The epidemiology of eating disorders in six European countries: Results of the ESEMeD-WMH project

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Abstract

Few data are available to estimate the prevalence of eating disorders (EDs) and their correlates in the community. This paper reports data on EDs obtained in the framework of the ESEMeD project, aimed at investigating the prevalence of non-psychotic mental disorders in six European countries (Belgium, France, Germany, Italy, the Netherlands and Spain), using a new version of the Composite International Diagnostic Interview. The ESEMeD study was a general population cross-sectional household survey. In total, 21,425 respondents aged 18 or older provided data for the project between January 2001 and August 2003. A subsample (N = 4139) underwent a detailed investigation on EDs. Lifetime estimated prevalence of anorexia nervosa, bulimia nervosa, binge eating disorder, sub-threshold binge eating disorder, and any binge eating were 0.48%, 0.51%, 1.12%, 0.72%, and 2.15%, respectively, and they were 3–8 times higher among women for all EDs. However, since people under 18 were excluded from this study, our prevalence should be taken as lower-bound estimate of real frequencies. Indeed, cumulative lifetime prevalence analysis showed that the majority of eating disorders had their initial onset between 10 and 20 years of age. Role impairment and comorbidity with other mental disorders were highly common, yet only small proportions of patients with a lifetime diagnosis of EDs requested medical treatment. It still has to be proven whether early diagnostic identification and access to specialized care can reduce the burden caused by these disorders.

Introduction

Current diagnostic classifications recognize two main eating disorders (EDs), anorexia nervosa and bulimia nervosa, with symptomatic variants recorded as a global “not otherwise specified” class (APA, 1994, WHO, 1992). The binge ED has been proposed as a possible additional clinical category (Spitzer et al., 1992). The status of sub-threshold disorders is still debated: several studies have shown that sub-threshold disorders may cause less impairment and disability than full-blown disorders (Hudson et al., 2007), but other reports seem to indicate some kind of progression of sub-threshold disorders (Patton et al., 1999), therefore representing important antecedents of anorexia and bulimia nervosa.

Few data are available to estimate the prevalence of EDs. Most studies have concentrated on single samples selected at local level, or have investigated symptoms’ distribution by means of questionnaires rather than personal interviews (Hoek and van Hoeken, 2003, Miotto et al., 2003, Vega Alonso et al., 2005). Point prevalence of anorexia nervosa has been reported around 0.3% in American and European studies (Hoek and van Hoeken, 2003, Favaro et al., 2004), with lifetime prevalence approximating 0.5–0.6% in two large population-based surveys in the United State (US) and Canada (Garfinkel et al., 1996, Walters and Kendler, 1995), and reaching 1% in a very large population survey in the Netherlands (Bijl et al., 1998). Lifetime prevalence of bulimia nervosa has been estimated to range between 1% and 3% in three large surveys in New Zealand, the US and Canada (Bushnell et al., 1990, Garfinkel et al., 1995, Kendler et al., 1991), but as low as 0.6% in the Netherlands (Bijl et al., 1998).

Male/female ratios have been found to range from 1:5 to 1:10 for both anorexia and bulimia nervosa (Bushnell et al., 1990, Garfinkel et al., 1995, Garfinkel et al., 1996), although one large-scale survey, carried out in a national representative sample of US citizens, found higher prevalence among males than in past studies, resulting in a lower female/male ratio (Hudson et al., 2007). With regard to binge ED, data are sparse, with estimated prevalence around 3.3% among women and 0.8% among men in a large-scale population-based survey, conducted with telephone interviews in Austria (Kinzl et al., 1999), and, respectively, 3.5% and 2.0% in the US National Comorbidity Replication study (NCS-R) (Hudson et al., 2007).

This paper reports prevalence estimates of EDs obtained in the framework of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project (ESEMeD/MHEDEA 2000 Investigators, 2004a, ESEMeD/MHEDEA 2000 Investigators, 2004b), part of the World Mental Health (WMH) Survey initiative, aimed at investigating the prevalence of major mental disorders in six European countries (Belgium, France, Germany, Italy, the Netherlands and Spain), using a new version of the Composite International Diagnostic Interview (CIDI 3.0).

The aims of this study were: (i) to investigate the lifetime and 12-month prevalence of EDs, taking into account three main diagnostic entities (e.g., anorexia nervosa, bulimia nervosa, and binge ED) and two sub-threshold categories (sub-threshold binge ED and binge eating per se); (ii) to describe the major correlates of these diagnostic entities in terms of impairment in role functioning and comorbidity with other mental disorders; and (iii) to assess service use by affected people.

Section snippets

Sample

The study was cross-sectional in nature and individuals were assessed in person at their homes using computer-assisted interview (CAPI) techniques. The target population was the non-institutionalized adult population (aged 18 years or older) of Belgium, France, Germany, Italy, the Netherlands and Spain, that is a total of 212,000,000 European citizens. A stratified, multistage, clustered area, probability sample design was used.

In total 21,425 respondents provided data for the project between

Results

The investigated sample included a balanced proportion of participants by gender and age: mean age was 47.1 (95% CI 46.2–48.0); young people (18–29 years old) were 20% of the study sample. A third (35%) of the sample reported more than 12 years of full-time education, and the majority (55%) were in paid employment at the moment of the interview details on sampling method and on characteristics of the investigated sample are shown in Table 1.

Discussion

This study confirms the substantial prevalence of EDs in the general population of six major European countries. In our sample, EDs are associated to a substantial comorbidity with other mental disorders; however, the use of services among those affected people is low, with a suboptimal utilization of the mental health sector. We found lifetime prevalence estimates as low as 0.5% for both anorexia and bulimia nervosa, with significantly higher prevalence among females than males. However, the

Conflict of interest statement

To the best of our knowledge, no conflict of interest is foreseeable concerning the data and results described in this article.

Funding source

This project was funded by the European Commission (Contract QLG5-1999–01042); the Piedmont Region (Italy); Fondo de Investigacion Sanitaria, Instituto de Salud Carlos III, Spain (FIS 00 – 0028); Ministerio de Ciencia Y Tecnologia, Spain (SAF 2000–158–CE); Department de Sanitat, Generalitat de Catalunya, Spain; other local agencies and by an unrestricted educational grant from GlaxoSmithKline.

Contributors

The ESEMeD-WMH Investigators are: Jordi Alonso, Matthias Angermeyer, Sebastian Bernert, Ronny Bruffaerts, Traolach S. Brugha, Giovanni de Girolamo, Ron de Graaf, Koen Demyttenaere, Isabelle Gasquet; Josep Maria Haro, Steven J. Katz; Ronald C. Kessler, Viviane Kovess, Jean Pierre Lépine, Johan Ormel, Gabriella Polidori, and Gemma Vilagut.

Gemma Vilagut did all statistical analyses.

As for the manuscript, the authors, all co-jointly had the idea and wrote, revised and approved the final manuscript.

Acknowledgement

This project was funded by the European Commission (Contract QLG5-1999–01042, SANCO 2004123), the Piedmont Region (Italy), Fondo de Investigación Sanitaria, Instituto de Salud Carlos III, Spain (FIS 00/0028), Ministerio de Ciencia y Tecnología, Spain (SAF 2000–158–CE), Department de Salut, Generalitat de Catalunya, Spain, and other local agencies and by an unrestricted educational grant from GlaxoSmithKline. ESEMeD is carried out in conjunction with the World Health Organization World Mental

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