Section of Eating Disorders, Institute of Psychiatry and Mental Health Department, St George's Hospital Medical School, London
Section of Eating Disorders, Institute of Psychiatry
Section of Eating Disorders, Institute of Psychiatry and Guy's, King's and St Thomas's Medical School, London, UK
Boston University School of Medicine, Boston, Massachusetts, USA
Correspondence: Laura Currin, Section of Eating Disorders, Box 059, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Tel: +44 (0)20 7848 0367; fax: +44 (0)20 7848 0182; e-mail: l.currin{at}iop.kcl.ac.uk
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ABSTRACT |
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Aims To determine whether the incidence of anorexia nervosa remained stable, and that of bulimia nervosa continued to increase, in the years 1994-2000.
Method The General Practice Research Database was screened for new cases of anorexia and bulimia nervosa between 1994 and 2000. Annual incidence rates were calculated for females aged 10-39 years and compared with rates from the previous 5 years.
Results In 2000 primary care incidence rates were 4.7 and 6.6 per 100 000 population for anorexia and bulimia nervosa, respectively. The incidence of anorexia nervosa remained remarkably consistent over the period studied. Overall there was an increase in the incidence of bulimia, but rates declined after a peak in 1996.
Conclusions This study provides further evidence for the stability of anorexia nervosa incidence rates. Decreased symptom recognition and changes in service use might have contributed to observed changes in the incidence of bulimia nervosa.
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INTRODUCTION |
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METHOD |
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The GPRD was searched for first-time diagnoses of anorexia and bulimia nervosa made between 1 January 1994 and 31 December 2000. Annual incidence rates were calculated for women aged 10-39 years. This cohort represents the vast majority of registered cases, and was the group considered in the previous study (Turnbull et al, 1996). Incidence rates were calculated by dividing the number of eating disorder cases diagnosed annually by the total number of people in this age group registered with a general practitioner (GP) in that year. These annual incidence rates were then compared with figures collected using an identical method from the years 1988-1993 (Turnbull et al, 1996). In addition, incidence for the total population was calculated for the year 2000, and stratified by age group and gender.
During the period studied there have been changes to the formal diagnostic criteria for bulimia nervosa. However, the GPRD uses general practitioner rather than psychiatric diagnoses, minimising the effect of these changes. In addition, concurrent notes and referral letters for cases from the year of peak incidence were compared with those from the most recent year available to determine whether there had been changes in diagnostic habits.
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RESULTS |
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The results for bulimia nervosa are very different. As demonstrated by Turnbull et al (1996), the early 1990s showed a marked increase in primary care incidence for women aged 10-39 years which continued until 1996. Although there was an overall increase in reported cases of bulimia nervosa from 1988-2000, the incidence rate has fallen by 38.9% since this peak (Fig. 1). In 2000 the age- and gender-adjusted incidence of bulimia nervosa in primary care was 6.6 per 100 000 (95% CI 5.3-7.9). The incidence rate for females was 12.4 per 100 000 (9.9-14.9) compared with 0.7 per 100 000 (95% CI 0.1-1.3) for males. This represents a relative risk for females to males of approximately 18:1. The highest incidence, 35.8 per 100 000 (95% CI 23.0-48.6), was in females aged 10-19 years.
To control for the changing criteria applied to bulimia nervosa, diagnostic
validity was analysed in a subgroup of cases randomly selected from the years
1996 (n=26) and 2000 (n=19). There are considerable
difficulties associated with a retrospective validation of diagnoses owing to
the limited information available. Cases were defined as probable
bulimia nervosa if all but one of the DSM-IV criteria
(American Psychiatric Association,
1994) were mentioned in the case history. Seventeen of the cases
(37.3%) had insufficient information available to validate diagnoses. Of the
remaining cases, a similar proportion of cases in 1996 and 2000 were either
full or probable bulimia nervosa (82.3% and 81.8%,
respectively). It is important to note that all of the remaining cases were
considered to be eating disorder cases (either not otherwise
specified or anorexia
nervosa).
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DISCUSSION |
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CONTEXT OF FINDINGS |
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A major strength of our study is the use of a nationally representative primary care database. Because of the structure of the UK health system most patients will pass through the care of a GP, even if later referred to specialist services. Additionally, 20% of patients with anorexia nervosa and 40% of patients with bulimia nervosa are treated exclusively in primary care (Turnbull et al, 1996). Moreover, time trends were assessed using the same method over the entire study period, rather than depending on meta-analysis. However, the use of a primary care database is itself a limitation, in that the reported figures represent clinically meaningful cases rather than those meeting DSM-IV criteria. This parallels the picture seen in other studies of clinical cases. Several specialist services consistently report that the most common diagnosis is eating disorders not otherwise specified, and these cases are no less severe in presentation or illness duration than those meeting full diagnostic criteria (Millar, 1998; Ricca et al, 2001; Fairburn & Harrison, 2003; Turner & Bryant-Waugh, 2004). A second limitation is that only those identified by their GP are reported in this study; therefore, this study cannot estimate the true community incidence of these disorders. This limitation is shared by all epidemiological studies that use service registers.
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CHANGES IN BULIMIA NERVOSA |
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Intense UK press coverage of bulimia during the 1990s might also have contributed to the apparent rise in incidence. For example, the first reports of Princess Diana's battle with bulimia appeared in Andrew Morton's 1992 book Diana: Her True Story (Morton, 1992), and subsequent media interest might have focused attention on bulimic symptoms and improved public awareness of the disorder. It is notable that the Princess's death in 1997 coincided with the beginning of the decline in bulimia incidence. Greater familiarity has been implicated in the increased incidence of other diseases, including autism and repetitive strain injury (Brogmus et al, 1996; Kaye et al, 2001). Identification with a public figure's struggle with bulimia might have temporarily decreased the shame associated with the illness, and encouraged women to seek help for the first time. This would suggest that some of the 1990s peak might have been caused by the identification of long-standing cases, rather than a true increase in community incidence. The finding that the recent decline is largely due to a reduction in incidence in the older group (women aged 20-39 years) supports this conclusion.
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FUTURE WORK |
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Received for publication June 23, 2004. Accepted for publication September 3, 2004.
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