Eating disorders are reported to be on the rise in high-risk groups (Smink et al, 2012) with a lifetime prevalence reported to be around 5% (Treasure et al, 2010).

Associated with a profound effect on a person’s physical and mental health (Steinhausen, 2009; Johnson & Harrison, 2003; Fairburn & Harrison, 2003), they are also linked to an increased risk of mortality (Smink et al, 2012; Steinhausen, 2009).

The aim of a recent systematic review (Ágh et al, 2016) was to study both the health-related quality of life (HRQoL) and economic burden of eating disorders. The review focused on the three most common eating disorders, which are distinct illnesses with differing epidemiology and outcomes:

1. Anorexia Nervosa (AN)
2. Bulimia Nervosa (BN)
3. Binge Eating Disorder (BED)

Methods

A systematic literature search was performed in Medline, Embase, PsycINFO, PsycARTICLES, Academic Search Complete, CINAHL Plus, Business Source Premier, and the Cochrane Library.

Inclusion criteria were:

• English language articles
• Published in peer-reviewed journals (editorials, letters, case reports and reviews excluded)
• Specific to AN, BN or BED
• With an objective to study the HRQoL and/or economic burden of AN, BN and BED (of which results had to be reported separately).

Data was extracted on a variety of subjects, including characteristics of the study sample, data on healthcare resource use and costs, societal costs, and data on HRQoL. Cost data was converted to 2014 Euros for ease of comparison.

Results

Of the 7,211 articles identified during database searches, 69 studies were included in the review.

Health-related quality of life (HRQoL)

Data on HRQoL were reported in 41 studies; 18 for AN, 17 for BN, and 18 for BED:

• The Medical Outcome Study Short Form 36 (SF-36) and Short Form 12 (SF-12) were the most commonly used HRQoL questionnaires
• HRQoL was shown to be significantly worse with AN, BN, and BED compared with healthy populations
• Some evidence suggests that patients with eating disorders experienced reduced HRQoL when compared with other psychiatric conditions
• BN and BED appeared to having differing effects on the domains of HRQoL
• HRQoL of carers and family members (siblings) was shown in a number of studies to be reduced
• Differences were identified amongst study results, likely due to variations in study design and population heterogeneity.

Costs

Twenty studies considered healthcare utilisation (14 for AN, 12 for BN, and 8 for BED) and 17 studies looked at healthcare costs (9 for AN, 11 for BN, and only 2 for BED):

• Eating disorders were associated with increased healthcare resource use and healthcare costs
• In particular they were associated with a high rate of hospitalisations, outpatient visits, and emergency department visits
• The majority of treatment received was not for specifically treating eating disorders, rather the treatment of comorbid psychiatric illnesses and/or weight loss
• Identified annual healthcare costs varied considerably:
  • from €2,993 to €55,270 for AN
  • from €888 to €18,823 for BN
  • from €1,762 to €2,902 for BED.

Conclusions

The authors conclude that eating disorders are linked with higher healthcare resource use and associated costs, as well as having a serious impact on a patients HRQoL. Whilst the impact of AN, BN and BED was similar with respect to HRQoL, costs varied substantially and were in general higher for patients with AN.

Key differences were identified between BN and BED, for instance a difference in obesity levels, which may be linked to long-term HRQoL and healthcare cost differences. This was highlighted to be important as it suggests that the two disorders should be looked at and considered as very separate and distinct disorders.

The authors noted that there is limited long-term evidence of both HRQoL and economic burdens associated with all of the disorders, highlighting a need for further research.

Strengths and limitations

The study applied a clear systematic search strategy to a wide range of databases with two independent reviewers. It provides a comprehensive qualitative and tabular overview of the available evidence, as well as a summary with transparent discussion of the uncertainties existing in the evidence base.

There are also a number of limitations:

• No quality review was undertaken of the identified evidence, which makes it difficult to identify potential bias
• A wide range was identified in the cost data, and investigating the reasons for this was noted to be outside of the scope of the review. However, this would have been helpful for interpreting the results
• There is no discussion on the validity of the various HRQoL with respect to eating disorders
• A meta-analysis would have been useful to synthesise the evidence base and to summarise the impact of eating disorders on HRQoL
• As health economists often use this type of review, because HRQoL and healthcare costs are intrinsic for economic modelling, it would have benefitted from including utility scores. To capture these, a wider search including economic evaluations would have been required.

Summary

Eating disorders have a profound negative impact on HRQoL and result in increased healthcare costs. The three eating disorders considered (Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge Eating Disorder (BED)) were all shown to have different effects and as such, should be considered separately. Heterogeneity amongst the study characteristics and populations leads to variability within the data and makes it challenging to draw strong conclusions.

The paper does not present any firm findings that can be applied in practice. However, it does add to the evidence base and provides a summary of the HRQoL and economic burdens of eating disorders.

It also highlights some important evidence gaps and opportunities for research. For instance, the cost data was dominated by evidence in the US and Germany, and only direct healthcare costs were considered by the majority. Research is needed to examine the wider societal economic burden in a larger range of countries. Although many studies looked into the effect on HRQoL, research into the validity and reliability of the commonly used quality of life measures would enable reviewers to better interpret this information and would strengthen the robustness of future studies. Longer-term evidence is needed for both HRQoL and cost assessments.

Links

Primary paper

Ágh T, Kovács G, Supina D, Pawaskar M, Herman BK, Vokó Z, Sheehan DV. (2016) A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder. Eat Weight Disord. 2016 Mar 4. [Epub ahead of print] [PubMed abstract]

Other references

Fairburn CG, Harrison PJ. (2003) Eating disorders. Lancet 361:407–16. [PubMed abstract]

Johnson JG, Cohen P, Kasen S, Brook JS. (2002) Eating disorders during adolescence and the risk for physical and mental disorders during early adulthood. Arch. Gen. Psychiatry 59:545–52. [PubMed abstract]

Smink FRE, van Hoeken D, Hoek HW. (2012) Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr. Psychiatry Rep. 14:406–14. [PubMed abstract]

Steinhausen H-C. (2009) Outcome of eating disorders. Child Adolesc. Psychiatr. Clin. N. Am. 18:225–42. [PubMed abstract]

Treasure J, Claudino AM, Zucker N. (2010) Eating disorders. Lancet. 2010 Feb 13;375(9714):583-93. doi: 10.1016/S0140-6736(09)61748-7. [PubMed abstract]

Photo credits

• Hernán Piñera CC BY 2.0
• Nathan Csonka CC BY 2.0