Estimation of Eating Disorders Prevalence by Age and Associations With Mortality in a Simulated Nationally Representative US Cohort

Abstract

Importance: Eating disorders (EDs) are common psychiatric disorders associated with high mortality. However, data on ED disease dynamics and treatment coverage are sparse.

Objectives: To model the individual-level disease dynamics of ED from birth to age 40 years and to estimate the association of increased treatment coverage with ED-related mortality.

Design, setting, and participants: In this decision analytical model study, an individual-level Markov state transition model was empirically calibrated in April 2019 using a Bayesian approach to synthesize available clinical and epidemiologic ED data. The simulation model was calibrated to nationally representative US survey data from 2007 and 2011. A virtual cohort of 100 000 individuals (50 000 [50%] male) was modeled from birth to age 40 years for 4 ED diagnoses: anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding and eating disorders.

Exposures: Age-specific ED incidence and mortality rates and background (all-cause) mortality.

Main outcomes and measures: The main outcomes were age-specific 12-month and lifetime ED prevalence and number of deaths per 100 000 general population individuals by age 40 years. The mean and 95% uncertainty intervals (UIs) of 1000 simulations, accounting for stochastic and parameter uncertainty, are reported.

Results: The highest estimated mean annual prevalence of ED occurred at approximately age 21 years for both male individuals (7.4%; 95% UI, 3.5%-11.5%) and female individuals (10.3%; 95% UI, 7.0%-14.2%), with lifetime mean prevalence estimates increasing to 14.3% (95% UI, 9.7%-19.0%) for male individuals and 19.7% (95% UI, 15.8%-23.9%) for female individuals by age 40 years. Ninety-five percent of first-time cases occurred by age 25 years. Current treatment coverage averts an estimated mean of 41.7 deaths per 100 000 people (95% UI, 13.0-82.0 deaths per 100 000 people) by age 40 years, whereas increasing treatment coverage for all patients with ED could avert an estimated mean of 70.5 deaths per 100 000 people by age 40 years (95% UI, 26.0-143.0 deaths per 100 000 people).

Conclusions and relevance: In this simulation modeling study, the estimated lifetime prevalence of ED was high, with approximately 1 in 7 male and 1 in 5 female individuals having an ED by age 40 years. The initial onset of EDs was highly concentrated during adolescence and young adulthood, suggesting that this is a critical period for prevention efforts. However, the high estimated prevalence of recurring ED later in life highlights the importance of identification and treatment of ED at older ages as well. These findings suggest that increasing treatment coverage could substantially reduce ED-related mortality.

Figure 1.. Estimated Prevalence of Eating Disorders (EDs), by Age, Sex, and Type of ED

Estimated annual (A) and lifetime (B) prevalence of EDs are shown. Solid lines indicate means. Dashed lines indicate medians. Shaded areas indicate 95% uncertainty intervals. AN indicates anorexia nervosa; BED, binge eating disorder; BN, bulimia nervosa; and OSFED, other specified feeding and eating disorder.

Figure 2.. Number of Eating Disorder Episodes by Age 40 Years Among Simulated Individuals With History of Eating Disorder

Numbers of eating disorder episodes for simulated male (A) and female (B) patients are shown. Circles indicate means; vertical lines, 95% uncertainty intervals. AN indicates anorexia nervosa; BED, binge eating disorder; BN, bulimia nervosa; and OSFED, other specified feeding and eating disorders.

Figure 3.. Deaths Averted by Age 40 Years per 100 000 Individuals, by Treatment Scenario

Number of deaths due to eating disorders (EDs) averted by various treatment scenarios is shown. Squares indicate means; vertical lines, 95% uncertainty intervals.