A Longitudinal Investigation of Mortality in Anorexia Nervosa and Bulimia Nervosa
TL;DR: It is suggested that a long duration of illness, substance abuse, low weight, and poor psychosocial functioning raise the risk for mortality in anorexia nervosa.
Abstract: ObjectiveAlthough anorexia nervosa has a high mortality rate, our understanding of the timing and predictors of mortality in eating disorders is limited. The authors investigated mortality in a long-term study of patients with eating disorders.MethodBeginning in 1987, 246 treatment-seeking female patients with anorexia nervosa or bulimia nervosa were interviewed every 6 months for a median of 9.5 years to obtain weekly ratings of eating disorder symptoms, comorbidity, treatment participation, and psychosocial functioning. From January 2007 to December 2010 (median follow-up of 20 years), vital status was ascertained with a National Death Index search.ResultsSixteen deaths (6.5%) were recorded (lifetime anorexia nervosa, N=14; bulimia nervosa with no history of anorexia nervosa, N=2). The standardized mortality ratio was 4.37 (95% CI=2.4–7.3) for lifetime anorexia nervosa and 2.33 (95% CI=0.3–8.4) for bulimia nervosa with no history of anorexia nervosa. Risk of premature death among patients with lifetime ...
Citations
More filters
TL;DR: This consensus statement represents a set of recommendations developed following the 1st and 2nd International Symposia on the Female Athlete Triad and is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female athlete Triad.
Abstract: The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.
407 citations
TL;DR: Applying the DSM-5 criteria effectively reduces the frequency of the residual diagnosis EDNOS, by lowering the threshold for anorexia nervosa and bulimia nervosa, and adding BED as a specified eating disorder.
Abstract: Purpose of reviewTo review the recent literature about the epidemiology, course, and outcome of eating disorders in accordance with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).Recent findingsThe residual category eating disorder not otherwise specified' (EDNOS) was the most common DSM-IV eating disorder diagnosis in both clinical and community samples. Several studies have confirmed that the DSM-5 criteria for eating disorders effectively reduce the proportion of EDNOS diagnoses. The lifetime prevalence of DSM-5 anorexia nervosa among women might be up to 4%, and of bulimia nervosa 2%. In a cross-national survey, the average lifetime prevalence of binge eating disorder (BED) was 2%. Both anorexia nervosa and bulimia nervosa are associated with increased mortality. Data on long-term outcome, including mortality, are limited for BED. Follow-up studies of BED are scarce; remission rates in randomized controlled trials ranged from 19 to 65% across studies. On a community level, 5-year recovery rates for DSM-5 anorexia nervosa and bulimia nervosa are 69 and 55%, respectively; little is known about the course and outcome of BED in the community.SummaryApplying the DSM-5 criteria effectively reduces the frequency of the residual diagnosis EDNOS, by lowering the threshold for anorexia nervosa and bulimia nervosa, and adding BED as a specified eating disorder. Course and outcome studies of both anorexia nervosa and bulimia nervosa show that no significant differences exist between DSM-5 and DSM-IV definitions.
399 citations
TL;DR: A diagnosis of anorexia nervosa, chronicity, later age of onset, not living in a relationship, and an irregular type of discharge from index inpatient treatment were major predictors of a shorter time to death.
Abstract: Objective
To report on long-term mortality in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (ED-NOS), causes of death, and predictors of early death.
Method
A large sample of consecutively admitted inpatients (N = 5,839) was followed-up on vital status through the German civil registry office. Of these patients 1,639 were treated for AN, 1,930 for BN, 363 for BED, and 1,907 for ED-NOS. Data from the main inpatient hospital treatment were applied to bivariate and multivariate Cox regression analyses on survival time from onset of eating disorder to death or end of observation. Standardized mortality ratios (SMR) were computed matched for age, gender, and person-years.
Results
SMR were 5.35 for AN, 1.49 for BN, 1.50 for BED, 2.39 for narrowly defined ED-NOS, and 1.70 for widely defined ED-NOS. Patients with AN died earlier than patients with BN, BED, or ED-NOS who did not differ. A diagnosis of AN, chronicity, later age of onset, not living in a relationship, and an irregular type of discharge from index inpatient treatment were major predictors of a shorter time to death. Suicidality was a univariate predictor of a shorter time to death in BN only. AN patients mostly died from natural causes related to their eating disorder.
Discussion
Mortality in AN is excessive and considerably higher than in BN, BED, and ED-NOS. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:391–401).
314 citations
Cites background or result from "A Longitudinal Investigation of Mor..."
...These results are compatible with the findings of Franko et al.(25) who reported a decrease of premature mortality over time and a low BMI as predictors of early death in patients with lifetime AN....
[...]
...Data presented in a Kaplan-Meier Survival Curve are similar to those of Franko et al.25 Our data show that patients with AN have a shorter survival time from onset of the eating disorder than patients with BN, BED or ED-NOS....
[...]
...Franko et al.(25) reported that patients with lifetime AN tended to experience a shorter time to death than patients without a lifetime diagnosis of AN, which is quite consistent with our data....
[...]
...These results are compatible with the findings of Franko et al.25 who reported a decrease of premature mortality over time and a low BMI as predictors of early death in patients with lifetime AN....
[...]
...Data presented in a Kaplan-Meier Survival Curve are similar to those of Franko et al.(25) Our data show that patients with AN have a shorter survival time from onset of the eating disorder than patients with BN, BED or ED-NOS....
[...]
TL;DR: Outpatient family-based treatment focused on weight restoration, reducing blame, and empowering caregivers has emerged as particularly effective; cognitive behavioral therapy, individual therapy, and higher levels of care may also be appropriate.
Abstract: Despite their high prevalence, associated morbidity and mortality, and available treatment options, eating disorders (EDs) continue to be underdiagnosed by pediatric professionals. Many adolescents go untreated, do not recover, or reach only partial recovery. Higher rates of EDs are seen now in younger children, boys, and minority groups; EDs are increasingly recognized in patients with previous histories of obesity. Medical complications are common in both full and subthreshold EDs and affect every organ system. No single cause of EDs has emerged, although neurobiological and genetic predispositions are emerging as important. Recent treatment paradigms acknowledge that they are not caused by families or chosen by patients. EDs present differently in pediatric populations, and providers should have a high index of suspicion using new Diagnostic and Statistical Manual, 5th edition diagnostic criteria because early intervention can affect prognosis. Outpatient family-based treatment focused on weight restoration, reducing blame, and empowering caregivers has emerged as particularly effective; cognitive behavioral therapy, individual therapy, and higher levels of care may also be appropriate. Pharmacotherapy is useful in specific contexts. Full weight restoration is critical, often involves high-calorie diets, and must allow for continued growth and development; weight maintenance is typically inappropriate in pediatric populations. Physical, nutritional, behavioral, and psychological health are all metrics of a full recovery, and pediatric EDs have a good prognosis with appropriate care. ED prevention efforts should work toward aligning with families and understanding the impact of antiobesity efforts. Primary care providers can be key players in treatment success.
256 citations
TL;DR: Recovery from bulimia nervosa happened earlier, but recovery from anorexia nervosa continued over the long term, arguing against the implementation of palliative care for most individuals with eating disorders.
Abstract: Objective: The course of eating disorders is often protracted, with fewer than half of adults achieving recovery from anorexia nervosa or bulimia nervosa. Some argue for palliative management when duration exceeds a decade, yet outcomes beyond 20 years are rarely described. This study investigates early and long-term recovery in the Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa. Methods: Females with DSM-III-R/DSM-IV anorexia nervosa or bulimia nervosa were assessed at 9 and at 20 to 25 years of follow-up (mean [SD] = 22.10 [1.10] years; study initiated in 1987, last follow-up conducted in 2013) via structured clinical interview (Longitudinal Interval Follow-Up Evaluation of Eating Disorders [LIFE-EAT-II]). Seventy-seven percent of the original cohort was re-interviewed, and multiple imputation was used to include all surviving participants from the original cohort (N = 228). Kaplan-Meier curves estimated recovery by 9-year follow-up, and McNemar test examined concordance between recovery at 9-year and 22-year follow-up. Results: At 22-year follow-up, 62.8% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa recovered, compared to 31.4% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa by 9-year follow-up. Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery at 22 years. Early recovery was associated with increased likelihood of long-term recovery in anorexia nervosa (odds ratio [OR] = 10.5; 95% CI, 3.77-29.28; McNemar χ2 1 = 31.39; P <.01) but not in bulimia nervosa (OR = 1.0; 95% CI, 0.49-2.05; McNemar χ2 1= 0; P = 1.0). Conclusion: At 22 years, approximately two-thirds of females with anorexia nervosa and bulimia nervosa were recovered. Recovery from bulimia nervosa happened earlier, but recovery from anorexia nervosa continued over the long term, arguing against the implementation of palliative care for most individuals with eating disorders.
252 citations
References
More filters
TL;DR: In this article, a systematic literature search, appraisal, and meta-analysis were conducted of the MEDLINE/PubMed, PsycINFO, and Embase databases and 4 full-text collections (ie, ScienceDirect, Ingenta Select, Ovid, and Wiley-Blackwell Interscience).
Abstract: Context Morbidity and mortality rates in patients with eating disorders are thought to be high, but exact rates remain to be clarified. Objective To systematically compile and analyze the mortality rates in individuals with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Data Sources A systematic literature search, appraisal, and meta-analysis were conducted of the MEDLINE/PubMed, PsycINFO, and Embase databases and 4 full-text collections (ie, ScienceDirect, Ingenta Select, Ovid, and Wiley-Blackwell Interscience). Study Selection English-language, peer-reviewed articles published between January 1, 1966, and September 30, 2010, that reported mortality rates in patients with eating disorders. Data Extraction Primary data were extracted as raw numbers or confidence intervals and corrected for years of observation and sample size (ie, person-years of observation). Weighted proportion meta-analysis was used to adjust for study size using the DerSimonian-Laird model to allow for heterogeneity inclusion in the analysis. Data Synthesis From 143 potentially relevant articles, we found 36 quantitative studies with sufficient data for extraction. The studies reported outcomes of AN during 166 642 person-years, BN during 32 798 person-years, and EDNOS during 22 644 person-years. The weighted mortality rates (ie, deaths per 1000 person-years) were 5.1 for AN, 1.7 for BN, and 3.3 for EDNOS. The standardized mortality ratios were 5.86 for AN, 1.93 for BN, and 1.92 for EDNOS. One in 5 individuals with AN who died had committed suicide. Conclusions Individuals with eating disorders have significantly elevated mortality rates, with the highest rates occurring in those with AN. The mortality rates for BN and EDNOS are similar. The study found age at assessment to be a significant predictor of mortality for patients with AN. Further research is needed to identify predictors of mortality in patients with BN and EDNOS.
1,773 citations
TL;DR: The Longitudinal Interval Follow-up Evaluation (LIFE) is an integrated system for assessing the longitudinal course of psychiatric disorders that consists of a semistructured interview, an Instruction booklet, a coding sheet, and a set of training materials.
Abstract: • The Longitudinal Interval Follow-up Evaluation (LIFE) is an integrated system for assessing the longitudinal course of psychiatric disorders. It consists of a semistructured interview, an instruction booklet, a coding sheet, and a set of training materials. An interviewer uses the LIFE to collect detailed psychosocial, psychopathologic, and treatment information for a six-month follow-up interval. The weekly psychopathology measures ("psychiatric status ratings") are ordinal symptom-based scales with categories defined to match the levels of symptoms used in the Research Diagnostic Criteria. The ratings provide a separate, concurrent record of the course of each disorder initially diagnosed in patients or developing during the follow-up. AnyDSM-IIIor Research Diagnostic Criteria disorder can be rated with the LIFE, and any length or number of follow-up intervals can be accommodated. The psychosocial and treatment information is recorded so that these data can be linked temporally to the psychiatric status ratings.
1,521 citations
"A Longitudinal Investigation of Mor..." refers methods in this paper
...Over the course of the study, the Longitudinal Interval FollowUp Evaluation, adapted for eating disorders (14), was used to assess eating pathology, treatment, and comorbid psychiatric disorders....
[...]
TL;DR: The literature on the incidence, prevalence and mortality rates of eating disorders is discussed, with anorexia nervosa the most striking and binge eating disorder is more common among males and older individuals.
Abstract: Eating disorders are relatively rare among the general population. This review discusses the literature on the incidence, prevalence and mortality rates of eating disorders. We searched online Medline/Pubmed, Embase and PsycINFO databases for articles published in English using several keyterms relating to eating disorders and epidemiology. Anorexia nervosa is relatively common among young women. While the overall incidence rate remained stable over the past decades, there has been an increase in the high risk-group of 15–19 year old girls. It is unclear whether this reflects earlier detection of anorexia nervosa cases or an earlier age at onset. The occurrence of bulimia nervosa might have decreased since the early nineties of the last century. All eating disorders have an elevated mortality risk; anorexia nervosa the most striking. Compared with the other eating disorders, binge eating disorder is more common among males and older individuals.
1,481 citations
"A Longitudinal Investigation of Mor..." refers background in this paper
...In some (25) but not all (26, 27) studies, the standardized mortality ratio for bulimia nervosa has been reported to be lower than that for anorexia nervosa....
[...]
TL;DR: In this article, a new class of graphical and numerical methods for checking the adequacy of the Cox regression model is presented, derived from cumulative sums of martingale-based residuals over follow-up time and covariate values.
Abstract: SUMMARY This paper presents a new class of graphical and numerical methods for checking the adequacy of the Cox regression model The procedures are derived from cumulative sums of martingale-based residuals over follow-up time and/or covariate values The distributions of these stochastic processes under the assumed model can be approximated by zero-mean Gaussian processes Each observed process can then be compared, both visually and analytically, with a number of simulated realizations from the approximate null distribution These comparisons enable the data analyst to assess objectively how unusual the observed residual patterns are Special attention is given to checking the functional form of a covariate, the form of the link function, and the validity of the proportional hazards assumption An omnibus test, consistent against any model misspecification, is also studied The proposed techniques are illustrated with two real data sets
1,360 citations
01 Jan 2011
TL;DR: The study found age at assessment to be a significant predictor of mortality for patients with anorexia nervosa, and further research is needed to identify predictors of mortality in patients with BN and EDNOS.
Abstract: Data Sources: A systematic literature search, ap praisal, and meta-analysis were c onducted of the MFDUNElPuhMed. PsycINFO, and Embase databases and 4 full-text collections (ie, ScienceOirect, lngenta Se lect, Ovid, and Wiley-Blackwell Interscience) . Data Synthesis: From 143 potentially relevant ar ticles, we found 36 quantitative studies with sufficient data for extraction. The studies reported outcomes of AN during 166 642 person-years, BN during 32 798 person years, and EDNOS during 22 644 person-years. The weighted mortality rates (ie, deaths per 1000 person years) were 5.1 for AN, 17 for BN, and 3.3 for EONO� The standardized mortality ratios were 5.86 for AN, I.\)3 for BN, and 1.92 for FONOS. One in 5 individuals wllh AN who died had committed suicide
1,338 citations
"A Longitudinal Investigation of Mor..." refers background or result in this paper
...Although both are elevated, there was considerable variability in standardized mortality ratios across studies included in the meta-analysis (1), and these standardized mortality ratios are lower than those reported in studies with shorter follow-up periods (3, 4)....
[...]
...Mortality rates are higher in anorexia nervosa than in other psychiatric disorders (1), but few studies have examined when death is more likely to occur in the course of this eating disorder....
[...]