Elsevier

The Lancet

Volume 375, Issue 9714, 13–19 February 2010, Pages 583-593
The Lancet

Seminar
Eating disorders

https://doi.org/10.1016/S0140-6736(09)61748-7Get rights and content

Summary

This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

Introduction

This Seminar adds to the previous Lancet Seminar about eating disorders, which was published in 2003.1 We provide a concise review of eating disorders in young people, focusing on factors of particular relevance to the clinician such as diagnosis, epidemiology, pathogenesis, treatment, and prognosis. In this Seminar we draw attention to biological factors that could contribute to new interventions. Eating disorders also occur in prepubertal children, but studies in this age group are scarce and there is no consensus about either diagnosis or treatment.

Section snippets

Classification and diagnosis

Diagnosis is challenging because diagnostic symptoms and associated behaviours substantially overlap across the range of eating disorders. For example, extreme dietary restraint, binge eating, and overvalued ideas about weight and shape can be present in all forms of eating disorder. Additionally, the subjective interpretation and justification behind diagnostic behaviours is often not clear or is limited by developmental constraints (as in childhood anorexia nervosa), further complicating

Psychiatric comorbidity

Comorbidity is the rule rather than the exception for patients with eating disorders.19, 20 Developmental disorders (eg, those of the autistic spectrum and attention-deficit hyperactivity disorder) have been reported to affect about a fifth of patients with anorexia nervosa.21, 22 Moreover, a small proportion of adults with attention-deficit hyperactivity disorder have additional symptoms of eating disorders.23 Obsessive compulsive traits24, 25 or disorder,26 and anxiety disorders27, 28 and

Epidemiology

Eating disorders and related behaviours are common in young people. Investigators of a study of a large sample of American children aged 9–14 years reported that 7·1% of boys and 13·4% of girls displayed disordered eating behaviours.35 The pivotal effect on health has led to the inclusion of eating disorders among the priority mental illnesses for children and adolescents identified by WHO.36 Eating disorders have been reported worldwide both in developed regions and emerging economies such as

Pathogenesis

A comprehensive review published in 2004 summarised the risk factors for eating disorders,39 and a position paper from the Academy of Eating Disorders outlined the evidence supporting these diseases as biologically-based forms of severe mental illnesses.40 In this section we draw attention to some present areas of emphasis.

Medical complications

Although eating disorders can begin in adulthood, the highest incidence is between 10 and 19 years of age,79 potentially disrupting optimum growth and development. Most pathophysiological complications are reversible with improved nutritional status or remittance of abnormal eating and purging behaviours. However, some physical consequences can be life-threatening, such as electrolyte imbalances (eg, hypokalaemia) due to excessive vomiting or laxative and diuretic misuse. Additionally,

Prognosis

Recovery from anorexia nervosa becomes much less likely the longer that the illness has persisted. This finding contrasts with that of bulimia nervosa, for which the chance of recovery becomes higher the longer the illness duration.147 A systematic review148 has compiled data for all outcomes for eating disorders and reported an increased mortality rate for anorexia nervosa (the reported range is wide, varying with case mix and length of follow-up) and persistent psychiatric problems in many

Conclusions

This Seminar has attempted to synthesise new developments in eating disorders that have arisen since the previous Lancet Seminar, and to integrate these developments into the knowledge that is relevant for clinicians. The diagnostic criteria for anorexia nervosa and bulimia nervosa are under consideration and could be broadened in DSM-V, reducing the size of the population in the category for eating disorders not otherwise specified. Binge eating disorders will probably be accepted as an

Search strategy and selection criteria

We searched the Cochrane Library, Medline, and Embase up to March, 2009. We used the search terms: “anorexia nervosa”, “bulimia nervosa”, “binge eating disorder”, and “eating disorders” in combination with the terms “treatment”, “biology”, “outcome”, “epidemiology”, “comorbidity”, “personality”, “osteoporosis”, “medical”, “neuropsychology”, “neuroimaging”, “psychotherapy”, and “pharmacotherapy”. We manually searched the main eating disorder specialist journals and reference lists of

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