2006; 19:389–394.
8. Smink FRE, van Hoeken D, Hoek HW. Epidemiology of eating disorders:
incidence, prevalence and mortality rates. Curr Psychiatry Rep 2012;
14:406– 414.
9. Smink FRE, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of
eating disorders. Curr Opin Psychiatry 2013; 26:543–548.
10. Tong J, Miao S, Wang J, et al. A two-stage epidemiologic study on prevalence
of eating disorders in female university students in Wuhan, China. Soc
Psychiatry Psychiatr Epidemiol 2014; 49:499–505.
11. Pike KM, Borovoy A. The rise of eating disorders in Japan: issues of culture
and limitations of the model of ‘westernization’. Cult Med Psychiatry 2004;
28:493– 531.
12. Musaiger AO, Al-Mannai M, Tayyem R, et al. Risk of disordered eating
attitudes among adolescents in seven Arab countries by gender and obesity:
a cross-cultural study. Appetite 2013; 60:162 167.
13.
&
Doris E, Shekriladze I, Javakhishvili N, et al. Is cultural change associated with
eating disorders? A systematic review of the literature. Eat Weight Disord
2015; 20:149– 160.
A systematic review assessing the effect of acculturation to Western culture on
eating disorders. The authors evaluate mixed findings from 25 studies, stating that
even higher or less acculturation may be a risk factor for eating disorders in
conclusion, further cross-cultural research is needed.
14. Kessler RC, Berglund PA, Chiu WT, et al. The prevalence and correlates of
binge eating disorder in the World Health Organization World Mental Health
Surveys. Biol Psychiatry 2013; 73:904– 914.
15. Palavras MA, Kaio GH, Mari JdJ, Claudino AM. A review of Latin American
studies on binge eating disorder. Rev Bras Psiquiatr 2011; 33 (Suppl
1):S81– S108.
16. van Hoeken D, Veling W, Smink FRE, Hoek HW. The incidence of anorexia
nervosa in Netherlands Antilles immigrants in the Netherlands. Eur Eat Disord
Rev 2010; 18:399– 403.
17. Marques L, Alegria M, Becker AE, et al. Comparative prevalence, correlates of
impairment, and service utilization for eating disorders across U.S. Ethnic
Groups: implications for reducing ethnic disparities in healthcare access for
eating disorders. Int J Eat Disord 2011; 44:412–420.
18. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. J Clin Epi-
demiol 2009; 62:1006– 1012.
19. Elm Ev, Altman DG, Egger M, et al. The Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) statement: guidelines for
reporting observational studies. PLoS Med 2007; 4:e296.
20. Loney PL, Chambers LW, Bennett KJ, et al. Critical appraisal of the health
research literature: prevalence or incidence of a health problem. Chronic Dis
Can 1998; 19:170– 176.
21. Doi SAR, Barendregt JJ, Khan S, et al. Advances in the meta-analysis of
heterogeneous clinical trials II: The quality effects model. Contemp Clin Trials
2015; 45 (Pt A):123–129.
22. Barendregt JJ, Doi SA, Lee YY, et al. Meta-analysis of prevalence. J Epidemiol
Community Health 2013; 67:974– 978.
23. A
´ngel LA, Martı
´nez LM, Go
´mez MT. Prevalencia de trastornos del comporta-
miento alimentario (TCA) en estudiantes de bachillerato [Prevalence of eating
disorders in high school students]. Rev Fac Med 2008; 56:193 210.
24. Baader MT, Rojas CC, Molina FJL, et al. Diagno
´stico de la prevalencia de
trastornos de la salud mental en estudiantes universitarios y los factores de
riesgo emocionales asociados [Diagnostic of the prevalence of mental health
disorders in college students and associated emotional risk factors]. Rev Chil
Neuro-Psiquiatr 2014; 52:167–176.
25. Benjet C, Me
´ndez E, Borges G, Medina-Mora ME. Epidemiologı
´adelos
trastornos de la conducta alimentaria en una muestra representativa de
adolescentes [Epidemiology of eating disorders in a representative sample
of adolescents]. Salud Mental 2012; 35:483 490.
26. Benjet C, Borges G, Mendez E, et al. Eight-year incidence of psychiatric
disorders and service use from adolescence to early adulthood: longitudinal
follow-up of the Mexican Adolescent Mental Health Survey. Eur Child Adolesc
Psychiatry 2016; 25:163– 173.
27.
&&
Compte EJ, Sepulveda AR, Torrente F. A two-stage epidemiological study of
eating disorders and muscle dysmorphia in male university students in
Buenos Aires. Int J Eat Disord 2015; 48:1092 –1101.
This study is the first study on eating disorders in young males in Argentina. They
found no case of anorexia nervosa, bulimia nervosa, or BED, but a 1.9% prevalenc e
of eating disorders not otherwise specified.
28. de Freitas SR, Appolinario JC, Souza AdM, Sichieri R. Prevalence of binge
eating and associated factors in a Brazilian probability sample of midlife
women. Int J Eat Disord 2008; 41:471–478.
29. Herscovici CR, Bay L, Kovalskys I. Prevalence of eating disorders in Argentine
boys and girls, aged 10 to 19, who are in primary care. A two-stage
community-based survey. Eat Disord 2005; 13:467 –478.
30. Bay LB, Rausch Herscovici C, Kovalskys I, et al. Alteraciones alimentarias en
nin
˜os y adolescentes argentinos que concurren al consultorio del pediatra
[Eating abnormalities in Argentinian children and adolescents occuring at
pediatric consultations]. Arch Argent Pediatr 2005; 103:305–316.
31. Swanson SA, Saito N, Borges G, et al. Change in binge eating and binge
eating disorder associated with migration from Mexico to the US. J Psychiatr
Res 2012; 46:31– 37.
32. Mancilla-Diaz JM, Franco-Paredes K, Vazquez-Arevalo R, et al. A two-stage
epidemiologic study on prevalence of eating disorders in female university
students in Mexico. Eur Eat Disord Rev 2007; 15:463– 470.
33. Lima Mascarenhas MT, Guimara
˜es de Almeida MM, Arau
´jo TMd, Kalil Prisco
AP. Transtornos alimentares na populac¸a
˜o de 20 a 59 anos de Feira de
Santana (BA), 2007 [Eating disorders in population aged 20 59 years from
Feira de Santana (BA), Brazil, 2007]. Cad Sau
´de Colet 2011; 19:179– 186.
34. Kalil Prisco AP, Araujo TMd, Guimara
˜es de Almeida MM, Bernardes Santos
KO. Prevalence of eating disorders in urban workers in a city of the northeast
of Brazil. Cien Saude Colet 2013; 18:1109–1118.
35.
&
Morales A, Gomes A, Jimenez B, et al. Binge eating disorder: prevalence,
associated factors and obesity in university students. Rev Colomb Psiquiatr
2015; 44:177– 182.
In this recent study, the prevalence rate of BED in Venezuelan students was 3.2%.
It is the first study based on the DSM-5 criteria for BED in Venezuela.
36. Ortı
´z SP, Caro JM, Mesa CLd. Factores de riesgo de los trastornos de la
conducta alimentaria en jo
´venes escolarizados en Cundinamarca (Colombia).
Rev Colomb Psiquiatr 2010; 39:313– 328.
37. Pivetta LA, Gonc¸alves-Silva RMV. Compulsa
˜o alimentar e fatores associados
em adolescentes de Cuiaba
´, Mato Grosso, Brasil [Binge eating and asso-
ciated factors among teenagers in Cuiaba
´, Mato Grosso State, Brazil]. Cad
Sau
´de Pu
´blica 2010; 26:337– 346.
38. Quintero-Pa
´rraga E, Pe
´rez-Montiel AC, Montiel-Nava C, et al. Trastornos
de la conducta alimentaria. Prevalencia y caracterı
´sticas clı
´nicas en
adolescentes de la ciudad de Maracaibo, Estado Zulia, Venezuela [Eating
behavior disorders. Prevalence and clinical features in adolescents in
the city of Maracaibo, Zulia State, Venezuela]. Invest Clı
´n 2003;
44:179– 193.
39. Rueda-Jaimes GE, Cadena Afanador. Laura del Pilar, et al. Validacio
´ndela
encuesta de comportamiento alimentario en adolescentes escolarizadas de
Bucaramanga, Colombia. Rev Colomb Psiquiatr 2005; 34:375 385.
40. Rueda Jaimes GE, Dı
´az Martı
´nez LA, Ortiz Barajas DP, et al. Validacio
´n del
cuestionario SCOFF para el cribado de los trastornos del comportamiento
alimentario en adolescentes escolarizadas [Validation of the scoff question-
naire for screening the eating behaviour disorders of adolescents in school].
Aten Primaria 2005; 35:89–94.
41. Rueda-Jaimes GE, Camacho Lopez PA, Rangel-Martinez-Villalba AM. Internal
consistency and validity of the BITE for the screening of bulimia nervosa in
university students, Colombia. Eat Weight Disord 2008; 13:e35– e39.
42. Va
´zquez Are
´valo R, Mancilla Dı
´az JM, Mateo Gonza
´lez C, Aguilar L. Trastornos
del comportamiento alimentario y factores de riesgo en una muestra incidental
de jo
´venes mexicanos [Eating disorders and risk factors in an incidental
sample of young Mexicans]. Rev Mex Psicol 2005; 22:53 63.
43. Alegria M, Woo M, Cao Z, et al. Prevalence and correlates of eating disorders
in Latinos in the United States. Int J Eat Disord 2007; 40 (Suppl):S15 –21.
44.
&&
Schooler D, Daniels EA. I am not a skinny toothpick and proud of it’: Latina
adolescents’ ethnic identity and responses to mainstream media images.
Body Image 2014; 11:11– 18.
Latina girls expressions’ of ethnicity was connected to more positive expressions
relating to their body after viewing thin-ideal White women. This supports the
theory that the Latina identity and body image might serve as a protective factor for
eating disorder when exposed to thin-ideal media.
Eating disorders
370 www.co-psychiatry.com Volume 29 Number 6 November 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
45. Warren CS, Gleaves DH, Rakhkovskaya LM. Score reliability and factor
similarity of the Sociocultural Attitudes Towards Appearance Question-
naire-3 (SATAQ-3) among four ethnic groups. J Eat Disord 2013; 1:14.
46. Rakhkovskaya LM, Warren CS. Ethnic identity, thin-ideal internalization, and
eating pathology in ethnically diverse college women. Body Image 2014;
11:438– 445.
47. Brandys MK, de Kovel CGF, Kas MJ, et al. Overview of genetic research in
anorexia nervosa: The past, the present and the future. Int J Eat Disord 2015;
48:814– 825.
48. Haynos AF, Fruzzetti AE. Anorexia nervosa as a disorder of emotion dysre-
gulation: evidence and treatment implications. Clin Psychol: Sci Pract 2011;
18:183– 202.
49. Marques L, Alegria M, Becker AE, et al. Comparative prevalence, correlates of
impairment, and service utilization for eating disorders across US ethnic
groups: Implications for reducing ethnic disparities in healthcare access
for eating disorders. Int J Eat Disord 2011; 44:412 420.
50. Striegel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J
Eat Disord 2003; 34 (Suppl):S19– S29.
51. Davis C. The epidemiology and genetics of binge eating disorder (BED). CNS
Spectrums 2015; 20:522– 529.
52. Jennings KM, Kelly-Weeder S, Wolfe BE. Binge eating among racial
minority groups in the United States: an integrative review. J Am Psychiatr
Nurses Assoc 2015; 21:117– 125.
53.
&&
Reyes-Rodriguez ML, Gulisano M, Silva Y, et al. Las penas con pan duelen
menos’: The role of food and culture in Latinas with disordered eating
behaviors. Appetite 2016; 100:102– 109.
In this recent qualitative study the topics discussed by Latinas with ED in nutrition
therapy sessions were analyzed. Latin culture values were discussed in all of the
sessions, which shows the importance of cultural aspects in treatment of eating
disoders.
54. Marcus MD, Wildes JE. Disordered eating in obese individuals. Curr Opin
Psychiatry 2014; 27:443– 447.
55. Bertoli S, Leone A, Ponissi V, et al. Prevalence of and risk factors
for binge eating behaviour in 6930 adults starting a weight
loss or maintenance programme. Public Health Nutr 2016; 19:
71–77.
56. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence
of overweight and obesity in children and adults during 1980– 2013: a
systematic analysis for the Global Burden of Disease Study 2013. Lancet
2014; 384:766– 781.
Epidemiology of eating disorders in Latin America Kolar et al.
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 371
... When it comes to evaluating the ethnic variable, the data on the population of young African women is very similar to that found in American women of African descent, as well as in Latin American countries, which is to say that this population seems to be more affected by BN and BED diagnoses [6,75]. Some scholars stipulate that this fact is associated with the local standard of beauty and cultural factors that become protective (e.g., Black North American women are more likely to be satisfied with their bodies when compared to Caucasian North American women) [76,77]. However, it is also hypothesized that the diagnosis of ED is underdiagnosed due to the lack of specialized professionals [69,75,77]. ...
... Some scholars stipulate that this fact is associated with the local standard of beauty and cultural factors that become protective (e.g., Black North American women are more likely to be satisfied with their bodies when compared to Caucasian North American women) [76,77]. However, it is also hypothesized that the diagnosis of ED is underdiagnosed due to the lack of specialized professionals [69,75,77]. ...
... For BN and BED diagnoses, the data is similar to that found in American, European, and Asian studies [73,[78][79][80][81]. In Brazil, specifically, the prevalence of BN is 1-2%, and BED is 4.7% [72,73,77]; concerning AN, there is no record of Brazilian data on the prevalence of this diagnosis, which cannot be understood as being inexistent. Thus, some studies stipulate that data from Latin America, including Brazil, for AN prevalence would range between 0.1 and 0.5% [6,77,81,82]. ...
Article
Full-text available
Body image distortion (BID) is a common symptom in eating disorders (ED), but its neurobiological underpinnings remain unclear. We aimed to discuss, through a systematic review, BID's neurobiology through studies that used neuroimaging tools in ED patients. The review was developed using the guideline PRISMA, following a 27-step checklist and four-phase flowchart. The following databases were consulted: Lilacs, Scielo, Pepsic, APA/Psycnet, Pubmed, Scopus, Bireme, Cochrane and 1.692 articles were found, 1.95% were included in this research. Anorexia nervosa (AN): Key findings included altered activity in the amygdala, insula, and anterior cingulate cortex, suggesting dysfunctions in emotional response, body perception, and cognitive processes. Additionally, studies have reported changes in functional connectivity between brain regions and reduced gray matter volume in specific areas. Bulimia nervosa (BN): Key findings include alterations in the prefrontal cortex, insula, and anterior cingulate cortex, suggesting dysfunctions in decision-making, impulse control, body perception, and emotional regulation. AN/BN: While AN-R and AN-P showed greater activation in the amygdala, BN patients exhibited greater activation in the prefrontal cortex and occipital and parietal lobes. Both groups presented alterations in functional connectivity and excessive preoccupation with body image, suggesting shared neural underpinnings despite subtype-specific differences. Binge eating disorder (BED): one article exhibits increased activation in the left fusiform body area (FBA) when viewing body stimuli, suggesting an attentional bias towards the body, without corresponding increases in emotional areas. BID in ED seems to be linked to alterations in paralimbic structures (cingulate cortex and insula), the default-mode network, and parietal, temporal, and occipital regions. These brain areas are associated with the subjective self, ego, and perceptual processes. The findings suggest that ED patients may have a perceptual judgment error and excessive self-reference, leading to dysfunctional behaviors as an attempt to resolve this perceptual distortion.
... The investigators found that the pooled prevalence of EDs in individuals with CD was 8.88%, with subgroup meta-analysis revealing a rate of 6.37% in adults and 11.97% in children, and the prevalence of BN was 7.26% [13]. These values exceed those documented in previous systematic reviews of the general population [28][29][30], indicating that the development of CD might intersect with factors that precipitate EDs. ...
Article
Full-text available
Celiac disease (CD) and eating disorders (EDs) are complex chronic conditions in adolescents, sharing symptoms such as weight change, malnutrition, and gastrointestinal symptoms. CD, an autoimmune disorder triggered by gluten ingestion, is managed through a strict gluten-free diet that can unintentionally foster disordered eating behaviors due to dietary restrictions. Conversely, EDs may mask and complicate CD symptoms, leading to diagnostic delays and treatment challenges. Evidence reveals an increased risk of EDs in CD individuals and vice versa, indicating a potential bidirectional relationship. This review explores the mechanisms and clinical implications of this interplay and proposes integrated screening and care strategies to improve the quality of life for individuals with both conditions.
Article
Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind‐body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first‐line treatments for FEDs are mainly psychological and/or nutrition‐focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine‐grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients’ illness and recovery trajectories and facilitate development of novel intervention approaches.
Article
Full-text available
Eating disorders have historically been considered "culture-bound" phenomena, confined to Western societies and, specifically, young White females with, predominantly, anorexia nervosa. Eating disorder research tended to align with these perceptions and, until relatively recently, few studies had been conducted to establish the prevalence of eating disorders in non-Western countries. Evidence from epidemiological surveys, undertaken largely in the last three decades, have shown that eating disorders are present in African, Asian, Middle Eastern and South American societies and, in many cases, the prevalence estimates are comparable to those in the West. However, there is evidence to suggest that precipitating factors, presentations and cultural perceptions of eating disorders differ between sociocultural contexts. This may result in under-diagnosis of eating disorders in non-White individuals and may be a barrier to successful management. These considerations are exemplified by studies in the South Asian population in the UK which have shown a different symptom profile than that found in White individuals. Clinicians who are not attuned to these cultural differences may fail to recognise an eating disorder diagnosis. South Asian populations may present with somatic concerns and the absence of "fat phobia". Culture-specific familial expectations, religious observances and issues of self-identity may have a greater role in the development and maintenance of eating pathologies in this, and other, minority ethnic groups. Greater awareness of these factors among clinicians would increase the prospects for recognition, diagnosis and successful outcomes.
Article
The Latin‐American scientific community has achieved significant progress towards gender parity, with nearly equal representation of women and men scientists. Nevertheless, women continue to be underrepresented in scholarly communication. Throughout the 20th century, Latin America established its academic circuit, focusing on research topics of regional significance. Through an analysis of scientific publications, this article explores the relationship between gender inequalities in science and the integration of Latin‐American researchers into the regional and global academic circuits between 1993 and 2022. We find that women are more likely to engage in the regional circuit, while men are more active within the global circuit. This trend is attributed to a thematic alignment between women's research interests and issues specific to Latin America. Furthermore, our results reveal that the mechanisms contributing to gender differences in symbolic capital accumulation vary between circuits. Women's work achieves equal or greater recognition compared to men's within the regional circuit, but generally garners less attention in the global circuit. Our findings suggest that policies aimed at strengthening the regional academic circuit would encourage scientists to address locally relevant topics while simultaneously fostering gender equality in science.
Article
Full-text available
Background Eating disorders (EDs) are associated with high morbidity and mortality, affecting predominantly young people and women. A delay in starting treatment is associated with chronic and more severe clinical courses; however, evidence on barriers and facilitators of access to care in Latin America is scarce. We aimed to identify barriers and facilitators of ED treatment in Chile from the perspective of patients, relatives, and health professionals. Methods Qualitative approach through semi-structured interviews with patients, their relatives, and health professionals. Participants were recruited from two ED centers in Santiago, Chile (one public and one private). Analysis was mainly based on Grounded Theory, using MAXQDA software. Results 40 interviews were conducted (n = 22 patients, 10 relatives, and 8 health professionals). The mean age of patients was 21.8 years, while the mean duration of untreated ED was 91.4 months (median 70 months). Five categories emerged with intersections between them: patient (P), family and social environment (FSE), health professionals (HP), healthcare system (HCS), and social and cultural context (SCC). Relevant barriers appeared within these categories and their intersections, highlighting a lack of professional knowledge or expertise, cultural ignorance or misinformation regarding EDs, and patient’s ego-syntonic behaviors. The main facilitators were patients’ and relatives’ psychoeducation, recognition of symptoms by family members, and parents taking the initiative to seek treatment. Conclusions This study provides information regarding access to treatment for patients living with EDs in Chile. A practical public health approach should consider the multi-causality of delay in treatment and promoting early interventions. Plain English Summary Eating disorders (EDs) may severely affect the daily functioning of people enduring them. A delay in starting treatment is associated with a disease that is more difficult to treat. To our knowledge, there are no published studies carried out in Latin America exploring factors influencing treatment initiation in EDs patients. This study aimed to identify facilitators of and barriers to treating patients with EDs in Chile. We interviewed patients (n = 22), their relatives (n = 10), and health professionals (n = 8) from a private and a public center in Santiago, Chile. Our analysis showed that the main barriers to starting treatment were the lack of professional knowledge in ED, the monetary cost of illness, and cultural misinformation. Facilitators were related to the role of the family in recognizing and addressing the disease while being educated in EDs by professionals. This study helps to provide data about treatment access in developing countries. While facilitators and barriers were similar to others reported in the literature, the untreated ED’s duration was longer. It is essential to address these barriers to provide access to treatment more efficiently and prevent severe and enduring forms of disease.
Article
Full-text available
José Ernesto dos Santos, Ph.D., started the first Brazilian eating disorder treatment center, Grupo de Assistência aos Transtornos Alimentares (GRATA) in 1986 1 and much progress has been made since then. At present, researchers around the world are discussing culture-oriented strategies to address better treatments and explore individuals' care processes and experiences in their respective countries. However, few studies cover Brazilian prevalence rates. In 2016, Kolar et al. 2 reported rates ranging from 0.04% to 0.09% for anorexia nervosa, and from 0.13% to 0.27% for bulimia nervosa. In 2022, prevalence rates rose to 0.7% for bulimia nervosa, 1.4% for binge eating disorder, and 6.2% for recurrent binge eating. 3 To illustrate, other prominent studies include a meta-analysis on disordered eating, 4 a qualitative investigation on the limited knowledge among healthcare professionals, 5 and a comparison of two socioeconomically distinct groups and their food choices, 6 reflecting advances for Brazilian studies focused on eating behavior. On the other hand, the same level of research is not observed with eating disorder samples. The Brazilian scenario The relentless pursuit of an idealized thinness, perpetuated by media and dominant cultural norms, has distinct characteristics in Brazil. The country's prevalence of cosmetic procedures and plastic surgeries significantly shapes societal pressures and body image perceptions. Addressing these issues in the Brazilian context relies heavily on the availability and commitment of human resources, materials, and tools for screening and treatment. While many Brazilian studies focus on identifying symptoms using scales like the Eating Attitudes Test (EAT-26) or the Binge Eating Scale (BES), other countries have progressed further, delving into treatment methodologies. Assessing the accuracy and psychometric properties of a scale developed abroad is fundamental for addressing the socio-cultural nuances of a country as vast as Brazil. Why are we lagging so far behind, then? In Brazil's public health system, training healthcare teams in the diagnosis and management of eating disorders and disseminating assessment protocols could improve patient identification, screening, and integration into the system, thereby enhancing data reporting. While other countries have made more significant progress in studying severe eating disorders, Brazil has successfully conducted extensive research on other mental disorders, using advanced diagnostic technologies and randomized clinical trials, resulting in comprehensive guidelines. We hope that university-based initiatives, rather than private groups, will address this gap. Given the high standard and free access to graduate education in Brazil, it is of utmost importance that such knowledge be widely disseminated. Primary research themes addressed by national studies cover a diverse range of topics, namely, socioeconomic profile among adolescents from higher socioeconomic classes, 7 suggesting that the southeast was not absorbing the most vulnerable populations. Another study investigated the presence of psychiatric and physical comorbidities, showing a high prevalence of depression, anxiety, and attention deficit hyperactivity disorder (ADHD). 8 Others have reported that eating disorders significantly affect individuals' quality of life, including physical, emotional, and social aspects. 9 Finally, small initiatives in clinical trials have been described. 10
Article
Full-text available
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
Article
Full-text available
Objectives Investigating for the first time in Germany Diagnostic and Statistical Manual Fifth Edition (DSM-5) prevalences of adolescent full syndrome, Other Specified Feeding or Eating Disorder (OSFED), partial and subthreshold anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). Method A national school-based cross-sectional survey with nine schools in Germany was undertaken that was aimed at students from grades 7 and 8. Of the 1775 students who were contacted to participate in the study, 1654 participated (participation rate: 93.2%). The sample consisted of 873 female and 781 male adolescents (mean age=13.4 years). Prevalence rates were established using direct symptom criteria with a structured inventory (SIAB-S) and an additional self-report questionnaire (Eating Disorder Inventory 2 (EDI-2)). Results Prevalences for full syndrome were 0.3% for AN, 0.4% for BN, 0.5% for BED and 3.6% for OSFED-atypical AN, 0% for BN (low frequency/limited duration), 0% for BED (low frequency/limited duration) and 1.9% for purging disorder (PD). Prevalences of partial syndrome were 10.9% for AN (7.1% established with cognitive symptoms only, excluding weight criteria), 0.2% for BN and 2.1% for BED, and of subthreshold syndrome were 0.8% for AN, 0.3% for BN and 0.2% for BED. Cases on EDI-2 scales were much more pronounced with 12.6–21.1% of the participants with significant sex differences. Conclusions The findings were in accordance with corresponding international studies but were in contrast to other German studies showing much higher prevalence rates. The study provides, for the first time, estimates for DSM-5 prevalences of eating disorders in adolescents for Germany, and evidence in favour of using valid measures for improving prevalence estimates. Trial registration number DRKS00005050; Results.
Article
Full-text available
This study elucidated the experiences of eighteen Latina adults (mean age = 38.5 years) from “Promoviendo una Alimentación Saludable” Project who received nutritional intervention as part of the clinical trial. Half of the participants were first generation immigrants from Mexico (50%), followed by U.S. born with 16.7%. Remaining nationalities represented were Bolivia, Colombia, Guatemala, Honduras, Peru, and Venezuela with 33.3% combined. The average duration of living in the U.S. was 11.1 years. The mean body mass index (BMI) at baseline was 36.59 kg/m2 (SD = 7.72). Based on the DSM-IV, 28% (n = 5) participants were diagnosed with binge-eating disorder, 33% (n = 6) with bulimia nervosa purging type and 39% (n = 7) with eating disorder not otherwise specified. Participants received up to three nutritional sessions; a bilingual dietitian conducted 97.8% of sessions in Spanish. In total, fifty nutritional sessions were included in the qualitative analysis. A three step qualitative analysis was conducted. First, a bilingual research team documented each topic discussed by patients and all interventions conducted by the dietitian. Second, all topics were classified into specific categories and the frequency was documented. Third, a consensus with the dietitian was performed to validate the categories identified by the research team. Six categories (describing eating patterns, emotional distress, Latino culture values, family conflicts associated with disturbed eating behaviors, lack of knowledge of healthy eating, and treatment progress) emerged from patients across all nutritional sessions. Considering the background of immigration and trauma (60%, n = 15) in this sample; the appropriate steps of nutritional intervention appear to be: 1) elucidating the connection between food and emotional distress, 2) providing psychoeducation of healthy eating patterns using the plate method, and 3) developing a meal plan.
Article
Full-text available
We aimed to assess the prevalence, incidence, age-of-onset and diagnostic stability of threshold and subthreshold anorexia nervosa (AN) and bulimia nervosa (BN) in the community. Data come from a prospective-longitudinal community study of 3021 subjects aged 14-24 at baseline, who were followed up at three assessment waves over 10 years. Eating disorder (ED) symptomatology was assessed with the DSM-IV/M-CIDI at each wave. Diagnostic stability was defined as the proportion of individuals still affected with at least symptomatic eating disorders (EDs) at follow-ups. Baseline lifetime prevalence for any threshold ED were 2.9 % among females and 0.1 % among males. For any subthreshold ED lifetime prevalence were 2.2 % for females and 0.7 % for males. Symptomatic expressions of EDs (including core symptoms of the respective disorder) were most common with a lifetime prevalence of 11.5 % among females and 1.8 % among males. Symptomatic AN showed the earliest onset with a considerable proportion of cases emerging in childhood. 47 % of initial threshold AN cases and 42 % of initial threshold BN cases showed at least symptomatic expressions of any ED at any follow-up assessment. Stability for subthreshold EDs and symptomatic expressions was 14-36 %. While threshold EDs are rare, ED symptomatology is common particularly in female adolescents and young women. Especially threshold EDs are associated with a substantial risk for stability. A considerable degree of symptom fluctuation is characteristic especially for subthreshold EDs.
Article
Full-text available
Background: Whether the incidence of eating disorders in Western, industrialized countries has changed over time has been the subject of much debate. The purpose of this primary-care study was to examine changes in the incidence of eating disorders in The Netherlands during the 1980s, 1990s and 2000s. Method: A nationwide network of general practitioners (GPs), serving a representative sample (~1%) of the total Dutch population, recorded newly diagnosed patients with anorexia nervosa (AN) and bulimia nervosa (BN) in their practice during 1985-1989, 1995-1999, and 2005-2009. GPs are key players in the Dutch healthcare system, as their written referral is mandatory in order to get access to specialized (mental) healthcare, covered by health insurance. Health insurance is virtually universal in The Netherlands (99% of the population). A substantial number of GPs participated in all three study periods, during which the same case identification criteria were used and the same psychiatrist was responsible for making the final diagnoses. Incidence rates were calculated and for comparison between periods, incidence rate ratios. Results: The overall incidence rate of BN decreased significantly in the past three decades (from 8.6 per 100 000 person-years in 1985-1989 to 6.1 in 1995-1999, and 3.2 in 2005-2009). The overall incidence of AN remained fairly stable during three decades, i.e. 7.4 per 1 00 000 person-years in 1985-1989, 7.8 in 1995-1999, and 6.0 in 2005-2009. Conclusions: The incidence rate of BN decreased significantly over the past three decades, while the overall incidence rate of AN remained stable.
Article
Full-text available
Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
Article
Full-text available
Studies using traditional screening instruments tend to report a lower prevalence of eating disorders (EDs) in men than is observed in women. It is therefore unclear whether such instruments are valid for the assessment of ED in males. Lack of a formal diagnostic definition of muscle dysmorphia syndrome (MD) makes it difficult to identify men at risk. The study aimed to assess the prevalence of ED and MD in male university students of Buenos Aires. A cross-sectional, two-stage, representative survey was of 472 male students from six different schools in Buenos Aires, mostly aged between 18 and 28 years. The first stage involved administration of self-report questionnaires (Eating Attitude Test-26; scores ≥15 indicate "at risk" status). In Stage 2 students at risk of developing EDs were evaluated with a clinical interview, the Eating Disorder Examination (EDE; 12th edition). Two control students were interviewed for every at risk student. The prevalence of EDs among university male students was 1.9% (n = 9). All participants with an ED presented with illness classified as eating disorder not otherwise specified (EDNOS). Using the Drive for Muscularity Scale (DMS) with a 52-point threshold we identified possible MD in 6.99% (n = 33) of the sample. The prevalence of ED detected in this study is comparable with previous findings in male populations, and below that observed in female populations. However, the prevalence of possible cases of MD resembles the total rate of EDs in women. Characteristics associated with EDs and MD in men are also discussed. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2015). © 2015 Wiley Periodicals, Inc.
Article
Background: Binge eating disorder (BED) is a disorder of eating behavior that can affect people of all ages. Aim: To determine the prevalence of BED according to criteria of the Diagnostic and Statistical Manual of Mental Disorders-V, associated factors and their relationship to obesity in university students at Barquisimeto (Venezuela), between September 2013 and February 2014. Patients and methods: A study was conducted on a sample of 497 university students of both sexes (371 females), between 18 and 28 years old. A questionnaire was applied and anthropometric measurements were recorder:Weight, height, body mass index (BMI), waist circumference (CW) and waist-height ratio (WHR). Results: The prevalence of BED was 3.20%. Factors associated with BED were body image dissatisfaction, family dysfunction, and depressive symptoms. BED was significantly associated with global obesity and central obesity. Conclusions: Changes in diagnostic criteria of BED, introduced in DSM-V, do not appear to increase the prevalence of BED. Important psychosocial factors associated with BED were identified. BED was strongly associated with global and central obesity. Further studies need to be carried out, with more rigorous designs to elucidate the effects of the new definition by DSM-V, and to determine the causal nature of the associations found.