Review articleQuality of life in eating disorders: A meta-analysis
Introduction
An eating disorder (ED) is characterized by an abnormal eating behaviour with either insufficient or excessive food intake, accompanied by feelings of distress or concern about weight or body shape, sometimes in combination with compensatory behaviour, to the detriment of the person׳s physical health. Anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) are well-known diagnoses that are described in the Diagnostic and Statistical manual of Mental disorders (DSM-IV) (Association, 2000). AN is characterized by an inadequate intake of nutrition and an inability to maintain a minimum stable, healthy weight. BN is characterized by recurrent episodes of binge eating followed by compensatory behaviour. Patients with symptoms of an ED not meeting the diagnostic criteria of AN or BN are diagnosed with EDNOS, which constitutes the most common group of EDs with approximately half of patients diagnosed with an ED receiving this diagnosis (Button et al., 2005). The diagnostic group is highly heterogeneous and included patients with binge eating disorder (BED) prior to the publication of the DSM-5. (Hay et al., 2010).
The DSM-5 (Association, 2013), a revised edition of DSM-IV, was published in May 2013 and included BED as an autonomous diagnosis. In DSM-IV this diagnosis only appeared in the appendix (Moran, 2012). BED is defined by recurrent episodes of binge eating accompanied by a sense of loss of control.
Less than half of the patients suffering from AN recover and approximately one-fifth will develop a chronic course (Steinhausen, 2002). A meta-analysis published in 2011 (Arcelus et al., 2011) revealed an approximate six-fold increase in mortality compared to the general population with a standardized mortality ratio of 5.9, which equals the highest mortality of any psychosomatic disorder (Erdur et al., 2012). Patients with an ED also have a high occurrence of relapse (30–50%) (Guarda, 2008). There is no evidence that the prognosis has improved throughout the 20th century (Steinhausen, 2002).
EDs comprise a variety of symptoms that severely impair physical, mental and social aspects of everyday life. The term Global Burden of Disease (GBD) was introduced in 1990 after an extensive collaboration between health experts with the aim to assess the mortality and disability in major diseases. The study introduced the term disability adjusted life years (DALY), which combines mortality and morbidity into one single measure by summing up the years of life lost (YLL) and the years lived with disability (YLD). In 2000, EDs were ranked as number 15 in the “top 20” disorders for women, ahead of for instance psychoses and rheumatoid arthritis (Ware and Sherbourne, 1992, Public Health Division, D.o.H.S, 1999). In 1999, the number of DALYs was found to be similar for EDs and schizophrenia in women (Ware et al., 1993).
Studies have shown that patients with EDs present lower health-related quality of life (HRQoL) compared to other psychiatric disorders, including severe depression and compared to the general population (de la Rie et al., 2005). It is unclear whether there are differences between the ED diagnostic groups, although a recent review found that patients with BED tended to report the lowest HRQoL (Jenkins et al., 2011). These differences have not, to our knowledge, been explored further.
The classification of EDs remains controversial (Hebebrand and Bulik, 2011) and several changes have been made in the DSM-5 with the introduction of new diagnoses and changes in the existing criteria. Potential differences in HRQoL could assist in classifying EDs and highlight the importance of establishing specific treatment options for each ED.
The aim of this meta-analysis was to explore the differences in HRQoL between AN, BN, EDNOS and BED, measured by the Medical Outcomes Study Short Form-36 Health Survey (SF-36). To our knowledge, no previous attempts have been made to pool the results of the existing research in this area.
Section snippets
Search strategy
A systematic review of the current literature was conducted using a keyword-based search in the databases PubMed and PsychInfo using the following terms: anorexia or bulimia or EDNOS or eating disorders OR binge eating AND quality of life OR QoL AND SF-36. Studies not in English and intervention studies without baseline values were excluded. We did not exclude studies based on publishing year or define an age restrictions. The search was conducted on May 15th 2012 and repeated on June 13th
Descriptives
The included studies were published between September 18th 2000 and March 23rd 2012. Five studies included patients with AN, four studies BN, two studies EDNOS and four studies BED (Table 1). One of the studies including AN divided the patients into two subtypes (AN restrictive type and AN binge purging type) (Padierna et al., 2000), and these were both included in the analysis of AN. Across the selected studies 757 patients had an ED diagnosis; 227 with AN, 216 with BN, 166 with EDNOS and 148
Discussion
This meta-analysis confirms that HRQoL is affected in patients with an ED, as they have significantly lower SF-36 subscale scores compared to a general population. We found that all areas of HRQoL except PF were affected, but there was no significant difference in HRQoL between the four diagnostic groups. These results are in line with previous studies, but did not to support the hypothesis that patients with BED have lower scores than patients with other EDs. The results of this analysis must
Conflict of interest
None
Role of funding source
None.
Acknowledgements
Proofreading by Claire Gudex, MBChB, MD, Centre of Endocrinology, Odense University Hospital, Denmark.
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