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The Prevalence of Preadolescent Eating Disorders in the United States

Open AccessPublished:January 22, 2022DOI:https://doi.org/10.1016/j.jadohealth.2021.11.031

      Abstract

      Purpose

      The prevalence of eating disorders (EDs) in young children remains relatively unknown. Here, we aimed to assess the prevalence of anorexia nervosa (AN), bulimia nervosa (BN), binge ED (BED), and their subclinical derivatives, among 10- to 11-year-old children in the United States.

      Methods

      Cross-sectional data from the year 1 sample of the nationwide Adolescent Cognitive Brain Development study were extracted, and unadjusted prevalence of EDs was reported, as per DSM-5 criteria.

      Results

      Among 10- to 11-year-old children in the United States, no cases of AN were reported. The prevalence of BN was negligible, whereas the prevalence of BED was 1.1%. The prevalence of subclinical AN, BN, and BED was 6%, 0.2%, and 0.5%, respectively.

      Discussion

      BED is the most prevalent ED subtype among preadolescent children in the United States, although subclinical markers for all ED subtypes are evident in this age range.

      Keywords

      Implications and Contribution
      This study suggests that full threshold eating disorders are relatively uncommon among 10- to 11-year-olds in the United States. Of all eating disorder phenotypes, binge eating disorder is the most prevalent. Subclinical eating disorders are more common, where some but not all diagnostic criteria are met.
      Eating disorders (EDs) are a constellation of burdensome, costly, and treatment refractory psychiatric disorders which portend elevated mortality and morbidity [
      • Santomauro D.F.
      • Melen S.
      • Mitchison D.
      • et al.
      The hidden burden of eating disorders: An extension of estimates from the Global Burden of Disease Study 2019.
      ]. Although most commonly developing in mid-adolescence, the prevalence of EDs in younger children has remained largely unknown. This is a particularly important concern given the greater prognosis afforded by early detection and intervention [
      • Curin L.
      • Schmidt U.
      A critical analysis of the utility of an early intervention approach in the eating disorders.
      ], with those treated within 3 years of illness onset showing a three-fold greater likelihood of weight normalization within 12 months [
      • McClelland J.
      • Hodsoll J.
      • Brown A.
      • et al.
      A pilot evaluation of a novel first episode and rapid early intervention service for eating disorders (FREED).
      ], and the noted elevation in psychiatric and medical morbidity in younger patients with EDs [
      • Campbell K.
      • Peebles R.
      Eating disorders in children and adolescents: State of the art review.
      ]. To date, one nationally representative study in the United States reported the prevalence of EDs to be 0.1% in children aged 8–11 years of age [
      • Merikangas K.R.
      • He J.P.
      • Brody D.
      • et al.
      Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES.
      ], although crucially, this study reflected DSM-IV diagnostic criteria, and did not delineate prevalence trends by ED subtype. A recent study reporting on the first wave of the Adolescent Brain Cognitive Development (ABCD) study reported the prevalence of EDs, delineated by subtype, in 9- to 10-year-old children, reporting prevalence rates of 0.1% for anorexia nervosa (AN), 0.0% for bulimia nervosa (BN), 0.6% for binge ED (BED), and 0.6% for other specified feeding and EDs [
      • Rozzell K.
      • Moon D.Y.
      • Klimek P.
      • et al.
      Prevalence of eating disorders among US children aged 9 to 10 years: Data from the Adolescent Brain Cognitive Development (ABCD) study.
      ]. However, these findings were based on a fraction (approximately a third) of the baseline sample of the ABCD data set. This study aims to build on previous findings and report ED prevalence estimates (delineated by subtype and as per DSM-5 criteria [
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ]) and the bodyweight of those afflicted, from the entire year 1 sample (ages 10–11 years) of the nationwide ABCD study.

      Methods

      Cross-sectional data of children aged 10–11 years from the ABCD Study, a large, diverse, population-based sample, at year 1 (2017–2019, release 3.0) were analyzed in 2021. Institutional review board approval was obtained from the University of California, San Diego, and at each study site (N = 21), and caregivers provided written informed consent. ED diagnosis was determined using parent/caregiver responses to the computerized Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5), based on DSM-5 criteria [
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ], and subclinical EDs were determined by the presence of some but not all diagnostic criteria for AN, BN, and BED (Table 1). Unadjusted prevalence of EDs was estimated. Analyses were conducted using Stata 15.1, incorporating propensity weights, which matched key sociodemographic ABCD study variables to those of the American Community Survey, which is a large probability sample of US households. Although not designed to be nationally representative, the use of propensity weights allows for results to be closely matched to the US population of 10- to 11-year-olds [
      • Heeringa S.G.
      • Berglund P.A.
      A guide for population-based analysis of the Adolescent Brain Cognitive Development (ABCD) study baseline data. bioRxiv.
      ]. Results are based on this weighted sample [
      • Heeringa S.G.
      • Berglund P.A.
      A guide for population-based analysis of the Adolescent Brain Cognitive Development (ABCD) study baseline data. bioRxiv.
      ].
      Table 1An overview of the criteria used to determine eating disorder classifications
      Eating disorderDiagnostic criteria
      Anorexia nervosa (AN) (binge eating/purging subtype)• Fear surrounding becoming obese
      • Emaciation
       ○ <Fifth percentile of the BMI for age and sex
      • Sense of self-worth connected to weight
      • Use of weight control vomiting or other weight control methods or eating binges in the last 2 weeks
      Anorexia nervosa (AN) (restricting subtype)• Fear surrounding becoming obese
      • Emaciation
      • Sense of self-worth connected to weight
      • Absence of use of weight control vomiting or other weight control methods or eating binges in the last 2 weeks
      Bulimia nervosa (BN)• Presence of binge eating episodes
      • Use of weight control vomiting or other weight control methods in the last 2 weeks
      • Frequent use of weight control methods in the last 12 weeks
      • Frequent binge eating episodes in the last 12 weeks
      • Sense of self-worth connected to weight
      Binge eating disorder (BED)• Presence of eating binges
      • Frequent binge eating episodes
      • Duration over the last 12 weeks
      • Feelings of distress surrounding binge eating
      • Absence of compensatory behaviors
      • Absence of BN or AN diagnosis
      Other specified feeding or eating disorder (subclinical AN)• Presence of emaciation AND absence of current AN or current AN in partial remission
       ○ Applies only if fear of becoming obese and sense of self-worth connected to weight are absent
      OR
      • Presence of fear surrounding becoming obese, presence of sense of self-worth connected to weight, presence of emaciation (no more than 1 BMI point over cutoff) AND absence of current AN or current AN in partial remission
      Other specified feeding or eating disorder (subclinical BN)• Presence of eating binges
      • Presence of weight control methods
      • Sense of self-worth connected to weight
      • Absence of diagnosis for current AN, current AN in partial remission, current BN, current BN in partial remission
      Other specified feeding or eating disorder (subclinical BED)• Presence of eating binges
      • Frequent binge eating episodes
      • Presence of at least 1 of characteristics of binge eating
      • Feelings of distress surrounding binge eating
      • Absence of diagnosis for any other current eating disorder
      BMI = body mass index.

      Results

      Among the sample of 11,082 10- to 11-year-old children, 51.3% were boys. The sample was racially and ethnically diverse (53.9% non-Hispanic White, 19.5% Hispanic, 16.5% non-Hispanic Black, 5.6% non-Hispanic Asian/Pacific Islander, 3.2% Native American, and 1.4% other race/ethnicity). No cases of AN were present in this sample. The prevalence of BN was negligible. The prevalence of BED was 1.1% overall (1.2% in boys and 1.0% in girls) (Table 2). Among children with BED, the mean body mass index was 26.5 (standard deviation 5.5) kg/m2 and the mean body mass index percentile was 92.1 (standard deviation 14.3).
      Table 2Prevalence of eating disorders among 11,082 10- to 11-year-old US children in the Adolescent Brain Cognitive Development study
      CountPopulation countPrevalence95% CIAdjusted F
      The adjusted F statistic is a variant of the second-order Rao-Scott adjusted chi-square statistic.
      p value
      Anorexia nervosa
       Total000.0%------
       Boys000.0%--
       Girls000.0%--
      Bulimia nervosa
       Total62,8260.0%0.0%–0.0%0.46.50
       Boys31,0520.0%0.0%–0.0%
       Girls31,7740.0%0.0%–0.2%
      Binge-eating disorder
       Total10582,1521.1%0.9%–1.3%0.47.49
       Boys6044,8291.2%0.9%–1.5%
       Girls4537,3231.0%0.7%–1.4%
      Other specified feeding and eating disorder: anorexia nervosa
       Total728475,0646.3%5.8%–6.8%1.00.32
       Boys392253,7006.5%5.8%–7.3%
       Girls336221,3646.0%5.3%–6.8%
      Other specified feeding and eating disorder: bulimia nervosa
       Total2015,9600.2%0.1%–0.3%0.16.69
       Boys108,9500.2%0.1%–0.5%
       Girls107,0100.2%0.1%–0.4%
      Other specified feeding and eating disorder: binge-eating disorder
       Total6047,0390.6%0.5%–0.8%0.06.81
       Boys3324,9030.6%0.4%–0.9%
       Girls2722,1360.6%0.4%–0.9%
      ABCD propensity weights were applied based on the American Community Survey from the US Census.
      CI = confidence interval.
      a The adjusted F statistic is a variant of the second-order Rao-Scott adjusted chi-square statistic.
      The prevalence of subclinical BN was marginally greater than full threshold prevalence, at 0.2% in boys and girls. In contrast, the prevalence of subclinical BED was marginally less than that of full threshold presentations, at 0.6% in boys and girls. The prevalence of subclinical AN was substantially greater than that of full threshold presentations, at 6.5% in boys and 6% in girls.

      Discussion

      Among 10- to 11-year-old children in the United States, BED is the most prevalent full threshold ED subtype. Broader evidence relating to the onset of EDs suggests that BED most commonly onsets in young adulthood [
      • Kessler R.C.
      • Berglund P.A.
      • Chiu W.T.
      • et al.
      The prevalence and correlates of binge eating disorder in the world health organization world mental health surveys.
      ]—the latest among all ED phenotypes—although our findings indicate that BED is evident in children as young as 10 years of age. One potential source of the discrepancy between our findings and broader epidemiological findings may relate to the inclusion of parental reports in arriving at diagnoses. A diagnosis of BED rests on an adequate understanding of complex cognitive processes, such as what constitutes a loss of control, and an adequate appraisal as to what represents an ‘abnormally large volume of food’ [
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ]. To that end, the inclusion of parental reports in informing diagnoses in the present study may facilitate an earlier detection of BED, given the abstract concepts involved in diagnosis.
      Notably, and despite being linked the subsequent development of obesity and cardiometabolic complications in adulthood [
      • Mitchell J.E.
      Medical comorbidity and medical complications associated with binge-eating disorder.
      ], our data indicate that even at 10–11 years of age, BED is most prevalent among overweight and obese children. These data serve to underscore the importance of early screening for BED, and may potentially augment efforts to curb pediatric obesity, and related sequelae, throughout later adolescence. In keeping with previous findings from earlier waves of the ABCD study [
      • Rozzell K.
      • Moon D.Y.
      • Klimek P.
      • et al.
      Prevalence of eating disorders among US children aged 9 to 10 years: Data from the Adolescent Brain Cognitive Development (ABCD) study.
      ], we note that the prevalence of EDs is not skewed toward females, as has been widely reported in the ED field [
      • Murray S.B.
      • Nagata J.M.
      • Griffiths S.
      • et al.
      The enigma of male eating disorders: A critical review and synthesis.
      ]. Cumulatively, these findings illustrate that screening for EDs in children, and for BED in particular, ought to extend to all genders and include parental observations of child behavior.
      The prevalence of subclinical ED presentations is noteworthy. Data relating to BN and BED suggest that subclinical markers may be evident in children as young as 10–11 years of age and in boys and girls alike. In the context of AN, these data suggest that subclinical markers may be substantially greater than the prevalence of full threshold diagnoses. However, the determination of subclinical AN in this data set may (i) include those with low weight status without the cognitive markers of AN, and the extent to which this conflates subclinical AN with constitutionally thin yet nonpathological children is unclear, and (ii) exclude those with atypical AN whose weight is above the fifth percentile. Nevertheless, this greater preponderance of subclinical markers of AN in boys discords with literature suggesting a greater prevalence of AN in girls and women, and data suggesting a heightened preference for muscular body types in young boys [
      • Murray S.B.
      • Nagata J.M.
      • Griffiths S.
      • et al.
      The enigma of male eating disorders: A critical review and synthesis.
      ], and warrants further investigation.
      Limitations of our study include the inability to assess other ED subtypes, some of which are known to onset earlier than other ED phenotypes (e.g., avoidant and restrictive food intake disorder), and the noted ambiguities around the prevalence of subclinical ED behaviors in this age group.

      Funding Sources

      S.B.M. was supported by the National Institutes of Health (K23 MH115184). J.M.N. was supported by the National Institutes of Health (K08HL159350) and the American Heart Association Career Development Award (CDA34760281). Data used in the preparation of this article were obtained from the ABCD Study (https://abcdstudy.org), held in the NIMH Data Archive (NDA). This is a multisite, longitudinal study designed to recruit more than 10,000 children aged 9–10 years and follow them over 10 years into early adulthood. The ABCD Study was supported by the National Institutes of Health and additional federal partners under award numbers U01DA041022, U01DA041025, U01DA041028, U01DA041048, U01DA041089, U01DA041093, U01DA041106, U01DA041117, U01DA041120, U01DA041134, U01DA041148, U01DA041156, U01DA041174, U24DA041123, and U24DA041147. A full list of supporters is available at https://abcdstudy.org/nihcollaborators. A listing of participating sites and a complete listing of the study investigators can be found at https://abcdstudy.org/principal-investigators.html. ABCD consortium investigators designed and implemented the study and/or provided data but did not necessarily participate in analysis or writing of this report.

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