Outline. ED: the old and the new. Ea+ng Disorders and related behaviours in adolescence: results from popula+on-based studies

Transcription

1 Ea+ng Disorders and related behaviours in adolescence: results from popula+on-based studies Nadia Micali Dept. of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY US & Ins+tute of Child Health University College London London UK Outline ED and DSM-5 Epidemiology -ED -ED behaviours Three studies: -prevalence of ED -Correlates and adverse outcomes ED: the old and the new Anorexia Nervosa amenorrhea Bulimia Nervosa Minimum frequency: once a week Ea+ng Disorders not Otherwise specified -Binge Ea+ng Disorder Minimum frequency: once a week OSFED The Incidence of ED amongst females aged in the UK Micali et al.,

2 The Incidence of ED amongst males aged in the UK Incidence rates of ED in females by age-bands in 2009 IR per 100, " 160" 140" 120" 100" 80" 60" 40" 20" 0" 10(14" 15(19" 20(29" 30(39" 40(49" IR=1.7/1,000 AN" BN" EDNOS" ALL"ED" Micali et al., 2013 Age bands Prevalence of adolescent AN l US Na+onal Comorbidity Survey US adolescents aged years: life+me prevalence: 0.3%, 12-mo prevalence 0.2% (M=F) l Portugal: 0.4% in adolescent females (aged 12-23) l Finland: 2.2% adolescent girls aged (life+me) l Overall about 0.4-2% Prevalence of adolescent BN l US: life+me 0.9%; M= 0.5%; F=1.3% l Portugal: 0.3% in adolescent girls (aged 12-23) l Finland: 1.7% in females aged l Overall ~ 1-2% Swanson et al., 2011; Keski-Rakhonen et al., 2009, Machado et al., 2007 Swanson et al., 2011; Keski-Rakhonen et al., 2007, Machado et al.,

3 Prevalence of adolescent EDNOS l Portugal: 2.4% in adolescent females Ea+ng disorders behaviours in US adolescents l US: -BED: life+me 1.6%; M=0.8, F=2.3% l EDNOS most common ED: BED Swanson et al., 2011; Machado et al., 2007 Ackard et al., 2007 ED and ED behaviours in adolescence: prevalence, correlates and adverse outcomes ALSPAC and GUTS Field et al, Pediatrics, 2012 Field et al. JAMA Pediatrics, 2013 Micali et al, JAACAP,

4 Growing Up Today Study (GUTS) Established in 1996 Par+cipants are the offspring of women in the Nurses Health Study II (NHS II) 9039 girls and 7843 boys 9-15 years at baseline Follow-up Ques+onnaires were mailed annually un+l 2001, then biennially Non-responders are sent a reminder and/ or postcard, followed by a another ques+onnaire Children who do not respond aher these measures have been taken are sent an abbreviated survey Weight & Weight Concerns Self-reported weight and height collected on all surveys Weight concerns measured with the McKnight Risk Factor Survey (MRFS) Binge Ea+ng Binge ea+ng: at least monthly/weekly episodes of ea+ng a large amount of food AND feeling out of control during the episodes (LOC) Overea&ng: at least monthly/weekly episodes of ea&ng a large amount of food, but NOT feeling out of control during the episodes (no LOC) 4

5 Purging During the past year, did you make yourself throw up to lose weight or keep from gaining weight? During the past year, did you take laxa+ves to lose weight or keep from gaining weight? Ea+ng Disorder Classifica+on AN Underweight < 18 years Age-specific cut-off predic+ng BMI < 18.5 at age 18 > 18 years BMI < 18.5 High concerns with weight and shape Ea+ng Disorder Classifica+on BN Binge eat with loss of control > weekly (DSM-5) >monthly Purging > weekly (DSM-5) >monthly Ea+ng Disorder Classifica+on AN BN BED Binge eat with LOC > weekly > weekly (DSM-5) > monthly No or infrequent purging 5

6 Ea+ng Disorder Classifica+on AN BN BED Purging Disorder (PD) Purge > weekly > weekly (DSM-5) > monthly No or infrequent binge ea+ng Ea+ng Disorder Classifica+on AN BN BED Purging Disorder (PD) EDNOS Overeat, but no loss of control Binge weekly (DSM-IV)/monthly (DSM-5) Purge weekly (DSM-IV)/monthly (DSM-5) Age-specific prevalence of ea+ng disorders among girls in GUTS Age-specific prevalence of ea+ng disorders among girls in GUTS 5% 4% 3% 2% 1% 0% 9-12 yrs yrs yrs yrs yrs 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 9-12 yrs yrs yrs yrs yrs AN BN AN BN BED 6

7 Age-specific prevalence of ea+ng disorders among girls in GUTS Age-specific prevalence of ea+ng disorders among girls in GUTS 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 9-12 yrs yrs yrs yrs yrs AN BN BED Purging Disorder 25% 20% 15% 10% 5% 0% 9-12 yrs yrs yrs yrs yrs AN BN BED Purging Disorder EDNOS Methods All analyses restricted to 8594 females with follow-up data Lagged analysis Generalized es+ma+ng equa+ons with an independence working covariance Becoming overweight Age, BMI, die+ng Methods Star+ng to use drugs other than marijuana Star+ng to binge drink frequently Developing high depressive symptoms 7

8 Becoming overweight Methods Star+ng to use drugs Age, sib who used drugs, sib who was drinking < 21, friends who use drugs, adult who drinks, region Star+ng to binge drink Developing high depressive symptoms Methods Becoming overweight Star+ng to use drugs Star+ng to binge drink Age, sibling who used was drinking < 21, friends who use drugs, adult who drinks, region Developing high depressive symptoms Becoming overweight Star+ng to use drugs Star+ng to binge drink Methods Developing high depressive symptoms Age, BMI, depressive symptoms Ea+ng disorder subtypes predic+ng star+ng to use drugs OR (95% CI) Non-disordered 1.0 (referent) BN 3.9 ( ) 1 BED 0.5 ( ) PD 1.7 ( ) 1 EDNOS 1.5 ( ) 1: no change when using monthly cut-off 8

9 Ea+ng disorder subtypes predic+ng star+ng to binge drinking frequently Non-disordered BN (monthly cut-off) BED (monthly cut-off) PD (monthly cut-off) EDNOS (monthly cut-off) OR (95% CI) 1.0 (referent) 1.7 ( ) 2.59 ( ) 1.1 ( ) 1.42 ( ) 1.8 ( ) 1.75 ( ) 1.6 ( ) 1.40 ( ) Ea+ng disorder subtypes predic+ng becoming overweight or obese Non-disordered OR (95% CI) 1.0 (referent) BN 0.8 ( ) BED 1.8 ( ) PD (monthly cut-off) 1.0 ( ) 1.49 ( ) EDNOS 1.1 ( ) Ea+ng disorder subtypes predic+ng developing high depressive symptoms Non-disordered OR (95% CI) 1.0 (referent) BN 0.4 ( ) BED (monthly cut-off) 2.3 ( ) 1.77 ( ) PD 1.2 ( ) EDNOS 1.3 ( ) Conclusions Fewer EDNOS cases with DSM-5, but s+ll the largest group AN and BN are the least common disorders BED looks different than other ea+ng disorders: prospec+ve associa+on with depressive sx, overweight/obesity PD looks like BN, should it be combined? 9

10 Sample-Avon Longitudinal Study of Parents and Children (ALSPAC) -General popula+on sample of ~14,000 women recruited in pregnancy and their children -Cohort members have been followed up regularly Qs sent 6,140 (58%) adolescents responded at age 14 years 5,069 (52%) at age 16 years Sample Qs have also been regularly mailed to parents ED symptoms Age 14/16 yrs Weight & shape concern: 3 Qs from the McKnight Risk Factor Survey ED behaviours: Ques+ons about purging, binge ea+ng, fas+ng, excessive exercise derived from the Youth Risk Behavior Surveillance System ques+onnaire enquiring about the previous year BMI (age- and gender-adjusted) Objec+ve weight and height 10

11 ED symptoms Age 14/16 yrs-parental report Parents completed the Developmental and Well-being Assessment (DAWBA)-ED sec+on Sensi+vity analyses showed binge ea+ng and purging not overlapping with youth report Parental report used for AN diagnosis ED diagnoses AN: Objec+ve underweight and food restric+on/ fas+ng/excessive exercise and shape and weight concern BN: Binge ea+ng and purging once/week BED: Binge ea+ng once/week and at least 3 cogni+ve symptoms (ea+ng fast or faster than normal; ea+ng un+l stomach hurt or they felt sick, ea+ng large amounts when not hungry, ea+ng alone, feeling guilty about amount eaten) ED diagnoses-osfed PD: Purging once/week Subthreshold BN (S-BN): Binge ea+ng and purging once/month Subthreshold BED (S-BED): Binge ea+ng once/month and cogni+ve symptoms OSFED-other1: Monthly binge ea+ng/ purging/ excessive exercising or fas+ng OSFED-other2: < Monthly binge ea+ng/ purging/ excessive exercise or fas+ng ED behaviours Any frequency: -Excessive exercise: exercising for weight loss or to avoid weight gain AND exercising even when injured or sick or impact on school work due to the amount of +me spent exercising; -Purging: self-induced vomi+ng, laxa+ve use or other medicines for weight loss or to avoid weight gain -Fas+ng for weight loss or to avoid weight-gain 11

12 Outcomes Obtained via Qs or structured interviews at age 15.5/16 AND 17.5/18 Depression: -Short Moods & Feelings ques+onnaire (smfq) Drug use (any): -Specific Qs (ecstasy, amphetamines, crack/cocaine, opiates, seda+ves, hallucinogens, solvents, other) Alcohol (binge drinking): -Alcohol Use Disorders Iden+fica+on Test (AUDIT) Anxiety disorder (past 6 months): -Developmental and wellbeing assessment (DAWBA) Deliberate Self-Harm -Past month (DAWBA) at 15.5; -past year (CIS-R) at 17.5 Weight Objec+vely measured at 15.5 and 17.5 years of age WHO age and gender adjusted BMI cut offs for underweight (18.5), overweight (25) and obesity (30) based on UK reference charts as per Cole et al. 2000, 2007 Underweight Overweight Obesity Methods GEE models to inves+gate prospec+ve associa+ons of ED with lagged outcomescrude and adjusted MI by chained equa+ons used to impute missing covariate data All analyses adjusted for wave of assessment, gender, maternal educa+on, maternal parity Addi+onal adjustment for presence of outcome disorder at previous wave ED prevalence (14 years) (n=6,140) All (n=6,140) Girls (n=3,416) Boys (n=2,742) AN 153 (2.48%) 109 (3.19%) 44 (1.60%) BN 16 (0.26%) 14 (0.41%) 2 (0.07%) BED 30 (0.50%) 21 (0.61%) 9 (0.33%) OSFED PD 26 (0.42%) 21 (0.61%) 5 (0.18%) Subthreshold BN 82 (1.33%) 58 (1.70%) 24 (0.88%) Subthreshold BED 2 (0.03%) 1 (0.03%) 1 (0.04%) OSFED-other (7.52%) 380 (11.12%) 83 (3.03%) OSFED-other (6.40%) 240 (7.03%) 154 (5.62%) ALL ED 1,166 (18.95%) 844 (24.70%) 322 (11.74%) ALL ED (excluding OSFED-other) 160 (5.03%) 224 (6.55%) 85 (3.09%) 12

13 ED prevalence (16 years) (n=5,069) All (n=5,069) Girls (n=3,059) Boys (n=2,154) AN 91 (1.75%) 72 (2.35%) 19 (0.88%) BN 42 (0.81%) 41 (1.34%) 1 (0.05%) BED 60 (1.15%) 47 (1.54%) 13 (0.60%) OSFED PD 80 (1.53%) 75 (2.45%) 5 (0.23%) Subthreshold BN 168 (3.22%) 137 (4.48%) 31 (1.44%) Subthreshold BED 22 (0.42%) 22 (0.72%) 0 OSFED-other (12.07%) 465 (15.20%) 164 (7.61%) OSFED-other (15.92%) 656 (21.44%) 174 (8.08%) ALL ED 1,922(36.87%) 1,515 (49.52%) 407 (18.89%) ALL ED (excluding OSFED-other) 463 (9.13%) 394 (12.88%) 69 (3.20%) Adjusted odds ra+os (95% Confidence intervals) for Depression AN * BN * * BED *: p 0.05, :p 0.001, *: p PD S-T BN S-T BED OSFED-Other1 * * OSFED-Other2 Adjusted odds ra+os (95% Confidence intervals) for Anxiety * * * 5 0 AN BN BED *: p 0.05, :p 0.001, *: p PD * * * S-T BN S-T BED OSFED-Other1 OSFED-Other2 Adjusted odds ra+os (95% Confidence intervals) for Drug use 30 * * 5 * 0 AN BN BED *: p 0.05, :p 0.001, *: p PD S-T BN S-T BED OSFED-Other1 OSFED-Other2 13

14 Adjusted odds ra+os (95% Confidence intervals) for DSH AN BN * BED PD * S-T BN S-T BED * OSFED-Other1 * OSFED-Other2 Weight outcomes AN predicted underweight at the following wave: adjusted OR=2.43 ( ), p BED predicted obesity OR=3.58 ( ), p=0.04 BN predicted overweight & obesity OR=3.43 ( ) OSFED 1 and 2 both predicted overweight and obesity respec+vely OR=1.80 ( ) OR=1.74 ( ) *: p 0.05, :p 0.001, *: p Summary I Specific associa&on pa`erns: -binge/purge disorders associated with later drug use -strong associa+on between ED and DSH, driven by purging? -all ED with depression and anxiety Underweight in AN persistent BED and BN and OSFED-other associated with obesity/overweight Summary II Low behaviour frequency OSFED and higher behaviour frequency OSFED similarly associated with adverse outcomes Preven+ng more common ED behaviours likely to impact a large part of the popula+on Are current diagnos+c frequency thresholds jus+fied? 14

15 Conclusions ED and disordered ea+ng are common in the general popula+on Sub-threshold disorders are associated with adverse outcomes Need to be aware of presenta+ons in boys and girls Dr Alison Field Dr Nicholas Horton Dr Ross Crosby Prof Janet Treasure Francesca Solmi Sonja Swanson Acknowledgements All ALSPAC par+cipants All GUTS par+cipants R01-MH THANK YOU! 15