The estimated burden of bulimia nervosa in the Middle East and North Africa region, 1990-2019.

OBJECTIVE: We aimed to report the burden of bulimia nervosa (BN) in the Middle East and North Africa (MENA) region by age, sex, and sociodemographic index (SDI), for the period 1990-2019. METHODS: Estimates of the prevalence, incidence, and disability-adjusted life-years (DALYs) attributable to BN were retrieved from the Global Burden of Disease study 2019, between 1990 and 2019, for the 21 countries in the MENA region. The counts and age-standardized rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals. RESULTS: In 2019, the estimated regional age-standardized point prevalence and incidence rates of BN were 168.3 (115.0-229.6) and 178.6 (117.0-255.6) per 100,000, which represented 22.0% (17.5-27.2) and 10.4% (7.1-14.7) increases, respectively, since 1990. Moreover, in 2019 the regional age-standardized DALY rate was 35.5 (20.6-55.5) per 100,000, which was 22.2% (16.7-28.2) higher than in 1990. In 2019, Qatar (58.6 [34.3-92.5]) and Afghanistan (18.4 [10.6-29.2]) had the highest and lowest age-standardized DALY rates, respectively. Regionally, the age-standardized point prevalence of BN peaked in the 30-34 age group and was more prevalent among women. In addition, there was a generally positive association between SDI and the burden of BN across the measurement period. DISCUSSION: In the MENA region, the burden of BN has increased over the last three decades. Cost-effective preventive measures are needed in the region, especially in the high SDI countries. PUBLIC SIGNIFICANCE: This study reports the estimated burden of BN in the MENA region and shows that its burden has increased over the last three decades.

Prevalence of diagnosed eating disorders in US transgender adults and youth in insurance claims.

OBJECTIVE: We estimated the prevalence of diagnosed eating disorders, overall and by select demographics, among commercially insured individuals identified as transgender in a national claims database. METHODS: From the 2018 IBM® MarketScan® Commercial Database, there were 10,415 people identifiable as transgender based on International Classification of Disease (ICD-10) codes and procedure codes, specific to gender-affirming care, from inpatient and outpatient claims. Eating disorders were identified from ICD-10 codes and included anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified, avoidant restrictive feeding and intake disorder, and other specified feeding and eating disorders. We estimated the prevalence of specific eating disorders diagnoses by selecting patient characteristics. RESULTS: Of individuals receiving some form of gender-affirming care, 2.43% (95% confidence interval: 2.14%-2.74%) were diagnosed with an eating disorder: 0.84% anorexia nervosa, 0.36% bulimia nervosa, 0.36% binge eating disorder, 0.15% avoidant restrictive feeding and intake disorder, 0.41% other specified feeding and eating disorders, and 1.37% with an unspecified eating disorder. Among transgender-identifiable patients aged 12-15 years, 5.60% had an eating disorder diagnosis, whereas 0.52% had an eating disorder diagnosis in patients aged 45-64 years. DISCUSSION: In patients identifiable as transgender, with receipt of gender-affirming care, the prevalence of diagnosed eating disorders was low compared to extant self-reported data for eating disorder diagnosis in transgender individuals. Among this population, eating disorders were highest in adolescents and young adults. Clinically verified prevalence estimates for eating disorder diagnosis in transgender people with a history of gender-affirming care warrant further investigation. PUBLIC SIGNIFICANCE: The present study aims to provide clinically validated, contemporary prevalence estimates for diagnosed eating disorders among a medically affirmed population of transgender adults and children in the United States. We report low prevalence of having any eating disorder relative to prevalence estimates reported in prior literature without clinical validation. These findings may be explained by access to affirming care and medical care generally.

Healthcare use and costs of adults with anorexia nervosa and bulimia nervosa in Taiwan.

OBJECTIVE: This study aimed to examine the health service use and healthcare costs of adults with anorexia nervosa (AN) and bulimia nervosa (BN) in Taiwan. METHOD: AN and BN cases between 2002-2013 were extracted from a national health insurance database. For each AN and BN case, we randomly selected 10 controls with no eating disorder, matched for sex, age, urbanization of residence, and year of medical visit. The percentage and frequency of health services use and costs in the year preceding and after the diagnosis of AN/BN were compared between groups. We used generalized linear models with gamma distribution and log link function to determine the effects of age, sex, and psychiatric comorbidities on the total cost adjusting for physical comorbidities and to calculate the mean cost difference between groups by using marginal and incremental effects. RESULTS: Both individuals with AN and BN had significantly elevated healthcare utilization and costs compared to controls during the baseline and one-year period after diagnosis. Patients with AN had more than three times higher total costs (US $792) and patients with BN had two times higher total costs (US $320) than individuals without eating disorders. Comorbidity of depressive disorder and older age significantly increased healthcare costs among both individuals with AN and BN. DISCUSSION: There are high medical and economic burdens of care for individuals with AN and BN. Early diagnosis and integrated care for eating disorders are important tasks to reduce disease burden in Taiwan.

The influence of school on whether girls develop eating disorders.

BACKGROUND: Clinical anecdote suggests that rates of eating disorders (ED) vary between schools. Given their high prevalence and mortality, understanding risk factors is important. We hypothesised that rates of ED would vary between schools, and that school proportion of female students and proportion of parents with post-high school education would be associated with ED, after accounting for individual characteristics. METHOD: Multilevel analysis of register-based, record-linkage data on 55 059 females born in Stockholm County, Sweden, from 1983, finishing high school in 2002-10. Outcome was clinical diagnosis of an ED, or attendance at a specialist ED clinic, aged 16-20 years. RESULTS: The 5-year cumulative incidence of ED diagnosis aged 16-20 years was 2.4%. Accounting for individual risk factors, with each 10% increase in the proportion of girls at a school, the odds ratio for ED was 1.07 (1.01 to 1.13), P = 0.018. With each 10% increase in the proportion of children with at least one parent with post-high school education, the odds ratio for ED was 1.14 (1.09 to 1.19), P < 0.0001. Predicted probability of an average girl developing an ED was 1.3% at a school with 25% girls where 25% of parents have post-high school education, and 3.3% at a school with 75% girls where 75% of parents have post-high school education. CONCLUSIONS: Rates of ED vary between schools; this is not explained by individual characteristics. Girls at schools with high proportions of female students, and students with highly educated parents, have higher odds of ED regardless of individual risk factors.

Disordered eating and the contradictions of neoliberal governance.

The last decade has seen the development of an important literature on the contradictions between neoliberal norms of corporal citizenship and the forms of consumption that market-based food systems promote. This paper seeks to contribute to the literature by exploring the relationship between these contradictions and the increased prevalence of particular eating disorders (binge eating disorder (BED) and bulimia nervosa). Within contemporary neoliberal food systems bingeing is increasingly normalised and consumption temporally disorganised. At the same time, neoliberal public health policy, and the wider 'health' entertainment media it legitimates, focuses on the promotion of 'correct' forms of consumer agency. Individuals who fail to manage consumption 'appropriately' are stigmatised. The growth of bulimia and BED can be related to the contradictory pressures that the food system and regime of corporal governance place on individuals. The paper also seeks to explore how the increased medicalisation and biomedicalisation of eating since the 1980s fits within a broader neoliberal governance strategy. By medicalising key social problems the neoliberal state depoliticises these issues. Medicalisation and biomedicalisation obscure the role of capitalism in generating these problems and encourage a focus on individual dysfunction.

Multiple comorbidities of 21 psychological disorders and relationships with psychosocial variables: a study of the online assessment and diagnostic system within a web-based population.

BACKGROUND: While research in the area of e-mental health has received considerable attention over the last decade, there are still many areas that have not been addressed. One such area is the comorbidity of psychological disorders in a Web-based sample using online assessment and diagnostic tools, and the relationships between comorbidities and psychosocial variables. OBJECTIVE: We aimed to identify comorbidities of psychological disorders of an online sample using an online diagnostic tool. Based on diagnoses made by an automated online assessment and diagnostic system administered to a large group of online participants, multiple comorbidities (co-occurrences) of 21 psychological disorders for males and females were identified. We examined the relationships between dyadic comorbidities of anxiety and depressive disorders and the psychosocial variables sex, age, suicidal ideation, social support, and quality of life. METHODS: An online complex algorithm based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, was used to assign primary and secondary diagnoses of 21 psychological disorders to 12,665 online participants. The frequency of co-occurrences of psychological disorders for males and females were calculated for all disorders. A series of hierarchical loglinear analyses were performed to examine the relationships between the dyadic comorbidities of depression and various anxiety disorders and the variables suicidal ideation, social support, quality of life, sex, and age. RESULTS: A 21-by-21 frequency of co-occurrences of psychological disorders matrix revealed the presence of multiple significant dyadic comorbidities for males and females. Also, for those with some of the dyadic depression and the anxiety disorders, the odds for having suicidal ideation, reporting inadequate social support, and poorer quality of life increased for those with two-disorder comorbidity than for those with only one of the same two disorders. CONCLUSIONS: Comorbidities of several psychological disorders using an online assessment tool within a Web-based population were similar to those found in face-to-face clinics using traditional assessment tools. Results provided support for the transdiagnostic approaches and confirmed the positive relationship between comorbidity and suicidal ideation, the negative relationship between comorbidity and social support, and the negative relationship comorbidity and quality of life. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).

The benefits of using semi-continuous and continuous models to analyze binge eating data: A Monte Carlo investigation.

OBJECTIVE: Change in binge eating is typically a primary outcome for interventions targeting individuals with eating pathology. A range of statistical models exist to handle these types of frequency distributions, but little empirical evidence exists to guide the appropriate choice of statistical model. METHOD: Monte Carlo simulations were used to investigate the utility of semi-continuous models relative to continuous models in various situations relevant to binge eating treatment studies. RESULTS: Semi-continuous models yielded more accurate estimates of the population, while continuous models were higher powered when higher levels of missing data were present. DISCUSSION: The present findings generally support the use of semi-continuous models applied to binge eating data, with total sample sizes of roughly 200 being adequately powered to detect moderate treatment effects. However, models with a significant amount of missing data yielded more favorable power estimates for continuous models.

Family history of education predicts eating disorders across multiple generations among 2 million Swedish males and females.

PURPOSE: To investigate which facets of parent and grandparent socio-economic position (SEP) are associated with eating disorders (ED), and how this varies by ED subtype and over time. METHODS: Total-population cohort study of 1,040,165 females and 1,098,188 males born 1973-1998 in Sweden, and followed for inpatient or outpatient ED diagnoses until 2010. Proportional hazards models estimated associations with parental education, income and social class, and with grandparental education and income. RESULTS: 15,747 females and 1051 males in our sample received an ED diagnosis, with rates increasing in both sexes over time. ED incidence in females was independently predicted by greater educational level among the father, mother and maternal grandparents, but parent social class and parental income showed little or no independent effect. The associations with education were equally strong for anorexia nervosa, bulimia nervosa and ED not-otherwise-specified, and had increased over time. Among males, an apparently similar pattern was seen with respect to anorexia nervosa, but non-anorexia ED showed no association with parental education and an inverse association with parental income. CONCLUSIONS: Family history of education predicts ED in gender- and disorder-specific ways, and in females the effect is observed across multiple generations. Particularly given that these effects may have grown stronger in more recent cohorts, these findings highlight the need for further research to clarify the underlying mechanisms and identify promising targets for prevention. Speculatively, one such mechanism may involve greater internal and external demands for academic success in highly educated families.

[Body dissatisfaction and its risk factors: Hungarian adaptation of the Body Shape Questionnaire Short Form 14]. / A testtel való elégedetlenség mérése és rizikótényezöi: a testforma kédöív rövidített formájának (Body Shape Questionnaire Short From 14) hazai adaptációja.

INTRODUCTION: Body dissatisfaction has severe impact on obesity related psychological distress and other mental health problem. The main goals of this study were to present psychometric analysis of the Hungarian version of Body Shape Questionnaire Short Form 14 (BSQ-14), and to explore the risk factors of body dissatisfaction in participants of a health promotion program. METHODS: The study design is a cross-sectional analysis nested in a prospective study. Our respondents (n=377; 61% women; the mean age=38.8 SD=9.58, BMI=27.0 kg/m2 SD=5.52) participate in a countrywide worksite health promotion program targeting weight problems and physical inactivity. Measures included the Hungarian version of Body Shape Questionnaire Short Form 14, Eating Disorder Inventory Bulimia scale, body weight, body high, self-reported lifetime jojo effect (weight cycling), weight dissatisfaction. RESULTS: The one-factor measurement model is supported by confirmatory factor analysis with inclusion two error covariances. Internal consistency of this scale is excellent (Chronbach α=0.95). A multivariate analysis revealed that gender (female), actual weight, bulimic tendency, self-reported lifetime jojo effect and higher educational attainment are associated with higher body dissatisfaction. CONCLUSIONS: The reliability and construct validity of the Hungarian version of Body Shape Questionnaire Short Form 14 are supported in the present study. Measuring body dissatisfaction might provide a good tool to identify high risk groups and risk factors for psychological distress and to develop optimal intervention programs.

Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness.

Women have consistently higher prevalence rates of anxiety disorders, but less is known about how gender affects age of onset, chronicity, comorbidity, and burden of illness. Gender differences in DSM-IV anxiety disorders were examined in a large sample of adults (N=20,013) in the United States using data from the Collaborative Psychiatric Epidemiology Studies (CPES). The lifetime and 12-month male:female prevalence ratios of any anxiety disorder were 1:1.7 and 1:1.79, respectively. Women had higher rates of lifetime diagnosis for each of the anxiety disorders examined, except for social anxiety disorder which showed no gender difference in prevalence. No gender differences were observed in the age of onset and chronicity of the illness. However, women with a lifetime diagnosis of an anxiety disorder were more likely than men to also be diagnosed with another anxiety disorder, bulimia nervosa, and major depressive disorder. Furthermore, anxiety disorders were associated with a greater illness burden in women than in men, particularly among European American women and to some extend also among Hispanic women. These results suggest that anxiety disorders are not only more prevalent but also more disabling in women than in men.

Bulimic eating disorders in primary care: hidden morbidity still?

The current study examined the features of women with bulimic-type eating disorders (n = 24) attending primary care in two smaller urban regions of the USA. The assessment included measures of eating disorder psychopathology, medical comorbidity, impairment in role functioning, potential barriers to treatment and actual use of health services. Eating disorders, primarily variants of bulimia nervosa and binge eating disorder not meeting formal diagnostic criteria, were associated with marked impairment in psychosocial functioning. Although two-thirds of participants recognized a problem with their eating, less than 40% had ever sought treatment from a health professional for an eating or weight problem and only one in ten had sought such treatment from a mental health specialist. Only one-third had ever been asked about problems with eating by a primary care practitioner or other health professional. However, more than 80% had sought treatment from a health professional for symptoms of anxiety or depression. Most reported some degree of discomfort in discussing eating problems with others, and half reported that they would not be truthful about such problems if asked. Having an eating disorder was associated with several chronic medical conditions, including joint pain, gastrointestinal problems and fatigue. Although the small sample size limits any firm conclusions, the findings suggest that the health burden of bulimic-type eating disorders is substantial but remains largely hidden. Efforts may be needed to improve the eating disorders "mental health literacy" of both patients and primary care practitioners in order to facilitate early, appropriate intervention.

Screening for binge eating disorders using the Patient Health Questionnaire in a community sample.

OBJECTIVE: To examine the operating characteristics of the Patient Health Questionnaire eating disorder module (PHQ-ED) for identifying bulimia nervosa/binge eating disorder (BN/BED) or recurrent binge eating (RBE) in a community sample and to compare true positive (TP) versus false positive (FP) cases on clinical validators. METHOD: Two hundred and fifty-nine screen-positive individuals and a random sample of 89 screen negative cases completed a diagnostic interview. Sensitivity, specificity, and positive predictive value (PPV) were calculated. TP and FP cases were compared using t-tests and Chi-square tests. RESULTS: The PHQ-ED had high sensitivity (100%) and specificity (92%) for detecting BN/BED or RBE, but PPV was low (10 or 19%). TP and FP cases did not differ significantly on frequency of subjective bulimic episodes, objective overeating, restraint, on BMI, and on self-rated health. DISCUSSION: The PHQ-ED is recommended for use in large populations only in conjunction with follow-up questions to rule out cases without objective bulimic episodes.

Health care utilization in patients with eating disorders.

OBJECTIVE: To examine health care costs among patients with eating disorders (EDs) using the Blue Cross Blue Shield of North Dakota claims database system. METHOD: Four groups of individuals enrolled between 1999 and 2005 were identified: (1) a group diagnosed with EDs at the beginning of the study period, in 2000 or 2001; (2) a group diagnosed with EDs later in the study period, in 2004 or 2005; (3) a comparison group with depression; and (4) a non-eating disordered comparison group. RESULTS: Health care costs were high for patients diagnosed with an ED during the period when the diagnosis was made but remained elevated in the years following. Such costs were consistently higher than those for the non-eating disordered comparison group, but similar to the depression comparison group. DISCUSSION: Health care costs remained elevated after a diagnosis of an ED for an extended period of time.

Ecological momentary assessment of affect, stress, and binge-purge behaviors: day of week and time of day effects in the natural environment.

OBJECTIVE: The present study examined ecological momentary assessments of binge/vomit behavior, mood, and type and severity of stressors in a sample of 133 women with bulimia nervosa. METHOD: Participants completed an ecological momentary assessment protocol for a period of 2 weeks. RESULTS: Mixed-effects and multilevel logistic models revealed significant variation across time of day and day of the week in the occurrence of binging, vomiting, positive and negative affect, and the severity and types of stressful events. DISCUSSION: These findings explicate how momentary and daily experiences vary in the natural environments of women with bulimia nervosa, and document critical time periods for intervention.

Assessment and treatment of co-occurring eating disorders in publicly funded addiction treatment programs.

OBJECTIVE: Publicly funded addiction treatment programs were surveyed to increase understanding of treatment options for persons with co-occurring eating and substance use disorders. METHODS: Data were collected between 2002 and 2004 from face-to-face interviews with program directors of a nationally representative sample of 351 addiction treatment programs. RESULTS: Half of the programs screen patients for eating disorders; 29% admit all persons with eating disorders, and 48% admit persons with eating disorders of low severity. Few programs attempt to treat eating disorders. Programs that admit and treat patients with eating disorders are more likely to emphasize a medical-psychiatric model of addiction, use psychiatric medications, admit patients with other psychiatric disorders, and have a lower caseload of African-American patients. CONCLUSIONS: Generally, patients with co-occurring eating and substance use disorders do not appear to receive structured assessment or treatment for eating disorders in addiction treatment programs. These results highlight the need for education of addiction treatment professionals in assessment of eating disorders.

Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost?

OBJECTIVE: We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. METHOD: Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. RESULTS: Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. CONCLUSION: EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.

Self-report versus interview assessment of purging in a community sample of women.

OBJECTIVE AND METHODS: Agreement between self-report and interview assessment of purging behaviours was examined in a community sample of women with a high level of eating disorder symptoms (n = 324) who completed both the Eating Disorder Examination (EDE) and Eating Disorder Examination Questionnaire (EDE-Q). RESULTS: Of 46 individuals who reported any use of self-induced vomiting or laxative misuse on the questionnaire, 19 (41.7%) denied these behaviours when subsequently questioned in a face-to-face interview. These individuals had lower levels of eating disorder psychopathology, functional impairment and general psychological distress, than participants who reported purging on both the questionnaire and at interview (n = 27). CONCLUSIONS: The assumption of interview superiority in the assessment of specific aspects of eating disorder psychopathology should not be uncritically accepted. Caution should be exercised in drawing conclusions concerning the level of agreement between self-report and interview assessment of purging based on research in clinical samples.

Personality-based clusters in bulimia nervosa: differences in clinical variables and ecological momentary assessment.

The present study examined whether personality-based subgroups of bulimic individuals differed in eating disorder behavior, comorbid psychopathology, treatment history, and momentary assessments of mood and behavior. Participants completed an Ecological Momentary Assessment (EMA) protocol for a period of 2 weeks. Latent profile analysis on the Dimensional Assessment of Personality Pathology revealed 3 groupings of bulimic participants: Interpersonal-emotional, Stimulus seeking-hostile, and Low personality pathology. The personality-based groups differed in histories of mood, anxiety, substance use disorders, features of borderline personality disorder, treatment history, and several momentary measures. These findings suggest that personality variation within the bulimia nervosa diagnostic construct may be associated with meaningful conceptual and clinical differences, including daily experiences in the natural environment.

Health service utilization for eating disorders: findings from a community-based study.

BACKGROUND: Prior use of health services was examined in a community sample of women with bulimic-type eating disorders. METHOD: Participants (n = 159) completed a structured interview for the assessment of eating disorder psychopathology as well as questions concerning treatment-seeking and type of treatment received. RESULTS: Whereas a minority (40.3%) of participants had received treatment for an eating problem, most had received treatment for a general mental health problem (74.2%) and/or weight loss (72.8%), and all had used one or more self-help treatments. Where treatment was received for an eating or general mental health problem, this was from a primary care practitioner in the vast majority of cases. Only half of those participants who reported marked impairment associated with an eating problem had ever received treatment for such a problem and less than one in five had received such treatment from a mental health professional. CONCLUSION: Women with bulimic-type eating disorders rarely receive treatment for an eating problem, but frequently receive treatment for a general mental health problem and/or for weight loss. The findings underscore the importance of programs designed to improve the detection and management of eating disorders in primary care.

The assessment of binge eating disorder in obese women: a comparison of the binge eating scale with the structured clinical interview for the DSM-IV.

The purpose of the present study was to evaluate the clinical usefulness of the Portuguese version of the Binge Eating Scale (BES) to assess binge eating disorder (BED) in a clinical sample. The BES is a self-reported instrument developed to identify binge eaters within the obese population. The scale, at the cutoff point of 17, was compared with the Structured Clinical Interview for the DSM-IV-Patient version (SCID-I/P). It was administered to 178 obese Brazilian women, aged 18 to 60 years, seeking treatment for obesity at an outpatient clinic. To assess the test-retest reliability, 121 individuals filled the instrument again 15 days later. The Portuguese version of BES showed a sensitivity of 97.8%, a specificity of 47.7%, a positive predictive value of 66.7% and a negative predictive value of 95.3%. The test-retest reliability, measured by kappa statistics, was 0.66. Cronbach's alpha was 0.89. These results suggest that the BES is valid as a screening instrument for BED in obese Brazilian women seeking treatment for obesity.