How many people will struggle with an eating disorder during their lifetime?
It sounds like an obvious, easy-to-answer question, but it’s more complicated than you might think. Since the vast majority of people with eating disorders never seek formal treatment for their disorder or are formally diagnosed (Hart
et al., 2011), researchers can’t just search medical records. Still, scientists in the US and around the world are trying to gather data to give sufferers, loved ones, and the general community more information about how many people have eating disorders.
Researchers calculate the frequency of eating disorders using two main measurements:
Incidence- the number of people who first develop an eating disorder during a specific period of time (usually one year)
Prevalence- the total number of people who have an eating disorder during a specific period of time
NEDA has gathered data on the prevalence of eating disorders from the U.S., UK, and Europe to try and get a better idea of exactly how common eating disorders are. Older data from other countries that use more strict definitions of anorexia and bulimia give lower prevalence estimates:
? In a study of 31,406 Swedish twins born from 1935-1958, 1.2% of the women had strictly defined anorexia nervosa during their lifetime, which increased to 2.4% when a looser definition of anorexia was used (Bulik
et al., 2006).
? For twins born between 1975 and 1979 in Finland, 2.2-4.2% of women (Keski-Rahkonen
et al., 2007) and 0.24% of men (Raevuori et al., 2009) had experienced anorexia during their lifetime.
? At any given point in time between 0.3-0.4% of young women and 0.1% of young men will suffer from anorexia nervosa, 1.0% of young women and 0.1% of young men will suffer from bulimia, with similar rates for binge eating disorder (Hoek & van Hoeken, 2003).
Several more recent studies in the US have used broader definitions of eating disorders that resulted in a higher prevalence of eating disorders but ones that more accurately reflect the range of disorders that occur.
? A 2007 study asked 9282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in
Biological Psychiatry, found that
0.9% of women and 0.3% of men had anorexia during their life
1.5% of women and 0.5% of men had bulimia during their life
3.5% of women and 2.0% of men had binge eating disorder during their life (Hudson et al., 2007).
? When researchers followed a group of 496 adolescent girls for 8 years (Stice
et al., 2010), until they were 20, they found:
5.2% of the girls met criteria for DSM-V anorexia, bulimia, or binge eating disorder.
When the researchers included FEDNEC criteria, a total of 13.2% of the girls had suffered from a DSM-V eating disorder by age 20.
Feeding and Eating Disorders Not Elsewhere Classified (FEDNEC) encompasses atypical anorexia nervosa, subthreshold bulimia and binge eating disorder, and purging disorder.
? Combining information from several sources, Eric Stice and Cara Bohon (2012) found that
Between 0.9% and 2.0% of females and 0.1% to 0.3% of males will develop anorexia
Subthreshold anorexia occurs in 1.1% to 3.0% of adolescent females
Between 1.1% and 4.6% of females and 0.1% to 0.5% of males will develop bulimia
Subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females
Between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder
Subthreshold binge eating disorder occurs in 1.6% of adolescent females
Averaging these data, we estimate that 6.15% of women have a full-blown eating disorder and an additional 7% have a subthreshold condition. Approximately 2.0% of males have a full-blown eating disorder. Estimates of subthreshold eating disorders in men aren’t currently available.
This means that 19 million women in the US have an eating disorder, and an additional 21 million women have a subthreshold disorder. 6 million men also have an eating disorder.
Eating disorder diagnosis over time
Have these numbers changed over time? That question isn’t clear. It does appear that, at least for the last two decades, the rates of new diagnoses of anorexia and bulimia have remained relatively stable in recent years.
? An ongoing study in Minnesota has found incidence of anorexia increasing over the last 50 years only in females aged 15 to 24. Incidence remained stable in other age groups and in males (Lucas
et al., 1999).
? A Dutch study published in the
International Journal of Eating Disorders found that new diagnoses of anorexia and bulimia remained relatively steady in the Netherlands from 1985-1989 to 1995-1999 (van Son et al., 2006).
? An analysis of many studies from Europe and North America revealed that rates of anorexia increased sharply until the 1970s, where they have stabilized.
? Rates of bulimia increased during the 1980s and early and 1990s, where they have remained the same or decreased slightly (Smink, van Hoeken, & van Hoek, 2012).
? A British study also found stability in new anorexia and bulimia diagnoses in both males and females, although rates of EDNOS diagnoses increased in both groups (Micali
et al., 2013).
? Eating disorder symptoms are beginning earlier in both males and females, which agrees with both formal research (Favaro
et al., 2009) and clinical reports.
Eating disorders in males
Long written off as just a “woman’s disease,” new research is showing that substantial numbers of men also suffer from eating disorders.
? Previous studies indicated that only 1 in 10 eating disorder sufferers were male (Andersen & Holman, 1997). Newer studies show that as many as 1 in 3 eating disorder sufferers are male (Hudson
et al., 2007).
? Several small studies indicate that males are more likely to have been overweight before the onset of the eating disorder than females (Sharp
et al., 1994; Carlat & Camargo, 1991).
? Males are more likely to engage in excessive exercise as a purging method than females (Weltzin
et al., 2005).
? Although eating disorders affect a higher proportion of males with eating disorders identify as gay or bisexual than females, the majority of males with eating disorders are straight (Strother
et al., 2012).
? Males have eating disorders that are just as severe as those found in females, and also have similar responses to treatment (Weltzin
et al., 2012).
Eating disorders in LGBT populations
Eating disorders affect people of all sexual orientations.
? 15% of gay and bisexual males had a full or subthreshold eating disorder at some point in their life, compared to 4.6% of heterosexual males (Feldman & Meyer, 2007).
? Eating disorder prevalence in lesbian and bisexual females were no different than those in heterosexual females: 9.7% vs 8% (Feldman & Meyer, 2007).
? Compared with heterosexual men, gay and bisexual men had a significantly higher prevalence of lifetime full syndrome bulimia, subclinical bulimia, and any subclinical eating disorder (Ray, 2007)
? No studies of prevalence in the transgender community have been conducted to date
Eating disorders in minority populations
Minority populations are not immune to eating disorders. Research suggests that these disorders can strike minorities at higher rates than white populations.
? The National Comorbidity Survey Replication found no difference in eating disorder prevalence in adults in any racial or ethnic group (Hudson
et al., 2007).
? Adolescent Hispanics were significantly more likely to suffer from BN, and the researchers reported a trend towards a higher prevalence of binge eating disorder in all minority groups (Swanson
et al., 2011).
? Despite similar rates of eating disorders as whites, minorities are significantly less likely to receive help for their eating issues (Marques
et al., 2011; Becker et al., 2003).
Eating disorder related hospitalizations
Hospitalizations among eating disorder patients are on the increase in the US. According to a 2009 report from the Agency for Healthcare Research and Quality,
? Eating disorder related hospitalizations increased 18 percent from 1999-2000 to 2005-2006. Anorexia nervosa hospitalizations increased 17 percent, bulimia nervosa hospitalizations decreased 7 percent, and all other eating disorder hospitalizations increased 38 percent.
? Hospitalization of males with eating disorders increased 37 percent between 1999 and 2006.
? Rates of hospitalization of children under 12 for an eating disorder increased 112 percent during this time (Zhao & Encinosa, 2009).
A 2011 update to this study found that
? In 2008-2009, there were 29,533 eating disorder-related hospital stays, which increased by 24 percent compared to 1999-2000.
? Between 2007-2008 and 2008-2009, total eating disorder hospitalizations declined by 23 percent.
? The total cost of eating disorder hospitalizations peaked in 2007-2008 at $296 million (Zhao & Encinosa, 2011).
Mortality in eating disorders
? A review of nearly fifty years of research confirms that anorexia nervosa has the highest mortality rate of any psychiatric disorder (Arcelus
et al., 2011).
? Risk of death from suicide or medical complications is markedly increased for individuals with eating disorders (Crow et al., 2009). The researchers state, “Individuals with eating disorder not otherwise specified, which are sometimes viewed as a “less severe” eating disorder, have elevated mortality risks, similar to those found in anorexia nervosa.” This study demonstrated an increased risk of suicide across eating disorder diagnoses.
? Individuals with anorexia are 7.7 times more likely to die in the first 10 years of their illness than someone without an eating disorder. Risk factors for early death are alcohol abuse, low BMI, and difficulties with social functioning (Franko
et al., 2013).
Prevalence vs. funding
Despite the prevalence of eating disorders they continue to receive inadequate research funding.
Illness Prevalence NIH Research Funds (2011)
Alzheimer’s Disease: 5.1 million $450,000,000
Autism: 3.6 million $160,000,000
Schizophrenia: 3.4 million $276,000,000
Eating disorders: 30 million $28,000,000
Research dollars spent on Alzheimer’s Disease averaged $88 per affected individual in 2011. For Schizophrenia the amount was $81. For Autism, $44. For eating disorders the average amount of research dollars per affected individual was just $0.93. (National Institutes of Health, 2011)
Eating disorders are serious illnesses
In August of 2010, American Viewpoint (a nationally recognized public opinion research company) conducted a telephone survey of American adults for the National Eating Disorders Association. The national survey shows an increased public awareness of eating disorders and a shift in how eating disorders are viewed.
The survey polled a nationwide sample of one thousand adults in the United States. Among the findings were the following:
? 82% percent of respondents believe that eating disorders are a physical or mental illness and should be treated as such, with just 12% believing they are related to vanity.
? 85% of the respondents believe that eating disorders deserve coverage by insurance companies just like any other illness.
? 86% favor schools providing information about eating disorders to students and parents.
? 80% believe conducting more research on the causes and most effective treatments would reduce or prevent eating disorders
? 70% believe encouraging the media and advertisers to use more average sized people in their advertising campaigns would reduce or prevent eating disorders.
In October 2010, the NEDA National Survey findings were made available online at http://nationaleatingdisorders.org/uploads/file/NEDA_Survey_Whitepaper.pdf
Heritability of eating disorders
Genetic factors play an important role in the development of eating disorders. In a recent review of the scientific literature, researchers found the following (Thornton, Mazzeo, & Bulik, 2011):
? Close relatives of people with anorexia are 11.3 times more likely to develop anorexia
? Close relatives of people with bulimia are 4.4 to 9.6 times more likely to develop bulimia
? Close relatives of people with binge eating disorder are 1.9 to 2.2 times more likely to develop binge eating disorder
? Genetic effects account for 88% of the liability for developing anorexia and 59 to 83% of the liability for bulimia
Body dissatisfaction, dieting, and the media
Body dissatisfaction and thin ideal internalization are both significant risk factors for the development of eating pathology and eating disorder behaviors like dieting and binge eating (Stice, 2002).
? About 70% of adolescent girls would prefer to be thinner (Wertheim, Paxton, & Blaney, 2009).
? For males body dissatisfaction leads to pursuit of a lean, muscular ideal, and may lead to health-threatening dieting behavior as well as 3-12% of adolescent boys using anabolic steroids (Cafri
et al. 2005).
? Although body image improves for women in late middle age, about 60% continue to be dissatisfied with their body size and shape; these women continue to be at risk for eating disorders (Grogan, 2011).
? 42% of 1st-3rd grade girls want to be thinner (Collins, 1991).
? 81% of 10 year olds are afraid of being fat (Mellin
et al., 1991).
? Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives (Neumark-Sztainer, 2005).
? 35-57% of adolescent girls engage in crash dieting, fasting, self-induced vomiting, diet pills, or laxatives. Overweight girls are more likely than normal weight girls to engage in such extreme dieting (Boutelle
et al., 2002; Neumark-Sztainer & Hannan, 2000; Wertheim et al., 2009).
? 35% of “normal dieters” progress to pathological dieting. Of those, 20-25% progress to partial or full-syndrome eating disorders (Shisslak, Crago, & Estes, 1995).
Andersen AE & Holman JE. (1997). Males with eating disorders: challenges for treatment and research.
Psychopharmacological Bulletin, 33(3):391-7. PMID: 9550883
Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with Anorexia Nervosa and other eating disorders.
Archives of General Psychiatry, 68(7), 724-731. doi:10.1001/archgenpsychiatry.2011.74.
Becker, A. E., Franko, D. L., Speck, A. and Herzog, D. B. (2003), Ethnicity and differential access to care for eating disorder symptoms.
International Journal of Eating Disorders, 33: 205–212. doi: 10.1002/eat.10129
Boutelle, K., Neumark-Sztainer, D.,Story, M., & Resnick, M. (2002). Weight control behaviors among obese, overweight, and nonoverweight adolescents.
Journal of Pediatric Psychology, 27, 531-540. doi: 10.1093/jpepsy/27.6.531
Bulik CM, Sullivan PF, Tozzi F, Furberg H, Lichtenstein P, and Pedersen NL. (2006). Prevalence, heritability, and prospective risk factors for anorexia nervosa.
Archives of General Psychiatry, 63(3):305-12. doi:10.1001/archpsyc.63.3.305.
Cafri, G., Thompson, J. K., Ricciardelli, L., McCabe, M., Smolak, L., & Yesalis, C. (2005). Pursuit of the muscular ideal: Physical and psychological consequences and putative risk factors. Clinical Psychology Review, 25, 215-239. doi: 10.1016/j.cpr.2004.09.003
Carlat DJ and Camargo CA Jr. (1991). Review of bulimia nervosa in males.
American Journal of Psychiatry, 148(7):831-43. PMID: 2053621.
Collins, M. E. (1991). Body figure perceptions and preferences among pre-adolescent children.
International Journal of Eating Disorders, 10(2), 199-208. DOI: 10.1002/1098-108X(199103)10:2<199::AID-EAT2260100209>3.0.CO;2-D
Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased Mortality in Bulimia Nervosa and Other Eating Disorders.
American Journal of Psychiatry, 12, 166. doi: 10.1176/appi.ajp.2009.09020247
Favaro A, Caregaro L, Tenconi E, Bosello R, and Santonastaso P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa.
Journal of Clinical Psychiatry, 70(12):1715-21. doi: 10.4088/JCP.09m05176blu.
Feldman, M. B. and Meyer, I. H. (2007), Eating disorders in diverse lesbian, gay, and bisexual populations. Int. J. Eat. Disord., 40: 218–226. doi: 10.1002/eat.20360
Franko DL, Keshaviah A, Eddy KT, Krishna M, Davis MC, Keel PK, and Herzog DB. (2013). A longitudinal investigation of mortality in anorexia nervosa and bulimia nervosa.
American Journal of Psychiatry, 70(8):917-25. doi: 10.1176/appi.ajp.2013.12070868.
Grogan, S. (2011). Body image development in adulthood. In T. Cash & L. Smolak (Eds.),
Body Image: A Handbook of Science, Practice, and Prevention (2nd ed.) (pp. 93-100). New York: Guilford.
Hart LM, Granillo MT, Jorm AF, and Paxton SJ. (2011). Unmet need for treatment in the eating disorders: a systematic review of eating disorder specific treatment seeking among community cases.
Clinical Psychology Reviews, 31(5):727-35. doi: 10.1016/j.cpr.2011.03.004.
Hoek HW and van Hoeken D. (2003). Review of the prevalence and incidence of eating disorders.
International Journal of Eating Disorders, 34(4):383-96. doi: 10.1002/eat.10222.
Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.
Biological Psychiatry, 61(3):348-58. doi:10.1016/j.biopsych.2006.03.040
Keski-Rahkonen A, Hoek HW, Susser ES, Linna MS, Sihvola E, Raevuori A, …, and Rissanen A. (2007). Epidemiology and course of anorexia nervosa in the community.
American Journal of Psychiatry, 164(8):1259-65. doi: 10.1176/appi.ajp.2007.06081388.
Lucas AR, Crowson CS, O’Fallon WM, Melton LJ 3rd. (1999). The ups and downs of anorexia nervosa.
International Journal of Eating Disorders, 26(4):397-405. DOI: 10.1002/(SICI)1098-108X(199912)26:4<397::AID-EAT5>3.0.CO;2-0
Marques, L., Alegria, M., Becker, A. E., Chen, C.-n., Fang, A., Chosak, A. and Diniz, J. B. (2011), Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders.
International Journal of Eating Disorders, 44: 412–420. doi: 10.1002/eat.20787
Mellin, L., McNutt, S., Hu, Y., Schreiber, G. B., Crawford, P., & Obarzanek, E. (1997). A longitudinal study of the dietary practices of black and white girls 9 and 10 years old at enrollment: The NHLBI growth and health study.
Journal of Adolescent Health, 20(1), 27-37. doi:10.1016/S1054-139X(96)00176-0
Micali N, Hagberg KW, Petersen I, and Treasure JL. (2013). The incidence of eating disorders in the UK in 2000–2009: findings from the General Practice Research Database.
BMJ Open, 3(5): e002646. doi: 10.1136/bmjopen-2013-002646.
National Institutes of Health. (2011). Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC) [Data set]. Retrieved from http://report.nih.gov/rcdc/categories/
Neumark-Sztainer, D. (2005).
I’m, Like, SO Fat!. New York: Guilford.
Neumark-Sztainer, D., & Hannan, P. (2000). Weight-related behaviors among adolescent girls and boys: A national survey.
Archives of Pediatric and Adolescent Medicine, 154, 569-577. doi:10.1001/archpedi.154.6.569.
Raevuori A, Hoek HW, Susser E, Kaprio J, Rissanen A, and Keski-Rahkonen A. (2009). Epidemiology of anorexia nervosa in men: a nationwide study of Finnish twins.
PLoS ONE, doi: 10.1371/journal.pone.0004402.
Sharp CW, Clark SA, Dunan JR, Blackwood DH, and Shapiro CM. (1994). Clinical presentation of anorexia nervosa in males: 24 new cases.
International Journal of Eating Disorders, 15(2):125-34. PMID: 8173558
Shisslak, C. M., Crago, M., & Estes, L. S. (1995). The spectrum of eating disturbances.
International Journal of Eating Disorders, 18(3), 209-219. PMID: 8556017
Smink FR, van Hoeken D, and Hoek HW. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates.
Current Psychiatry Reports, 14(4):406-14. doi: 10.1007/s11920-012-0282-y.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128, 825-848. PMID: 12206196
Stice E & Bohon C. (2012). Eating Disorders. In
Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley.
Stice E, Marti CN, Shaw H, and Jaconis M. (2010). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents.
Journal of Abnormal Psychology, 118(3):587-97. doi: 10.1037/a0016481.
Strother E, Lemberg R, Stanford SC, and Turberville D. (2012). Eating Disorders in Men: Underdiagnosed, Undertreated, and Misunderstood.
Eating Disorders, 20(5): 346-355. DOI:10.1080/10640266.2012.715512
Swanson SA, Crow SJ, Le Grange D, Swendsen J, and Merikangas KR. (2011). Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement.
Archives of General Psychiatry, 68(7):714-23. doi: 10.1001/archgenpsychiatry.2011.22.
Thornton LM, Mazzeo SE, and Bulik CM. (2011). The heritability of eating disorders: methods and current findings.
Current Topics in Behavioral Neuroscience, 6:141-56. doi: 10.1007/7854_2010_91.
van Son GE, van Hoeken D, Bartelds AI, van Furth EF, and Hoek HW. (2012). Time trends in the incidence of eating disorders: a primary care study in the Netherlands.
International Journal of Eating Disorders, 39(7):565-9. doi: 10.1002/eat.20316.
Weltzin TE, Cornella-Carlson T, Fitzpatrick ME, Kennington B, Bean P, and Jefferies C. (2012). Treatment issues and outcomes for males with eating disorders.
Eating Disorders, 20(5):444-59. doi: 10.1080/10640266.2012.715527.
Weltzin TE, Weisensel N, Franczyk D, Burnett K, Klitz C, and Bean P. (2005). Eating disorders in men: update.
Journal of Men’s Health and Gender, 2(2): 186–193. doi: 10.1016/j.jmhg.2005.04.008
Wertheim, E., Paxton, S., & Blaney, S. (2009). Body image in girls. In L. Smolak & J. K. Thompson (Eds.),
Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (2nd ed.) (pp. 47-76). Washington, D.C.: American Psychological Association.
Zhao, Y., & Encinosa, W. (2009). Hospitalizations for eating disorders from 1999 to 2006.
Healthcare Cost and Utilization Project Database, Statistical Brief 70. Retrieved from http://hcup-us.ahrq.gov/reports/statbriefs/sb70.jsp
Zhao, Y., & Encinosa, W. (2009). Hospitalizations for eating disorders from 1999 to 2006.
Healthcare Cost and Utilization Project Database, Statistical Brief 120. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.jsp