Does specialization of treatment influence mortality in eating disorders?--A comparison of two retrospective cohorts

A meta-analysis of mortality rates in eating disorders: An update of the literature from 2010 to 2024

Elevated mortality rates have been reported in individuals with eating disorders (EDs). However, no meta-analysis in the past decade has provided an updated, comprehensive synthesis of mortality across all ED diagnoses while exploring potential moderating factors. We conducted a systematic search in four databases (PsycINFO, MEDLINE, Embase and Web of Science) from 2010 to 29 Oct 2024. Studies that reported standardized mortality ratios (SMRs) in individuals with a diagnosed ED (including formal diagnoses and self-reports) were included. Random-effects meta-analyses were conducted to pool estimates across studies. Meta-regression was conducted to examine predictors of heterogeneity. Meta-analysis of SMRs of effect sizes revealed elevated mortality risk for individuals with an ED (regardless of ED subtype); weighted SMR = 3.39 (95 % CIs: 2.90, 3.95), p < .001, I2 = 95.1 %, Q(df=73) = 1492.39, p < .001. SMRs were highest for individuals with anorexia nervosa (5.21; k = 30), followed by eating disorder not otherwise specified (2.51; k = 8); bulimia nervisa (2.20; k = 18) and binge eating disorder (1.46; k = 3). Individuals with EDs demonstrate markedly heightened mortality rates, especially among those with anorexia nervosa. Our findings are crucial for identifying key factors influencing mortality in EDs, guiding targeted interventions to reduce preventable deaths.

Eating disorder outcomes: findings from a rapid review of over a decade of research

BACKGROUND

Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality.

METHODS

This paper forms part of a Rapid Review series scoping the evidence for the field of ED, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/MEDLINE were searched for studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review.

RESULTS

Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates.

CONCLUSION

Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

The gut microbiota contributes to the pathogenesis of anorexia nervosa in humans and mice

Anorexia nervosa (AN) is an eating disorder with a high mortality. About 95% of cases are women and it has a population prevalence of about 1%, but evidence-based treatment is lacking. The pathogenesis of AN probably involves genetics and various environmental factors, and an altered gut microbiota has been observed in individuals with AN using amplicon sequencing and relatively small cohorts. Here we investigated whether a disrupted gut microbiota contributes to AN pathogenesis. Shotgun metagenomics and metabolomics were performed on faecal and serum samples, respectively, from a cohort of 77 females with AN and 70 healthy females. Multiple bacterial taxa (for example, Clostridium species) were altered in AN and correlated with estimates of eating behaviour and mental health. The gut virome was also altered in AN including a reduction in viral-bacterial interactions. Bacterial functional modules associated with the degradation of neurotransmitters were enriched in AN and various structural variants in bacteria were linked to metabolic features of AN. Serum metabolomics revealed an increase in metabolites associated with reduced food intake (for example, indole-3-propionic acid). Causal inference analyses implied that serum bacterial metabolites are potentially mediating the impact of an altered gut microbiota on AN behaviour. Further, we performed faecal microbiota transplantation from AN cases to germ-free mice under energy-restricted feeding to mirror AN eating behaviour. We found that the reduced weight gain and induced hypothalamic and adipose tissue gene expression were related to aberrant energy metabolism and eating behaviour. Our 'omics' and mechanistic studies imply that a disruptive gut microbiome may contribute to AN pathogenesis.

Mortality and care of eating disorders

INTRODUCTION

Eating disorders (EDs) are considered serious mental illnesses, with one of the highest lethality among psychiatric disorders, even though the issue of mortality due to these conditions is still controversial. The present study was aimed at comparing the mortality rate in a cohort of ED patients representative of the geographic area with that of the age and gender-matched general population of central Italy.

METHODS

Patients were enrolled between 1994 and 2018, among those attending the eating disorders treatment network of the Florence area (EDTN), which is a regional multidisciplinary treatment reference center for EDs covering the clinical population of the metropolitan Florence area (Italy). The life status of participants was determined through linkage with the Regional Mortality Registry.

RESULTS

A total of 1277 individuals with EDs were included, including 368 with Anorexia Nervosa (AN), 312 with Bulimia Nervosa (BN), and 597 individuals with Binge Eating Disorder (BED). Twenty-two patients (1.72%) died, during a median follow-up of 7.4 years. The mortality rates among ED patients did not significantly differ from that of the general population of the same age and sex with a Standardized Mortality Ratio (SMR) of 1.19, 95% CI 0.79-1.81. Only among BN patients, the mortality was significantly increased after 10 years from clinical evaluation (SMR 11.24, 95% CI 3.62-34.84).

CONCLUSION

The low mortality in EDs, compared to published studies, might be due to the EDTN treatment strategy, based on a large network which makes an integrated multidisciplinary team available for almost all the patients with EDs of the geographical area.

Models of care for eating disorders: findings from a rapid review

BACKGROUND

Delayed diagnosis, gaps in services and subsequent delays in specialist care and treatment lead to poorer health outcomes for individuals with eating disorders (EDs) and drive significant government healthcare expenditure. Given the significant disease burden associated with EDs, it is imperative that current implementation research is summarised to identify gaps in care and enable refinement for optimal patient outcomes. This review aimed to provide an updated synthesis on models of care for EDs in developed healthcare systems.

METHODS

This paper was conducted as part of a series of Rapid Reviews (RRs) to be published in a special series in the Journal of Eating Disorders. To provide a current and rigorous review, peer-reviewed articles published in the English language between 2009 and 2021 across three databases (ScienceDirect, PubMed and Ovid/Medline) were searched, with priority given to higher level evidence (e.g., meta-analyses, large population studies, Randomised Control Trials (RCTs)). The current review synthesises data from included studies investigating models of care for people with EDs.

RESULTS

Sixty-three studies (4.5% of the original RR) were identified, which included several diagnostic populations, the most common being Anorexia Nervosa (AN) (30.51%). Across EDs, specialist care was found to improve patient outcomes, with many patients effectively being treated in outpatient or day programs with multi-disciplinary teams, without the need for lengthy inpatient hospitalisation. Few studies investigated the interaction of different ED services (e.g., inpatient, community services, primary care), however stepped care models emerged as a promising approach to integrate ED services in a targeted and cost-effective way. Issues surrounding low treatment uptake, underdiagnosis, long waiting lists and limited hospital beds were also evident across services.

CONCLUSION

Findings suggested further research into alternatives to traditional inpatient care is needed, with partial and shorter 'hospitalisations' emerging as promising avenues. Additionally, to tackle ongoing resource issues and ensure timely detection and treatment of EDs, further research into novel alternatives, such as active waiting lists or a greater role for primary care clinicians is needed. This paper is part of a larger Rapid Review series carried out to guide Australia's National Eating Disorders Research and Translation Strategy 2021-2031. Rapid reviews aim to thoroughly summarise an area of research over a short time period, typically to help with policymaking in this area. This Rapid Review summarises the evidence relating to how we care for people with eating disorders in Western healthcare systems. Topics covered include inpatient/hospital care, residential care, day programs, outpatient/community care, and referral pathways. Findings suggested specialist eating disorder services may enhance detection, referral, and patient care. Stepped care models presented as a cost-effective approach which may help with linkage between different eating disorder services. There was a trend towards shorter hospital stays and approaches which allow for greater connection with the community, such as day programs. Evidence was also found of treatment delays, due to system issues (long waiting lists, lack of accurate assessment and diagnosis) and patient-related barriers (stigma, recognition). Upskilling and involving primary care clinicians in diagnosis and referral as part of a stepped care model may help to address some of these concerns. Further efforts to improve mental health literacy and de-stigmatise help-seeking for eating disorders are needed.

What can we learn about eating disorder mortality from eating disorder diagnoses at initial assessment? A Danish nationwide register follow-up study using record linkage, encompassing 45 years (1970-2014)

Increased risk for premature mortality is well established for women and girls diagnosed with anorexia nervosa (AN), but less is known for other types of eating disorder (ED), and especially the mortality outcome for boys and men is under-studied. In this registry-based observational epidemiological study, we included all people appearing in the Danish Psychiatric Central Research Register with an eating disorder (ED) diagnosis in the time period from Jan 1,1970 to Dec 31, 2014 (N: 22,633). For each patient four controls without ED were selected, matched for age, sex and place of residence (N: 90486). In all 802 people with ED died over 255762.6 person-years of observation. Standardized mortality ratio (SMR) for all-cause mortality and suicide mortality was significantly increased for all ED-diagnoses in women. The SMRs for men were similar, but only reached significance for the diagnoses AN and unspecified ED. Mortality by natural causes and accidents was significantly increased in most ED-diagnoses in women. The unequal female-to-male ratio in this, and most other studies of ED-patients, suggests that boys and men with ED have unmet needs.

A systematic review of interventions to support transitions from intensive treatment for adults with anorexia nervosa and/or their carers

AIM

In the short term, intensive treatment focusing on restoring weight for anorexia nervosa can remediate many symptoms. However, there is a high level of relapse after discharge. This paper examines interventions developed to bridge the transition from intensive to less intensive forms of treatment for adult anorexia nervosa.

METHOD

We undertook a systematic review of the literature on interventions aimed at providing transition support. The Template for Intervention Description and Replication was used to describe components of the transition interventions. Patient's drop-out rates, weight, eating disorder psychopathology and mood data were extracted at end of treatment and follow-up to describe preliminary efficacy.

RESULTS

Fourteen studies were selected: nine used psychological interventions delivered through face-to-face talking therapy or guided self-help, three examined the use of fluoxetine and two assessed stepped-care approaches. Transition support was delivered to patients in 11 studies, to patients and carers in two studies, and carers alone in another study.

CONCLUSIONS

There was a great heterogeneity in the content and structure of the transition interventions evaluated. Overall, drop-out rates were lower for psychological support than pharmacological interventions or stepped-care approaches. Changes in eating disorder outcomes and mood were small to moderate throughout for studies that included a comparison group.

Time trends in treatment modes of anorexia nervosa in a nationwide cohort with free and equal access to treatment

BACKGROUND

Treating patients with anorexia nervosa (AN) remains a major challenge. The choice between an inpatient or an outpatient care setting is an essential issue for the patients and for their relatives with major health economic implications. However, health services-related studies are lacking. The present study was a descriptive exploration of time-trends in treatment modes of patients with free and equal access to health services.

METHODS

The study was based on a nationwide cohort of patients diagnosed for the first time with AN, each followed for 5 years in the registers covering the years 1994-2018. The per patient number of hospital admissions, cumulated number of days of hospitalization and number of outpatient visits during the first 5 years after initial diagnosis were considered.

RESULTS

The cohort of patients with AN with at least 5 years of follow-up amounted to N = 7,505. A clear trend was observed in the per patient five-year cumulated number of inpatient days, decreasing by 6% per year after adjustment for age at diagnosis, parental mental diagnosis, and family income. The five-year number of hospital admissions after initial diagnosis decreased by 2% per year, while no trend was observed for outpatient visits.

CONCLUSIONS

The per patient number of hospitalizations and cumulated days of hospitalization during 5 years after diagnosis were reduced for patients initially diagnosed with AN while there was no change in the number of outpatient visits. The factors contributing to these changes of treatment modes over time are in need of further study.

Venous thromboembolism in anorexia nervosa: four cases from a specialized unit. Indication for thromboprophylaxis?

BACKGROUND

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of mortality and morbidity. VTE may occur asymptomatic or subclinical. Fluid retention during intensive re-nutrition or rapid weight changes are well-known phenomena in anorexia nervosa (AN) and may represent a significant risk factor for VTE.

OBJECTIVE

The incidence of VTE in patients with AN is unknown, and the conditions may be overlooked in a complex clinical picture.

METHOD

This study report four cases of VTE in women with severe AN (age range 19-41 years, BMI range 10.6-13.1) admitted to a specialized unit for medical stabilization.

RESULTS

DVT or PE was diagnosed in all four patients. The patients were admitted for intensive re-nutrition according to conventional conservative guidelines with slow increase in energy supply (start low and advance slow). Due to suspected VTE, thromboprophylaxis was given during hospitalization, three of whom were undergoing re-nutrition.

CONCLUSION

The four presented cases suggest that VTE during re-nutrition in AN may be an overlooked risk which may not be sufficiently addressed in the literature. General recommendations should not be issued on the basis of case reports; however, we want to raise awareness and call for studies to identify the VTE risk and appropriate thromboprophylaxis in AN patients.

Fractures in women with eating disorders-Incidence, predictive factors, and the impact of disease remission: Cohort study with background population controls

OBJECTIVE

Malnutrition and low weight in eating disorders (EDs) are associated with increased fracture risk compared to the general population. In a cohort study, we aimed to determine fracture rates compared to age and gender matched controls (ratio 5:1), assess the impact of disease remission on fracture risk, and establish predictive factors for fractures.

METHOD

Of note, 803 ED patients referred to specialized ED treatment between 1994 and 2004 were included. In 2016, data on fractures were obtained through the Danish National Registry of Patients.

RESULTS

Fracture risk was increased in anorexia nervosa (AN; IRR 2.2 [CI 99%: 1.6-3.0]) but not in bulimia nervosa (BN; IRR 1.3, ns) or other specified feeding or eating disorders (OSFED; IRR 1.8, ns). IRR in the AN group were increased for vertebral fractures (IRR 3.8 [CI 99%: 1.4-10.3]), upper arm (IRR 3.0 (CI 99% 1.6-5.5) and hip (IRR 6.6 [CI 99%: 2.6-18.0]). Disease remission in AN is associated to lower fracture risk compared to active disease, but higher fracture risk compared to controls (IRR 1.7 [CI 99%: 1.1-2.7]). In regression analysis, age at debut of disease, nadir BMI and duration of disease before referral to treatment, independently predicted fracture.

DISCUSSION

We confirm increased fracture risk in AN, and show significant differences in fracture risk between patients in disease remission and patients with active disease. Furthermore, we show that age at debut of disease and duration of disease before referral to treatment is positively correlated to fracture risk, whereas nadir BMI is negatively correlated to fracture risk.

A Danish translation of the eating disorder quality of life scale (EDQLS)

BACKGROUND

In Denmark, only generic health-related quality of life measures have been developed to assess quality of life in patients with eating disorders. So far, no disease-specific questionnaires have been translated and validated. The objective of this study was to translate the Eating Disorders Quality of Life Scale into Danish and to perform a preliminary validation of the questionnaire in a small sample.

METHODS

The translation process was conducted according to recommendations from the World Health Organization, using the WHO-5 Well-Being Index as a reference standard. The validation process included 41 outpatients with eating disorders. Patients were recruited from specialized outpatient clinics in the Capital Region of Denmark and asked to complete the quality of life questionnaire and the WHO-5 Well-Being Index.

RESULTS

This study found poor agreement, but high correlation, between the two self-rating scales.

CONCLUSION

The translated questionnaire was concluded to be valid. However, a replication study on a larger sample with more male patients and more extensive symptoms is necessary.

Body composition and menstrual status in adults with a history of anorexia nervosa-at what fat percentage is the menstrual cycle restored?

OBJECTIVE

To study the association between body composition measures and menstrual status in a large sample of adult patients with a history of anorexia nervosa and to calculate the predicted probability of resumption of menstrual function. Furthermore, to establish whether fat percentage is superior to body mass index in predicting the resumption of menses.

METHOD

One hundred and thirteen adult women with a history of anorexia nervosa underwent a dual energy X-ray absorptiometry (DXA) scan and completed questionnaires regarding medication prescription and menstrual function.

RESULTS

Fifty percent of patients were expected to resume their menstrual function at a body mass index of 19 kg m^-2 or a fat percentage of 23%. Twenty-five percent of patients were expected to resume their menstrual function at body mass index 14 kg m^-2 or fat percentage 11%. Fat percentage and body mass index were equally capable of predicting the resumption of menses.

DISCUSSION

Fat percentage and body mass index were positive predictors of the resumption of menses, however, body composition measured by dual energy X-ray absorptiometry was not superior to body mass index in predicting menstrual recovery, which is of great clinical relevance as body mass index is easier and cheaper to obtain. Body composition measures only account for one of numerous factors involved in the resumption of menses. Regression models based on our data had a R² value of 0.14, indicating that only 14% of the variation in menstrual recovery could be explained by the variables included. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:370-377).

Patient- and clinician- reported outcome in eating disorders

Patient-reported outcome is increasingly applied in health sciences. Patients with eating disorders (EDs) characteristically have a different opinion of their needs to that of the health professionals, which can lead to ambivalence towards treatment and immense compliance difficulties. This cross-sectional study compared data assessed by the clinician to patient-reported measures in patients with a history of EDs. We included data from a cohort of patients with EDs (n=544) referred to a specialized ED unit in Denmark. Patient-reported measures included the Eating Disorder Inventory-2 (EDI-2) and the Short Form 36 (SF-36), and clinical data included remission status and body mass index (BMI). We found a positive association between BMI and EDI-2 scores for anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS), reflecting increasing ED symptomatology with increasing BMI. This association was not observed in bulimia nervosa (BN). We did not find a correlation between SF-36 scores and BMI in any of the diagnostic groups.