January 17, 2017

expert reaction to eating disorders in middle-aged women

A population-based study published in BMC Medicine has examined lifetime and 12-month prevalence of eating disorders (ED) among women in mid-life. It reported that a significant proportion of women will experience an ED by mid-life.

Dr Agnes Ayton, Vice Chair of the Faculty of Eating Disorders, Royal College of Psychiatrists, said:

“This is an important paper, which has several methodological strengths: it is population-based (rather than only including people who seek contact with health care, which is always the tip of the iceberg). It has used reliable assessment of the eating disorder, by interviewing with validated instruments, rather than relying on self-report. It was also able to identify risk factors, which were collected many years ago as part of the AVON Longitudinal Study, therefore avoiding recall bias.

“It demonstrates that the rates of eating disorders amongst middle age women are higher than it was thought, and that significant proportions of these people are unknown to services – so there is a large unmet need.

“The numbers are surprising, as most of the research has focused on adolescents and younger adults. However, they are not entirely unpredictable, as previous population-based studies have also shown that a large proportion of patients with eating disorders don’t seek help.

“The peak onset of eating disorders is around the age of 14-16 and this was documented in dr Micali’s previous work using the GP database (http://bmjopen.bmj.com/content/bmjopen/3/5/e002646.full.pdf). However, the numbers in the two studies are not entirely comparable for two reasons: 1. the GP database only includes people who have a diagnosed eating disorder; 2.the diagnostic criteria have changed since with the introduction of DSM-5. For example, the new diagnostic criteria for anorexia nervosa reflects the World Health Organisation categories of malnutrition (for adults, BMI<18.5 as opposed to previously BMI<17.5). This is important, as the previous anorexia diagnostic criteria were too narrow, excluding patients with the relevant psychopathology on the basis that their BMI was above 17.5 (many patients misinterpreted this as ‘too fat’).

“There is an implication on service provision, identifying significant unmet need: adult eating disorder services are very poorly resourced in the country, there are long waiting lists, due to insufficient staffing, which may contribute to people not seeking help. This is a shame, as evidence-based psychological treatment, such as Cognitive Behavioural Therapy for Eating disorders would be helpful for about two thirds of the patients. The strengthening of eating disorder services was included in the Chief Medical Officer’s report on Women’s Health (https://www.gov.uk/government/publications/chief-medical-officer-annual-report-2014-womens-health). This can only be achieved by investment into these services, as the treatment takes 20-40 sessions over 20-40 weeks. There is research into internet-based therapies, but that would only be sufficient for people with milder problems.

“One important shortcoming of this study is that it does not cover older women. In our experience, there are also patients with severe eating disorders amongst older adults (>65 years). The current draft NICE guidance has omitted this patient population, and is mainly focusing on younger people (https://www.nice.org.uk/guidance/indevelopment/GID-CGWAVE0703/consultation/html-content).

“Further research is needed to explore childhood risk factors such as sexual abuse and parenting in the future, taking into account potential genetic factors (which was not part of this study).”

Prof. Christopher Fairburn, Professor of Psychiatry, University of Oxford, said:

“This is a novel study with good methods and a large sample population. The researchers have done a good job, however, it is particularly difficult to use interviews to retrospectively diagnose people. Essentially you’re asking people about how they felt or behaved 10, 20 or 30 years ago and then using a series of criteria to determine whether they would have had a certain diagnosis at that time. Retrospective diagnoses can be accurate if the feature being assessed is unambiguous such as being extremely underweight or repeatedly making oneself vomit, but they are prone to overdiagnose conditions.

“The authors worked out that about 15% of middle-aged women have had an eating disorder at some point in their lives, 3.6% having had one in the past 12 months. If one focuses solely on those diagnoses one can be confident about, it still looks as though about 9% of all middle-aged women have had an eating disorder at some point in their life and that 1.9% of middle-aged women have met diagnostic criteria for one in the past 12 months. These are really high figures and are important – there really aren’t any other studies of this quality and size looking at this age span, which is why we haven’t seen this before.

“We also see from this study that very few of these women have had treatment. We knew this for teenagers but this is the first data we’ve seen across this wide age group. These women should know that a large proportion of them can be helped and that they are not alone or unusual in having an eating problem in middle age. They shouldn’t feel weird. 40-50% of women with anorexia can be cured completely – and the cure rate is as high as 60-70% in women with bulimia nervosa or binge eating disorder. So there really should be more publicity about this. GPs should be on the lookout and women should be told about this so that they can choose to seek help and know that there are treatments that can help them.”

* ‘Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors’ by Micali et al. published in BMC Medicine on Tuesday 17^th January.

Declared interests

Dr Ayton: “I don’t have any conflict of interest”

Prof. Fairburn: “None to declare”