Prevalence and Correlates of Eating Disorders in Adolescents: Results From the National Comorbidity Survey Replication Adolescent Supplement

Among adolescents with 12-month binge-eating disorder, 8.7% reported severe impairment.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

The median age at onset of subthreshold binge-eating disorder was 12.6 years.

“The median ages at onset of AN, BN, BED, and SBED were 12.3, 12.4, 12.6, and 12.6 years, respectively.”

Non-Hispanic white adolescents tended to report more anorexia nervosa.

“Significant ethnic differences emerged for BN, with Hispanic adolescents reporting the highest prevalence; there was a trend toward ethnic minorities reporting more BED, while non-Hispanic white adolescents tended to report more AN.”

The 12-month prevalence of bulimia nervosa among US adolescents was 0.6%.

“The 12-month prevalence rates of AN, BN, BED, and SBED were 0.2%, 0.6%, 0.9%, and 1.1%, respectively, with 12-month to lifetime prevalence ratios of 57.9%, 72.0%, 56.0%, and 44.5%, respectively.”

The adjusted odds ratio for comorbid disorders was 8.6 (95% CI, 2.7-27.3) for bulimia nervosa.

“The adjusted odds ratios (95% confidence intervals) for comorbid disorders by eating disorder subtype were 1.5 (0.54.4) for AN, 8.6 (2.7–27.3) for BN, 5.9 (2.5–13.8) for BED, 4.3 (2.0–8.8) for SAN, and 2.7 (1.8–4.1) for SBED.”

Among adolescents with 12-month bulimia nervosa, 78.0% reported impairment in the past 12 months.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

The lifetime prevalence of subthreshold binge-eating disorder among US adolescents was 2.5%.

“Lifetime prevalence rates of AN, BN, BED, SAN, and SBED were 0.3%, 0.9%, 1.6%, 0.8%, and 2.5%, respectively (Table 1).”

Significant ethnic differences emerged for bulimia nervosa, with Hispanic adolescents reporting the highest prevalence.

“Significant ethnic differences emerged for BN, with Hispanic adolescents reporting the highest prevalence; there was a trend toward ethnic minorities reporting more BED, while non-Hispanic white adolescents tended to report more AN.”

Adolescents with bulimia nervosa and binge-eating disorder reported that their eating problems most impaired their social and family relationships.

“Adolescents with BN and BED also reported that their eating problems most impaired their social and family relationships.”

Among adolescents with 12-month binge-eating disorder, 62.6% reported impairment in the past 12 months.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

The adjusted odds ratio for comorbid disorders was 5.9 (95% CI, 2.5-13.8) for binge-eating disorder.

“The adjusted odds ratios (95% confidence intervals) for comorbid disorders by eating disorder subtype were 1.5 (0.54.4) for AN, 8.6 (2.7–27.3) for BN, 5.9 (2.5–13.8) for BED, 4.3 (2.0–8.8) for SAN, and 2.7 (1.8–4.1) for SBED.”

The adjusted odds ratio for comorbid disorders was 2.7 (95% CI, 1.8-4.1) for subthreshold binge-eating disorder.

“The adjusted odds ratios (95% confidence intervals) for comorbid disorders by eating disorder subtype were 1.5 (0.54.4) for AN, 8.6 (2.7–27.3) for BN, 5.9 (2.5–13.8) for BED, 4.3 (2.0–8.8) for SAN, and 2.7 (1.8–4.1) for SBED.”

The median age at onset of anorexia nervosa was 12.3 years.

“The median ages at onset of AN, BN, BED, and SBED were 12.3, 12.4, 12.6, and 12.6 years, respectively.”

Nearly all adolescents with anorexia nervosa (88.9%) reported social impairment.

“Nearly all of those with AN (88.9%) reported social impairment, and 19.6% reported severe social impairment associated with their eating disorder.”

Among adolescents with 12-month bulimia nervosa, 10.7% reported severe impairment.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

Among adolescents with 12-month subthreshold binge-eating disorder, 34.6% reported impairment in the past 12 months.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

The lifetime prevalence of bulimia nervosa among US adolescents was 0.9%.

“Lifetime prevalence rates of AN, BN, BED, SAN, and SBED were 0.3%, 0.9%, 1.6%, 0.8%, and 2.5%, respectively (Table 1).”

Bulimia nervosa and binge-eating disorder were significantly associated with nearly every disorder assessed.

“In contrast, BN and BED were significantly associated with nearly every disorder assessed.”

The 12-month prevalence of subthreshold binge-eating disorder among US adolescents was 1.1%.

“The 12-month prevalence rates of AN, BN, BED, and SBED were 0.2%, 0.6%, 0.9%, and 1.1%, respectively, with 12-month to lifetime prevalence ratios of 57.9%, 72.0%, 56.0%, and 44.5%, respectively.”

Both subthreshold presentations showed modest amounts of comorbidity across classes of DSM-IV disorders.

“Both subthreshold presentations showed modest amounts of comorbidity across classes of DSM-IV disorders.”

Youths with eating disorders rarely reported that their eating problems led to complete loss of role functioning for an entire day.

“Although impairment in these domains was relatively high, youths with eating disorders rarely reported that their eating problems led to complete loss of role functioning for an entire day.”

Among adolescents with 12-month anorexia nervosa, 97.1% reported impairment in the past 12 months.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

Among adolescents with bulimia nervosa, 41.3% reported purging in their lifetime.

“Among adolescents with BN, 41.3% reported purging in their lifetime while the rest met criteria through nonpurging compensatory behaviors.”

There were no sex differences in the lifetime prevalence of subthreshold binge-eating disorder.

“Regarding lifetime prevalence estimates, there were no sex differences in the prevalence of AN or SBED, while BN, BED, and SAN were more prevalent in girls (Table 2).”

Among adolescents with 12-month subthreshold binge-eating disorder, 2.8% reported severe impairment.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

The 12-month prevalence of anorexia nervosa among US adolescents was 0.2%.

“The 12-month prevalence rates of AN, BN, BED, and SBED were 0.2%, 0.6%, 0.9%, and 1.1%, respectively, with 12-month to lifetime prevalence ratios of 57.9%, 72.0%, 56.0%, and 44.5%, respectively.”

19.6% of adolescents with anorexia nervosa reported severe social impairment.

“Nearly all of those with AN (88.9%) reported social impairment, and 19.6% reported severe social impairment associated with their eating disorder.”

Lifetime prevalence of binge-eating disorder was higher in girls.

“Regarding lifetime prevalence estimates, there were no sex differences in the prevalence of AN or SBED, while BN, BED, and SAN were more prevalent in girls (Table 2).”

Among adolescents with 12-month anorexia nervosa, 24.2% reported severe impairment.

“Among adolescents with 12-month AN, BN, BED, and SBED, 97.1%, 78.0%, 62.6%, and 34.6%, respectively, reported impairment in the past 12 months; 24.2%, 10.7%, 8.7%, and 2.8%, respectively, reported severe impairment (Table 4).”

The lifetime prevalence of binge-eating disorder among US adolescents was 1.6%.

“Lifetime prevalence rates of AN, BN, BED, SAN, and SBED were 0.3%, 0.9%, 1.6%, 0.8%, and 2.5%, respectively (Table 1).”

Lifetime prevalence of bulimia nervosa was higher in girls.

“Regarding lifetime prevalence estimates, there were no sex differences in the prevalence of AN or SBED, while BN, BED, and SAN were more prevalent in girls (Table 2).”

There was a trend toward ethnic minorities reporting more binge-eating disorder.

“Significant ethnic differences emerged for BN, with Hispanic adolescents reporting the highest prevalence; there was a trend toward ethnic minorities reporting more BED, while non-Hispanic white adolescents tended to report more AN.”

The median age at onset of bulimia nervosa was 12.4 years.

“The median ages at onset of AN, BN, BED, and SBED were 12.3, 12.4, 12.6, and 12.6 years, respectively.”

Measures of socioeconomic status were not significantly associated with any eating disorder presentation.

“Measures of socioeconomic status, including parental education, household income, and parental/surrogate marital status, were not significantly associated with any eating disorder presentation.”

The lifetime prevalence of anorexia nervosa among US adolescents was 0.3%.

“Lifetime prevalence rates of AN, BN, BED, SAN, and SBED were 0.3%, 0.9%, 1.6%, 0.8%, and 2.5%, respectively (Table 1).”

The median age at onset of binge-eating disorder was 12.6 years.

“The median ages at onset of AN, BN, BED, and SBED were 12.3, 12.4, 12.6, and 12.6 years, respectively.”

The adjusted odds ratio for comorbid disorders was 4.3 (95% CI, 2.0-8.8) for subthreshold anorexia nervosa.

“The adjusted odds ratios (95% confidence intervals) for comorbid disorders by eating disorder subtype were 1.5 (0.54.4) for AN, 8.6 (2.7–27.3) for BN, 5.9 (2.5–13.8) for BED, 4.3 (2.0–8.8) for SAN, and 2.7 (1.8–4.1) for SBED.”

The lifetime prevalence of subthreshold anorexia nervosa among US adolescents was 0.8%.

“Lifetime prevalence rates of AN, BN, BED, SAN, and SBED were 0.3%, 0.9%, 1.6%, 0.8%, and 2.5%, respectively (Table 1).”

The majority of respondents with an eating disorder met criteria for at least one other lifetime DSM-IV disorder.

“The majority of respondents with an eating disorder met criteria for at least 1 other lifetime DSM-IV disorder assessed in this study across the lifetime, with 55.2%, 88.0%, 83.5%, 79.8%, and 70.1% of adolescents with AN, BN, BED, SAN, and SBED, respectively, endorsing 1 or more comorbid psychiatric disorders (Table 3).”

There were no sex differences in the lifetime prevalence of anorexia nervosa.

“Regarding lifetime prevalence estimates, there were no sex differences in the prevalence of AN or SBED, while BN, BED, and SAN were more prevalent in girls (Table 2).”

Eating disorders were most strongly associated with social impairment.

“Eating disorders were most strongly associated with social impairment.”

Anorexia nervosa was not associated with any other mental disorder except oppositional defiant disorder.

“Anorexia nervosa was not associated with any other mental disorder except oppositional defiant disorder.”

The 12-month prevalence of binge-eating disorder among US adolescents was 0.9%.

“The 12-month prevalence rates of AN, BN, BED, and SBED were 0.2%, 0.6%, 0.9%, and 1.1%, respectively, with 12-month to lifetime prevalence ratios of 57.9%, 72.0%, 56.0%, and 44.5%, respectively.”

Only a minority (3.4%-27.5%) of individuals with eating disorders had talked to a professional specifically about their eating or weight problems.

“However, only a minority (3.4%–27.5%) of individuals with eating disorders had actually talked to a professional specifically about their eating or weight problems.”

Suicidality was more common among adolescents with bulimia nervosa compared with those with anorexia nervosa.

“Likewise, suicidality was more common among adolescents with BN compared with those with AN, corroborating findings from previous community surveys43 and some clinical studies.12–14”

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More than half of adolescents with subthreshold conditions had sought mental health specialty treatment.

“Most striking was the high endorsement of mental health service use for subthreshold conditions, with more than half of these adolescents having sought mental health specialty treatment.”

Among subjects with anorexia nervosa, 77.6% received some form of treatment in their lifetime.

“Among subjects with AN, BN, BED, SAN, and SBED, 77.6%, 88.2%, 72.6%, 70.5%, and 64.2%, respectively, received some form of treatment in their lifetime (Table 6).”

Among subjects with subthreshold binge-eating disorder, 3.4% sought treatment specifically for their eating or weight problems.

“However, much smaller proportions had sought treatment specifically for their eating or weight problems (27.5%, 21.5%, 11.4%, and 3.4% for AN, BN, BED, and SBED, respectively).”

Among subjects with bulimia nervosa, 21.5% sought treatment specifically for their eating or weight problems.

“However, much smaller proportions had sought treatment specifically for their eating or weight problems (27.5%, 21.5%, 11.4%, and 3.4% for AN, BN, BED, and SBED, respectively).”

Among subjects with binge-eating disorder, 72.6% received some form of treatment in their lifetime.

“Among subjects with AN, BN, BED, SAN, and SBED, 77.6%, 88.2%, 72.6%, 70.5%, and 64.2%, respectively, received some form of treatment in their lifetime (Table 6).”

Among subjects with binge-eating disorder, 11.4% sought treatment specifically for their eating or weight problems.

“However, much smaller proportions had sought treatment specifically for their eating or weight problems (27.5%, 21.5%, 11.4%, and 3.4% for AN, BN, BED, and SBED, respectively).”

Among subjects with bulimia nervosa, 88.2% received some form of treatment in their lifetime.

“Among subjects with AN, BN, BED, SAN, and SBED, 77.6%, 88.2%, 72.6%, 70.5%, and 64.2%, respectively, received some form of treatment in their lifetime (Table 6).”

Severe role impairment was more common among adolescents with anorexia nervosa relative to those with bulimia nervosa.

“By contrast, severe role impairment was more common among adolescents with AN relative to those with BN.”

Among subjects with anorexia nervosa, 27.5% sought treatment specifically for their eating or weight problems.

“However, much smaller proportions had sought treatment specifically for their eating or weight problems (27.5%, 21.5%, 11.4%, and 3.4% for AN, BN, BED, and SBED, respectively).”

The majority (72.6%-88.2%) of adolescents with eating disorders reported some contact with the service sector for emotional or behavioral problems.

“The majority (72.6%–88.2%) of adolescents with eating disorders reported some contact with the service sector for emotional or behavioral problems, with the most frequently used sectors being mental health specialty care, school services, general medical services, and human services.”

The majority of adolescents with an eating disorder received some sort of treatment for an emotional or behavioral problem.

“The majority of adolescents with an eating disorder received some sort of treatment for an emotional or behavioral problem.”

Among subjects with subthreshold binge-eating disorder, 64.2% received some form of treatment in their lifetime.

“Among subjects with AN, BN, BED, SAN, and SBED, 77.6%, 88.2%, 72.6%, 70.5%, and 64.2%, respectively, received some form of treatment in their lifetime (Table 6).”

The majority of youths who had received services had sought treatment from a mental health specialty.

“The majority of youths who had received services had sought treatment from a mental health specialty (68.8%, 60.9%, 60.4%, 54.3%, and 48.8% for AN, BN, BED, SAN, and SBED, respectively).”

Among subjects with subthreshold anorexia nervosa, 70.5% received some form of treatment in their lifetime.

“Among subjects with AN, BN, BED, SAN, and SBED, 77.6%, 88.2%, 72.6%, 70.5%, and 64.2%, respectively, received some form of treatment in their lifetime (Table 6).”

Lifetime suicidality was associated with all subtypes of eating disorders.

“Lifetime suicidality was associated with all subtypes of eating disorders (Table 5).”

Each eating disorder subtype was associated with significantly elevated levels of suicide ideation.

“Each eating disorder subtype was associated with significantly elevated levels of suicide ideation, while BN and SAN were further associated with suicide plans and BN and BED were associated with suicide attempts.”

The unweighted number of adolescents with anorexia nervosa in this sample is 34.

“In particular, as the unweighted number of adolescents with AN in this sample is only 34, the lack of findings for sociodemographic measures and comorbidity may be due to this methodologic issue rather than representing true null findings.”

Eating disorders and subthreshold eating conditions are prevalent in the general adolescent population.

“Eating disorders and subthreshold eating conditions are prevalent in the general adolescent population.”

Subthreshold eating conditions that were frequent in this population were characterized by many of the same severity markers as cases meeting diagnostic criteria.

“Subthreshold eating conditions that were frequent in this population were characterized by many of the same severity markers as cases meeting diagnostic criteria.”

Growing evidence from prospective cohort studies suggests that retrospective recall yields underestimates as opposed to overestimates of the true prevalence of psychiatric disorders.

“In fact, growing evidence from prospective cohort studies suggests that retrospective recall yields underestimates as opposed to overestimates of the true prevalence of psychiatric disorders.52,53”

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Lifetime prevalence estimates may be subject to unreliability of recall of past symptoms or disorders due to memory, bias, desirability of response, and other factors.

“Such estimates are critical for a comprehensive life-course understanding of these disorders but may also be subject to unreliability of recall of past symptoms or disorders due to memory, bias, desirability of response, and other factors.”

The unmet treatment needs in the adolescent population place these disorders as important public health concerns.

“The unmet treatment needs in the adolescent population place these disorders as important public health concerns.”

The large female to male ratio for subthreshold anorexia nervosa provides an indication that the sex difference may be genuine.

“One indication that the difference may be genuine is provided by the large female to male ratio for SAN.”

Patterns of comorbidity are suggestive of the clinical significance of subthreshold conditions in the population.

“Patterns of comorbidity are also suggestive of the clinical significance of these subthreshold conditions in the population.20,21”

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The significant association between suicide ideation and behavior with subthreshold conditions supports the importance of the spectrum concept of eating disorders.

“Likewise, the significant association between suicide ideation and behavior with subthreshold conditions supports the importance of the spectrum concept of eating disorders.”

The observed prevalence estimates were generally similar to those of previous studies.

“The observed prevalence estimates were generally similar to those of previous studies,1–8,22,23 and salient differences in sociodemographic and clinical correlates were observed between eating disorder subtypes.”

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The impact of eating disorders is demonstrated by generally strong associations with other psychiatric disorders, role impairment, and suicidality.

“Their impact is demonstrated by generally strong associations with other psychiatric disorders, role impairment, and suicidality.”

The high prevalence estimates of subthreshold anorexia nervosa (0.8%) and subthreshold binge-eating disorder (2.5%) provide evidence for a spectrum of eating disorders among youths in the general population.

“The high prevalence estimates of SAN (0.8%) and SBED (2.5%) provide evidence for a spectrum of eating disorders among youths in the general population.17–19”

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The ages at onset of each disorder were markedly younger in the present sample, suggesting that retrospective assessments of adults may overestimate the age at onset of these conditions.

“However, the ages at onset of each of these disorders were markedly younger in the present sample, thereby underscoring the likelihood that retrospective assessments of adults may overestimate the age at onset of these conditions for a variety of possible reasons.32”

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Subthreshold eating conditions were often characterized by many of the same severity markers as threshold cases.

“Subthreshold eating conditions were often characterized by many of the same severity markers as threshold cases.”

Differences in the correlates and clinical profiles between discrete subtypes in this study provide evidence for the validity of these distinctions.

“Although the frequent crossover of eating disorder subtypes in longitudinal studies of adults37–39 suggests a lack of diagnostic specificity of eating disorder subtypes,40–42 differences in the correlates and clinical profiles between discrete subtypes in our study provide evidence for the validity of these distinctions.”

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Attempts to minimize recall biases were built into the methods of the CIDI.

“Attempts to minimize such biases were built into the methods of the CIDI.28,51”

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The greater prevalence of bulimia nervosa in Hispanic adolescents highlights an important discrepancy between treatment-seeking samples and the full US adolescent population.

“Nonetheless, this larger prevalence highlights an important discrepancy between treatment-seeking samples and the full US adolescent population.36”

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The discrepancy between the lack of substantial comorbidity among adolescents in the current study and the high rates of comorbidity associated with anorexia nervosa among adults suggests that comorbid disorders may be a consequence of anorexia nervosa in youths.

“The discrepancy between the lack of substantial comorbidity among adolescents in the current study48 and the high rates of comorbidity associated with AN among adults1,2 suggests that comorbid disorders may be a consequence of AN in youths.”

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The small number of adolescents with combinations of eating disorders precluded investigation of the correlates of combinations of threshold-level eating disorders.

“In addition, the small number of adolescents with combinations of eating disorders (eg, only 6 adolescents met criteria for both AN and BN, and only 2 adolescents met criteria for both BN and BED) precluded our ability to investigate the correlates of combinations of threshold-level eating disorders.”

This is the first population-based study in the United States to present the prevalence of eating disorders across the full adolescent age range.

“To our knowledge, this is the first population-based study in the United States to present the prevalence of eating disorders across the full adolescent age range.”

This investigation provides the first report on the prevalence, correlates, impact, and service use patterns of both threshold and subthreshold eating disorders in a nationally representative sample of US adolescents.

“To our knowledge, this investigation provides the first report on the prevalence, correlates, impact, and service use patterns of both threshold and subthreshold eating disorders in a nationally representative sample of US adolescents.”

The prevalence of these disorders is higher than previously expected in this age range.

“The prevalence of these disorders is higher than previously expected in this age range, and the patterns of comorbidity, role impairment, and suicidality indicate that eating disorders represent a major public health concern.”

The lack of findings for sociodemographic measures and comorbidity may be due to a methodologic issue rather than representing true null findings.

“In particular, as the unweighted number of adolescents with AN in this sample is only 34, the lack of findings for sociodemographic measures and comorbidity may be due to this methodologic issue rather than representing true null findings.”

The patterns of comorbidity, role impairment, and suicidality indicate that eating disorders represent a major public health concern.

“The prevalence of these disorders is higher than previously expected in this age range, and the patterns of comorbidity, role impairment, and suicidality indicate that eating disorders represent a major public health concern.”

The diagnostic instrument had not been previously validated in adolescents.

“Concerning other limitations, our diagnostic instrument had not been previously validated in adolescents, and studies using earlier versions of the CIDI found that the instrument tended to underdiagnose eating disorders in adults.54”

Studies using earlier versions of the CIDI found that the instrument tended to underdiagnose eating disorders in adults.

“Concerning other limitations, our diagnostic instrument had not been previously validated in adolescents, and studies using earlier versions of the CIDI found that the instrument tended to underdiagnose eating disorders in adults.54”

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The use of this same instrument in two large adult population-based investigations permitted direct comparisons across studies.

“However, the use of this same instrument in 2 large adult population-based investigations permitted direct comparisons across studies.1,2”

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Analyses of associations may have been underpowered owing to the relatively small numbers of adolescents with eating disorders.

“Furthermore, analyses of associations may have been underpowered owing to the relatively small numbers of adolescents with eating disorders.”

The estimates in this article may be a lower bound of the true prevalence of eating disorders.

“Therefore, the estimates in this article may be a lower bound of the true prevalence of eating disorders.”

The structure of the survey may not capture all clinically significant cases that fall under a not-otherwise-specified (EDNOS) diagnosis.

“An additional concern is that the structure of the survey may not capture all clinically significant cases that fall under a not-otherwise-specified (EDNOS) diagnosis, which corresponds to a majority of the identified cases of eating disorders.”