High risk of premature death in patients with eating disorders, study finds
There is currently a lack of research on the long-term mortality in patients with eating disorders, despite the detrimental consequences that these disorders have on a person’s overall health and well-being. The majority of studies to date have focused solely on anorexia nervosa (AN) — an eating disorder that involves extreme emaciation as these individuals deprive their bodies of food and essential nutrients needed to function and survive — as the mortality rate is highest for this disorder, even compared to the death rates for bipolar disorder, depression and schizophrenia. AN can result in serious health problems and death in about 5 to 20 percent of those who have the disorder.
On the other hand, very little research exists for other eating disorders, including bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (ED-NOS), which are equally disabling but have lower mortality rates. BN is characterized by a repeated cycle of binge eating and unhealthy compensatory behaviors (e.g., self-induced vomiting, misuse of laxatives or diuretics, excessive exercise, taking diet pills), which can lead to major organ dysfunction and electrolyte imbalances. In addition, more than a third of adolescents with bulimia nervosa report they have attempted suicide.
The most common eating disorder in the United States is BED, which is characterized by episodes of binge eating that are not followed by purging or other non-purging compensatory behaviors. Two-thirds of people with BED are also obese, contributing substantially to high blood pressure and cholesterol levels; heart disease due to elevated triglycerides; Type 2 diabetes; kidney, liver and gallbladder disease; and other chronic health consequences, which can increase the risk of death among these individuals.
People who have eating disorders develop unhealthy patterns of behaviors regarding their weight, body size and image, and food intake (e.g., starvation; self-induced vomiting; misusing diet pills, laxatives or diuretics), which can result in serious health consequences and even death if left untreated. “Eating disorders have the highest mortality rate of any mental illness,” said Janet Whitney, director of Sovereign Health’s eating disorder program in San Clemente, California.
Mortality rates in eating disorders
The long-term mortality, causes of death and predictors of premature death associated with AN, BN, BED and ED-NOS were investigated by Manfred M. Fichter, M.D., and Norbert Quadflieg, Dipl. Psych., at the Ludwig-Maximilians University in Munich. A total of 5,839 patients, who were receiving specialized inpatient hospital treatment with cognitive behavior therapy (CBT) for eating disorders in Germany, were included in the study. Patients’ diagnoses of eating disorders were obtained using the Structured Inventory for Anorexic and Bulimic Eating Disorders Self-Rating form (SIAB-S) derived from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
There were 1,639 patients who were treated for AN, 1,930 for BN, 363 for BED and 1,907 for ED-NOS. The crude mortality rate (CMR) (i.e., the total number of deaths divided by the total number of patients) and the standardized mortality ratio (SMR) (i.e., the number of observed deaths divided by the number of expected deaths) were adjusted for age, gender and person-years.
As found in previous studies, the mortality rate was highest for AN (SMRAN = 5.35 and CMR = 5.9 percent), which was similar to the mortality rate for schizophrenia, if not higher. The researchers also indicated that the mortality rate for AN was five times higher than in the general population. The SMR was 1.49 for BN and 1.50 for BED, which was also significantly elevated compared to the general population, and 2.39 for ED-NOS. The CMRs were 4.7 percent for BED, 3.3 percent for ED-NOS and 2.5 percent for BN.
Natural and non-natural causes of premature death
During the follow-up, the researchers reported that 225 patients were deceased (97 with AN, 49 with BN, 17 with BED and 62 with ED-NOS). Deceased patients with BED were older and had an eating disorder for a longer duration at admission compared to deceased patients with AN, BN and ED-NOS.
Three-fourths of the patients died from natural causes. In AN, the most frequent causes of natural death were due to low body weight, which resulted in circulatory collapse, cachexia (i.e., a metabolic disorder that involves extreme weight and muscle loss) and multiple organ failure. Two AN cases and two BN cases died of bronchopneumonia infections. In addition, one patient with AN (gastric cancer) and one patient with BN (tongue cancer) also died of stomato-gastrointestinal cancer.
Other natural causes of death among patients with AN, BN, BED and ED-NOS included:
- Kidney failure
- Brain aneurysm
- Liver coma
- Cardiac infarction
- Suffocation during an asthma attack
There were six patients with AN, five patients with BN, one patient with BED and eight patients with ED-NOS who died of non-natural causes. The non-natural causes of death in patients with eating disorders included:
- Accident (two patients with AN and two patients with ED-NOS)
- Suicide (four patients with AN, five patients with BN, one patient with BED and five patients with ED-NOS)
- Murder (one patient with ED-NOS)
The researchers suggested that the acid through frequent vomiting, or higher rates of nicotine and/or alcohol consumption could increase cancer risk in the mouth, tongue or esophagus in these individuals. Two-thirds of patients with AN, and all non-natural deaths due to BN and BED, were attributable to suicide.
Predictors of survival time in patients with eating disorders
Lastly, the researchers sought to determine whether having the eating disorder for a longer period of time was associated with a higher risk for death. Following the onset of the disorder, survival time was shorter in patients with AN compared to those with BN and ED-NOS. Patients with AN were more likely to be deceased if they were between the ages of 25 and 34. On the other hand, deceased patients with BED were older.
Patients who were transferred to another institution or hospital or who were discharged early (i.e., premature discharge initiated by patient, therapist or mutual agreement) were more likely to die prematurely. Premature death was also more likely to occur when patients lived without a partner, developed the eating disorder at a later age or had a higher number of inpatient pre-treatments.
The researchers also found:
- Suicidality was predictive of a shorter time to death in patients with BN only
- Predictors of death in severe AN included lifetime self-induced vomiting, diuretic use and laxative use
- Patients with AN had a shorter survival time from the onset of the eating disorder compared to patients with BN, BED or ED-NOS
- In most cases, causes of death were natural for AN (83.8 percent), while the remaining causes of death were non-natural
- The number of deaths in the BN and BED groups was rather small
In summary, the researchers found that the risk of premature mortality was very high for patients with eating disorders, especially among patients with AN. These individuals were more likely to die from natural causes, especially patients with AN, from circulatory collapse, cachexia, infections and multiple organ failure. The suicide rates were a reason for concern among patients with all eating disorders assessed by the study.
This study highlights the importance of providing patients with support and motivation to change throughout their treatment, and avoiding transferring and discharging patients early, which were the main predictors of premature death in patients with AN, BN and BED. Clinicians should also be aware of the high suicide rates among patients with eating disorders.
The Sovereign Health Group recognizes the importance of providing patients with support and motivation to change throughout their treatment. Sovereign Health of California, San Clemente and Rancho San Diego, provide female adults and adolescents who have eating disorders, including anorexia nervosa and bulimia nervosa, with individualized, comprehensive behavioral treatment services based on their specific needs. For more information about eating disorders or the programs offered at Sovereign Health, please contact our 24/7 helpline to speak to a member of our team.
About the author
Amanda Habermann is a writer for the Sovereign Health Group. A graduate of California Lutheran University, she received her M.S. in clinical psychology with an emphasis in psychiatric rehabilitation. She brings to the team her background in research, testing and assessment, diagnosis and recovery techniques. For more information and other inquiries about this article, contact the author at email@example.com.