Prevalence of Eating Disorders Over The 2000-2018 Period
Prevalence of Eating Disorders Over The 2000-2018 Period
Prevalence of Eating Disorders Over The 2000-2018 Period
of Nutrition, Rouen University Hospital, Rouen, France; and 4 ClC-CRB 1404, Rouen University Hospital, Rouen, France
ABSTRACT in adolescents and even more in young adults and are sometimes
Background: Eating disorders (EDs) lead to multiple psychiatric severe. They may lead to multiple psychiatric and somatic
and somatic complications and thus constitute a major public health complications and are likely to have an impact in terms of quality
concern. of life and even mortality (2, 3). Indeed, individuals with EDs
Objectives: The aim of this study was to give an exhaustive view of have significantly elevated mortality rates, in particular with
the studies reporting the prevalence of the different EDs or total EDs anorexia nervosa (AN) (4, 5).
and to study their evolution. There are many forms of EDs, which are described in
Methods: A literature search following PRISMA Guidelines and the Diagnostic and Statistical Manual of Mental Disorders
limited to studies in English or French published between 2000 (DSM) and International Classification of Diseases and Related
and 2018 was performed and relevant studies were included in this Health Problems (ICD) classifications. The most widely used
systematic review on the prevalence of EDs. The literature search classification is the DSM classification. EDs appeared in 1980
revealed 94 studies with accurate ED diagnosis and 27 with broad within the DSM-III, their criteria were revised in 1987, and
ED diagnosis. evolved over time with DSM-IV in 1994, then another revised
Results: In 94 studies with accurate ED diagnosis, the weighted version in 2000. The latest classification of ED appeared in the
means (ranges) of lifetime ED were 8.4% (3.3–18.6%) for women DSM-5 in 2013 (6) (Figure 1). In parallel, the ICD, which is an
and 2.2% (0.8–6.5%) for men. The weighted means (ranges) of international classification published by the WHO, included EDs
12-month ED prevalence were 2.2% (0.8–13.1%) for women and for the first time in 1977 (ICD-9) and revised their classification
0.7% (0.3–0.9%) for men. The weighted means (ranges) of point in 1990 (ICD-10) (7).
prevalence were 5.7% (0.9–13.5%) for women and 2.2% (0.2–7.3%) In the most recent DSM-5 classification (Supplemental Data
for men. According to continents, the weighted means (ranges) of
1), the best characterized EDs are anorexia nervosa (AN), bulimia
point prevalence were 4.6% (2.0–13.5%) in America, 2.2% (0.2–
nervosa (BN), and binge eating disorder (BED), referred to
13.1%) in Europe, and 3.5% (0.6–7.8%) in Asia. In addition to
as the 3 typical EDs. Other EDs are referred to as “atypical”
the former, 27 other studies reported the prevalence of EDs as
forms of these disorders and named other specified feeding or
broad categories resulting in weighted means (ranges) of total point
eating disorders (OSFEDs). An OSFED is defined as a feeding
prevalence of any EDs of 19.4% (6.5–36.0%) for women and 13.8%
and eating disorder that causes clinically significant distress or
(3.6–27.1%) for men.
impairment in social life but does not meet the full criteria
Conclusions: Despite the complexity of integrating all ED preva-
lence data, the most recent studies confirm that EDs are highly
for typical EDs (i.e., atypical AN, BN, and BED, purging,
prevalent worldwide, especially in women. Moreover, the weighted and night eating syndrome). The residual category in DSM-5,
means of point ED prevalence increased over the study period from
3.5% for the 2000–2006 period to 7.8% for the 2013–2018 period.
Supplemental Data 1 and Supplemental Tables 1–5 are available from the
This highlights a real challenge for public health and healthcare
“Supplementary data” link in the online posting of the article and from the
providers. Am J Clin Nutr 2019;0:1–13. same link in the online table of contents at https://academic.oup.com/ajcn/.
Abbreviations used: AN, anorexia nervosa; BED, Binge Eating Disorder;
Keywords: eating disorders, prevalence, feeding disorders, anorexia BN, bulimia nervosa; DSM, Diagnostic and Statistical Manual of Mental
nervosa, bulimia nervosa, binge eating disorder Disorders; EAT, Eating Attitudes Test; ED, eating disorder; EDE, Eating
Disorders Examination; EDNOS, Eating Disorder Not Otherwise Specified;
ICD, International Classification of Diseases and Related Health Problems;
Introduction OSFED, other specified feeding or eating disorders.
Address correspondence to PD (e-mail: [email protected]).
Eating disorders (EDs) are characterized by severe distur- Received May 11, 2018. Accepted for publication October 30, 2018.
bances in eating behavior and body weight (1). EDs are frequent First published online 0, 2019; doi: https://doi.org/10.1093/ajcn/nqy342.
Am J Clin Nutr 2019;0:1–13. Printed in USA. Copyright © American Society for Nutrition 2019. All rights reserved. 1
2 Galmiche et al.
named unspecified feeding or eating disorders, includes all other (TW)] NOT “Feeding and Eating Disorders of Childhood”
disorders not included in the typical ED and OSFED categories. (MeSH) NOT “Female Athlete Triad Syndrome” (MeSH)
In DSM-IV, only one category included all EDs that did not NOT “Pica” (MeSH)+ filter on date.
strictly meet all the criteria for anorexia, bulimia, or hyperphagia: • For Pubpsych, Psychinfo, and Google Scholar: eating
eating disorder not otherwise specified (EDNOS). disorders and prevalence 2018 ≥ Publication Year≥ 2000.
This review aims to provide an exhaustive view of the studies
reporting the prevalence of the various EDs or total EDs. Many Searches were carried out until July 2018 and focused on the
studies carried out in various countries and with different methods articles in French and English, published from January 2000 to
of classification and evaluation have been retrieved. The purpose July 2018. The process was guided by the Preferred Reporting
of this systematic review is to describe the full range of prevalence Items for Systematic Reviews and Meta-Analyses (PRISMA)
studies published between 2000 and 2018, to see if a comparison guidelines (8, 9).
is possible and thus to reconstruct the evolution of ED prevalence
studies over recent years.
Study selection
From the Pubmed, Embase, Pubpsych, Medline, and Psychinfo
Methods databases, the research collected 2932, 2059, 599, 388, and 33
records (total = 6011 records), respectively, plus 208 records for
Literature search strategy Google Scholar. From the results of the initial search, 41 reviews
In order to collect all articles on the prevalence of EDs, were analyzed, which allowed us to identify 74 additional original
different electronic databases were consulted: Pubmed, Embase, articles, which were added to the records. The flowchart of the
Medline, Pubpsych, and Psychinfo; the search engine Google record collection is presented in Figure 2.
Scholar was also used. The characteristics of the research were a priori precisely
Accurate queries, using a combination of key words relevant defined to allow the sorting of articles. Thus, only articles
to EDs and epidemiology, were created to carry out prevalence regarding the general population (excluding populations with
research. The queries used were: specific pathologies, e.g., type 1 diabetes) were included in this
study. No limitations in the use of assessment and classification
• For Embase and Medline: “Prevalence”/de OR “epi- tools were imposed; all tools were accepted for search and only
demiology”/de AND (“eating disorder”/de OR “anorexia one assessment tool was finally used per study (Supplemental
nervosa”/exp OR “binge eating disorder”/exp OR “bu- Tables 1 and 2). There were no exclusion criteria based on sex
limia”/exp OR "osfed" OR “binge eating” OR anorexia∗ OR and age. After exclusion of duplicates, 2478 records remained in
bulimia∗ + filter on date and language. the analysis.
• For Pubmed: [Prevalence (meSH) OR prevalence (TW)] The articles were initially screened by title (84% excluded:
AND [“Feeding and Eating Disorders” (MeSH) OR 2082 of 2478), then by abstract (25% excluded: 99 of 396), and
“Disordered Eating Behavior” OR “Feeding and Eating finally by text (59% excluded: 176 of 297). The main reasons
Disorders” (TW) OR “Feeding and Eating Disorder” (TW) for exclusion at these different steps were: study on patient
OR “eating disorder” (TW) OR “eating disorders” (TW) groups without EDs (e.g., patients with nutritional insufficiency,
OR “Anorexia Nervosa” (MH) OR “Anorexia Nervosa” orthorexia, Crohn’s disease, and obesity), no prevalence data
(TW) OR “anorexia nervosa” (TW) OR anorexia∗ (TW) available, specific populations (such as athletes or diabetics),
OR “binge-eating disorder” (MeSH) OR “binge-eating eating behaviors but no EDs, no full text available, full article
disorder” (TW) OR “binge-eating disorders” (TW) OR in another language, no accurate diagnosis, and other study
“binge eating” (TW) OR “bulimia nervosa” (MH) OR objectives (risk factors, therapy, or comorbidity). Finally, 121
“bulimia nervosas” (TW) OR bulimia∗ (TW) OR osfed records were included in the present article (Figure 2). The whole
Prevalence of eating disorders—review 3
FIGURE 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the systematic literature search. ED, eating Downloaded from https://academic.oup.com/ajcn/advance-article-abstract/doi/10.1093/ajcn/nqy342/5480601 by Serials Dept user on 27 April 2019
disorder.
process of the literature screening was conducted by the same and other), evaluation method (face-to-face, online, phone, self-
person (MG), with double-checking by supervisors on randomly questionnaire), prevalence by type of ED, and bias.
selected publications.
Data synthesis
Data extraction To facilitate the understanding and integration of all available
information, the studies have been divided into 2 categories
Data extraction was limited to findings relevant to the research and 2 comprehensive tables (ordered according to the date
topic. The following data were extracted: first author, year of publication) by their characteristics, and the results of the
of publication, country, study design, source of population publications were constructed for each category:
(screening or participation rate, number of subjects), population
size and distribution (percentage women), age (mean age), ED • 94 studies reported prevalence data with accurate diagnosis
assessment tool, classification tool for ED (DSM III, IV, 5, of EDs (Supplemental Tables 1 and 2);
4 Galmiche et al.
FIGURE 6 Twelve-month prevalence (accurate diagnosis) of EDs FIGURE 7 Point prevalence (accurate diagnosis) of EDs according to
according to sex. (A) All, (B) AN, (C) BN, and (D) BED. Weighted means are sex. (A) All, (B) AN, (C) BN, (D) BED, and (E) EDNOS/other specified
represented by a black bar. (A) n = 5 (10, 16, 19, 21). (B) n = 8 (10, 16, 20– feeding or eating disorders. Weighted means are represented by a black bar.
22, 24, 25, 30). (C) n = 10 (10, 16, 20–25, 28, 30). (D) n = 11 (10, 16, 20–25, (A) n = 25 (10, 12–14, 18, 38–57); (B) n = 32 (12–15, 17, 18, 26, 32,
28, 30, 37). AN, anorexia nervosa; BED, binge eating disorder; BN, bulimia 38-40, 42, 45–48, 50, 52, 55–68); (C) n = 31 (12–15, 17, 18, 26, 32, 38,
nervosa; DSM, Diagnostic and Statistical Manual of Mental Disorders; ED, 39, 42, 44–48, 50, 52, 55–61, 63–65, 67–69); (D) n = 21 (38, 39, 12-14,
eating disorder. 18, 32, 45, 47, 48, 56, 57, 59, 61, 63, 64, 67–71); (E) n = 14 (12, 14, 17,
18, 38, 40, 41, 44, 45, 50, 56, 58, 64, 69). AN, anorexia nervosa; BED,
binge eating disorder; BN, bulimia nervosa; DSM, Diagnostic and Statistical
Manual of Mental Disorders; ED, eating disorder; EDNOS, eating disorders
not otherwise specified.
Prevalence of eating disorders—review 7
FIGURE 12 Evolution of the point prevalence of different types of EDs The support of the TargEDys SA company and of the Ministry of
over the 1982–2002 period, adapted from Nakai et al. (39). AN, anorexia Industry and Technology for the funding of MG’s PhD CIFRE thesis
nervosa; BED, binge eating disorder; BN, bulimia nervosa; ED, eating
contract is acknowledged. TargEDys SA is a start-up company developed
disorder; EDNOS, eating disorders not otherwise specified.
within academic laboratory U1073 focusing on microbiota gut–brain axis
modulation.
The authors’ contributions were as follows—MG: performed the medical
Evolution over time
literature search, the analysis of studies, and the writing of the manuscript;
As mentioned earlier, the difference in and evolution of the MPT: supervised the epidemiological methodology; PD: supervised the
tools used for the evaluation and classifications of EDs make writing and appropriate clinical analysis of the data; and all authors:
it difficult to evaluate the evolution of prevalence over time. contributed to the writing and revision of the manuscript and read and
Despite this, a few studies have evaluated the prevalence over approved the final manuscript.
time. In Japan, point prevalence evaluated with a questionnaire
derived from DSM-IV increased for all types of ED from 1.2%
in 1982 to 4.5% in 1992 and 12.7% in 2002 (Figure 12) (39).
Point prevalence of EDs also increased over time in Norway and References
Mexico (12, 40). Finally, the point prevalence of EDs (broad 1. Schmidt U, Adan R, Böhm I, Campbell IC, Dingemans A, Ehrlich S,
Elzakkers I, Favaro A, Giel K, Harrison A, et al. Eating disorders: the
categories) in the general Australian population increased 2-fold big issue. Lancet Psychiatry 2016;3:313–15.
between 1998 and 2008 (111). This tendency is confirmed at the 2. Pasold TL, McCracken A, Ward-Begnoche WL. Binge eating in obese
global level (Figure 8). adolescents: emotional and behavioral characteristics and impact
on health-related quality of life. Clin Child Psychol Psychiatry
Strengths and limitations 2014;19:299–312.
3. Crowell MD, Murphy TB, Levy RL, Langer SL, Kunin-Batson A,
The main strengths of this review are the number of Seburg EM, Senso M, Sherwood NE. Eating behaviors and quality of
publications on EDs highlighted (121 reports) and the diversity life in pre-adolescents at risk for obesity with and without abdominal
of prevalence studied: lifetime, 12-mo, and point prevalence. pain. J Pediatr Gastroenterol Nutr 2015;60:217–23.
4. Crow SJ, Peterson CB, Swanson SA, Raymond NC, Specker S, Eckert
ED prevalence studies typically involve multiple biases, ED, Mitchell JE. Increased mortality in bulimia nervosa and other
making comparisons difficult. eating disorders. Am J Psychiatry 2009;166:1342–6.
First, this review highlights the low, sometimes very low, 5. Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide
participation rates of some prevalence studies (Supplemental mortality in mental disorders: a meta-review. World Psychiatry
2014;13:153–60.
Tables 2 and 4). In addition, another selection bias is frequently 6. American Psychiatric Association. DSM-5, Manuel diagnostique et
found in cross-sectional studies. Indeed, the study population statistique des troubles mentaux, 5th ed. 2013, Elsevier Masson,
is often constituted based on voluntary participation and not France.
through random assignment; the motivation of these subjects to 7. WHO. International statistical classification of diseases and related
health problems. Geneva: World Health Organization; 2004. 824 p.
participate in the study may thus be related to the existence of 8. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items
risk factors. Finally, many prevalence studies use self-report to for systematic reviews and meta-analyses: the PRISMA statement. Int
assess and diagnose EDs and are often retrospective. Thus, a J Surg 2010;8:336–41.
bias of memorization may exist. All these factors may lead to 9. Gedda M. Traduction française des lignes directrices PRISMA pour
l’écriture et la lecture des revues systématiques et des méta-analyses.
underestimation of true prevalence. Kinésithérapie Rev 2015;15:39–44.
10. Micali N, Martini MG, Thomas JJ, Eddy KT, Kothari R, Russell E,
Bulik CM, Treasure J. Lifetime and 12-month prevalence of eating
Conclusion disorders amongst women in mid-life: a population-based study of
diagnoses and risk factors. BMC Med 2017;15:12.
In conclusion, this review confirms the highest prevalence for 11. Wade TD, Bergin JL, Tiggemann M, Bulik CM, Fairburn CG.
EDNOS, followed by BED, BN, and AN, according to DSM- Prevalence and long-term course of lifetime eating disorders in an adult
IV. In the new setting of DSM-5, OSFED remains the most Australian twin cohort. Aust N Z J Psychiatry 2006;40:121–8.
12. Zachrisson HD, Vedul-Kjelsås E, Götestam KG, Mykletun A. Time
prevalent, still followed by BED, BN, and AN. EDs are already trends in obesity and eating disorders. Int J Eat Disord 2008;41:
quite prevalent among adolescents (under 18 y), mainly due to 673–80.
the early onset of AN, whereas the highest prevalence data are 13. Favaro A, Ferrara S, Santonastaso P. The spectrum of eating disorders
reported in adults, due to the accumulation of prolonged disorders in young women: a prevalence study in a general population sample.
Psychosom Med 2003;65:701.
that appeared during adolescence and disorders newly onset in 14. Kjelsås E, Bjørnstrøm C, Götestam KG. Prevalence of eating disorders
adulthood. Although EDs were classically thought to be confined in female and male adolescents (14–15 years). Eat Behav 2004;5:
to developed Western countries, this study also highlights the 13–25.
10 Galmiche et al.
15. Hach I, Ruhl UE, Rentsch A, Becker ES, Türke V, Margraf J, Kirch disorders from a community sample of adolescents. J Abnorm Psychol
W. Recognition and therapy of eating disorders in young women in 2009;118:587–97.
primary care. J Public Health 2005;13:160–5. 36. Trace SE, Thornton LM, Root TL, Mazzeo SE, Lichtenstein P,
16. Preti A, de Girolamo G, Vilagut G, Alonso J, de Graaf R, Bruffaerts Pedersen NL, Bulik CM. Effects of reducing the frequency and
R, Demyttenaere K, Pinto-Meza A, Haro JM, Morosini P, et al. duration criteria for binge eating on lifetime prevalence of bulimia
The epidemiology of eating disorders in six European countries: nervosa and binge eating disorder: implications for DSM-5. Int J Eat
results of the ESEMeD-WMH project. J Psychiatr Res 2009;43: Disord 2012;45:531–6.
1125–32. 37. Cossrow N, Pawaskar M, Witt EA, Ming EE, Victor TW, Herman BK,
17. Isomaa R, Isomaa A-L, Marttunen M, Kaltiala-Heino R, Björkqvist Wadden TA, Erder MH. Estimating the prevalence of binge eating
The prevalence and correlates of binge eating disorder in the 110. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or
WHO World Mental Health Surveys. Biol Psychiatry 2013;73: self-report questionnaire? Int J Eat Disord 1994;16:363–70.
904–14. 111. Mitchison D, Hay P, Slewa-Younan S, Mond J. The changing
100. Makino M, Tsuboi K, Dennerstein L. Prevalence of eating disorders: demographic profile of eating disorder behaviors in the community.
a comparison of western and non-western countries. Medscape Gen BMC Public Health 2014;14:943.
Med [Internet] 2004;6(3):49. 112. Rodríguez-Cano T, Beato-Fernández L, Belmonte-Llario A. New
101. Pike KM, Hoek HW, Dunne PE. Cultural trends and eating disorders. contributions to the prevalence of eating disorders in Spanish
Curr Opin Psychiatry 2014;27:436. adolescents: detection of false negatives. Eur Psychiatry 2005;20:
102. Martínez-González MA, Gual P, Lahortiga F, Alonso Y, de Irala- 173–8.