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Eating Disorders During Adolescence and the Risk for Physical and Mental Disorders During Early Adulthood
Jeffrey G. Johnson, PhD;
Patricia Cohen, PhD;
Stephanie Kasen, PhD;
Judith S. Brook, PhD
Arch Gen Psychiatry. 2002;59:545-552.
ABSTRACT
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Background Data from a community-based longitudinal investigation were used to
investigate whether adolescents with eating disorders are at an elevated risk
for physical and mental disorders during early adulthood.
Methods Psychosocial and psychiatric interviews were administered to a representative
community sample of 717 adolescents and their mothers from 2 counties in the
state of New York in 1983, 1985 to 1986, and 1991 to 1993. In 1983, the mean
age of the youths was 13.8 years.
Results Adolescents with eating disorders were at a substantially elevated risk
for anxiety disorders, cardiovascular symptoms, chronic fatigue, chronic pain,
depressive disorders, limitations in activities due to poor health, infectious
diseases, insomnia, neurological symptoms, and suicide attempts during early
adulthood after age, sex, socioeconomic status, co-occurring psychiatric disorders,
adolescent health problems, body mass index, and worries about health during
adulthood were controlled statistically. Problems with eating or weight during
adolescence predicted poor health outcomes during adulthood, regardless of
whether an eating disorder had been present. Only 22% of the adolescents with
current eating disorders had received psychiatric treatment within the past
year.
Conclusion Eating disorders during adolescence may be associated with an elevated
risk for a broad range of physical and mental health problems during early
adulthood.
INTRODUCTION
PATIENTS WITH severe eating disorders have elevated rates of physical
illness,1-9
psychiatric disorder,10-16
suicide,17 and mortality.18-20
However, relatively little is known about the association between eating disorders
and subsequent health problems among individuals in the general population.21 Nearly all of the population-based epidemiological
studies of eating disorders and associated health problems have been cross-sectional
investigations. Directional inferences cannot be made from cross-sectional
data, and longitudinal research is needed to investigate whether individuals
with eating disorders in the community are at an elevated risk for subsequent
health problems. Because eating disorders often develop during adolescence,22 it is of particular interest to examine the long-term
health outcomes associated with adolescent eating disorders.
Most of the information available regarding the course and sequelae
of eating disorders has been provided by treatment outcome studies. Most of
these studies have investigated the outcome of treatment for anorexia nervosa,
although the outcome of adolescent-onset anorexia nervosa has not been extensively
investigated.23 A few recent studies have examined
outcomes associated with bulimia nervosa, but little information is available
regarding the long-term outcome of patients with bulimia nervosa.24 Most treatment outcome studies have investigated
the course of eating disorder symptoms, and relatively little information
has been obtained regarding other outcomes, including physical and mental
disorders.25 The available findings indicate
that, while many patients who are treated for eating disorders have fair or
satisfactory outcomes, patients with poor treatment outcomes are at risk for
physical illnesses,26-28
psychiatric disorders,29-31
suicide attempts,28 and mortality.32-33
Yet, because participants in treatment outcome studies tend to have
severe eating disorders and co-occurring health problems, the findings may
not be applicable to adolescents with eating disorders in the community. Most
eating disorders are not detected by primary care physicians,34
and most individuals with eating disorders in the community do not receive
treatment.35 Although some epidemiological
studies35-37 have
examined the course or development of eating disorders, to our knowledge,
no population-based prospective longitudinal study has investigated the association
between adolescent eating disorders and a broad range of physical and mental
health problems during adulthood.
We report such epidemiological findings from the Children in the Community
Study. Statistical procedures are used to control for age, sex, and parental
income, which are associated with many physical and psychiatric symptoms.
Preexisting health problems during adolescence are also controlled, permitting
investigation of the hypothesis that adolescent eating disorders contribute
to an increased risk for the development of mental and physical health problems.
PARTICIPANTS AND METHODS
PARTICIPANTS AND PROCEDURE
The participants in the present study were 717 youths (51% females)
and their mothers, who completed research interviews conducted in 1983, 1985
to 1986, and 1991 to 1993.38 The participating
families were a subset of 976 randomly sampled families from 2 upstate New
York counties, with children ranging in age from 1 to 10 years, with whom
maternal interviews had been conducted in 1975.39
During the 3 follow-up interviews, which were administered by extensively
trained and supervised lay interviewers, the youths and their mothers were
interviewed to assess Axis I and II psychiatric disorders and demographic
and other psychosocial variables. The mean age of the youths was 13.8 (SD,
2.6; range, 9-19) years in 1983, 16.1 (SD, 2.7; range, 11-23) years in 1985
to 1986, and 22.0 (SD, 2.7; range, 17-28) years in 1991 to 1993. The families
in this study generally represented families in the northeastern United States
for socioeconomic status and most demographic variables (38%), but they reflected
the sampled region, with high proportions of those taking the survey being
Roman Catholic (54%) and white (91%). Study procedures were approved according
to appropriate institutional guidelines. Written informed consent was obtained
after the interview procedures were fully explained. Youths and their mothers
were interviewed separately, and both interviewers were blind to the responses
of the other informant. Additional information regarding the study methods
is available from previous reports.38-39
ASSESSMENT OF PSYCHIATRIC DISORDERS, TREATMENT, AND PHYSICAL HEALTH
PROBLEMS
The parent and youth versions of the Diagnostic Interview Schedule for
Children (DISC-I)40 were administered in 1983,
1985 to 1986, and 1991 to 1993 to assess anxiety (obsessive-compulsive disorder,
overanxious disorder, panic disorder, separation anxiety disorder, and social
phobia), disruptive (attention-deficit disorder, conduct disorder, and oppositional
defiant disorder), eating (anorexia nervosa, binge-eating disorder, bulimia
nervosa, and eating disorder not otherwise specified), depressive (dysthymic
disorder and major depressive disorder), and substance use (alcohol and other
drug abuse or dependence) disorders. The eating disorders module of the DISC-I
assessed height, weight, and specific eating and weight problems. The height
and weight data were used to compute the youths' body mass index (BMI) (calculated
as weight in kilograms divided by the square of height in meters).
Following the publication of DSM-IV, computerized
diagnostic algorithms were developed to determine whether the diagnostic criteria
for DSM-IV eating disorders were met. Eating disorder
not otherwise specified was diagnosed, in accordance with DSM-IV guidelines, if there were clinically significant eating problems
(eg, anorexia without amenorrhea or self-induced vomiting), but these symptoms
did not meet the criteria for a specific eating disorder. Parents and youths
were interviewed because research has demonstrated that the use of multiple
informants tends to increase the reliability and validity of psychiatric diagnoses.41-42 Symptoms were considered present
if reported by either informant. Diagnostic findings were not provided to
either informant. Parental and youth reports of psychiatric symptoms were
positively correlated in the entire sample (r = 0.38, P<.001) and in the subsample of youths with eating disorders
(r = 0.40, P = .01). Previous
research43 has indicated that the reliability
and validity of the DISC-I as used in the present study are comparable to
those of other structured interviews.43
Personality disorders were assessed with items from the Personality
Diagnostic Questionnaire,44 the DISC-I, and
other measures.38 Items were selected based
on correspondence with DSM-III-R45
diagnostic criteria, combined using algorithms developed by a psychiatrist
and 2 clinical psychologists,46 and subsequently
modified to correspond with revisions in the DSM-IV22 diagnostic criteria. Adolescent personality disorder
diagnoses were assigned only if youths met the DSM-IV
diagnostic criteria in 1983 and 1985 to 1986 or if they met the DSM-IV diagnostic criteria at one assessment and were within one criterion
of the diagnosis at the other assessment. Research47-49
has supported the reliability and validity of the items and algorithms used
to assess personality disorders.
The version of the DISC-I administered in the present study was expanded
to assess the following physical health problems during adolescence and early
adulthood: cardiovascular illness, chronic allergies, chronic fatigue, chronic
orthopedic problems, chronic or frequent insomnia, chronic or frequent pain,
chronic respiratory illnesses, limitations in activities due to poor health,
migraine or other chronic headaches, neurological symptoms (eg, epilepsy),
other chronic illnesses (eg, diabetes), worries about health problems, and
fair or poor overall health. Susceptibility to infectious diseases (eg, influenza)
was assessed during early adulthood with an item assessing whether the participant
tended to become "sick more easily than other people." These health problems
were considered present if reported by either informant. Parental and youth
reports of physical health problems were positively correlated in the entire
sample (r = 0.42, P<.01)
and in the subsample of youths with eating disorders (r = 0.61, P<.01). Additional questions regarding
psychiatric treatment were asked during the maternal interviews and during
the youth interview in 1991 to 1993. The respondents were asked if the youth
had received treatment from a mental health professional and if such treatment
had been provided in the past year. Data were not obtained regarding specific
treatment for eating disorders.
DATA ANALYSIS
Descriptive statistics were computed to determine the prevalence of
all of the study variables. Analyses of contingency tables were conducted
to investigate whether eating disorders, weight loss behaviors, and behaviors
associated with weight gain during adolescence were associated with risk for
the development of mental and physical health problems during early adulthood.
Logistic regression analyses were conducted to investigate whether these associations
were significant after age; sex; anxiety; depressive, disruptive, personality,
and substance use disorders; corresponding health problems during adolescence;
parental income; co-occurring problems with eating or weight; and worries
about health during early adulthood were controlled statistically. To reduce
the likelihood of type II errors, these covariates were controlled sequentially
in a series of analyses, rather than simultaneously in a single analysis,
and bivariate odds ratios (ORs) are reported. To reduce the likelihood of
type I errors,  = .01 was used to determine whether the ORs were statistically
significant.
Analyses of contingency tables and logistic regression analyses were
conducted to investigate whether low body weight (defined as a BMI of  16.60,
identifying individuals whose BMI was at least 2 SDs below the sample mean)
or obesity (defined as a BMI of  28.25, identifying individuals whose BMI
was at least 2 SDs above the sample mean) during adolescence was associated
with an elevated risk for health problems during early adulthood.
RESULTS
DESCRIPTIVE STATISTICS
Thirty-six female subjects (10%) and 4 male subjects (1%) had eating
disorders during early or middle adolescence (Table 1). Of the 40 adolescents with current eating disorders, 9
(22%) had received treatment from a mental health professional during the
past year. Of these 9 youths, 8 (89%) had co-occurring psychiatric disorders.
In comparison, 17 (55%) of the 31 youths who were not treated by a mental
health professional had co-occurring psychiatric disorders ( 2
= 3.45, P = .06). Four individuals had eating disorders
during adolescence and early adulthood. Youths with eating disorders had a
mean of 6 problems with eating or weight during adolescence, regardless of
treatment status.
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Table 1. Eating and Weight Problems During Adolescence and Early Adulthood*
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The BMI scores of adolescents with eating disorders were not significantly
(t715 = 1.60, P = .12)
different from those of adolescents without eating disorders. However,
the adolescents who reported strict dieting
(t715 = 6.38,
P<.001), eating alone to conceal
unusual eating behavior (t715 = 3.03,
P = .004), frequent exercise to lose weight
(t715 = 9.27,
P<.001), fasting
for at least 24 hours (t715 = 3.45,
P = .001), recurrent fluctuations in weight
(t715 = 4.36,
P<.001), self-induced
vomiting (t715 = 2.32,
P = .02), and the use of medication to lose weight
(t715 = 3.48, P = .001) had significantly
higher BMI scores at a mean age of 16.1 years than those who did not have
these eating or weight problems.
HEALTH PROBLEMS ASSOCIATED WITH EATING DISORDERS DURING ADOLESCENCE
Eating disorders during adolescence were significantly associated with
co-occurring chronic fatigue (OR, 3.81; 95% confidence interval [CI], 1.48-9.76),
chronic or frequent insomnia (OR, 2.88; 95% CI, 1.44-5.76), chronic or frequent
pain (OR, 3.26; 95% CI, 1.71-6.21), migraine or other chronic headaches (OR,
3.38; 95% CI, 1.72-6.64), and any chronic health problems (OR, 2.33; 95% CI,
1.22-4.44). Adolescent eating disorders were also associated with co-occurring
anxiety (OR, 3.49; 95% CI, 1.73-7.04), depressive disorders (OR, 5.20; 95%
CI, 2.44-11.08), disruptive disorders (OR, 3.78; 95% CI, 1.84-7.76), personality
disorders (OR, 3.64; 95% CI, 1.73-7.66), substance use disorders (OR, 4.50;
95% CI, 2.01-10.09), and suicide attempts (OR, 5.02; 95% CI, 1.92-13.14) during
adolescence.
ADOLESCENT EATING DISORDERS AND PHYSICAL HEALTH OUTCOMES DURING EARLY
ADULTHOOD
Eating disorders during adolescence were associated with an increased
risk for cardiovascular symptoms, chronic fatigue, chronic or frequent insomnia,
chronic or frequent pain, neurological symptoms, frequent sickness, many activities
limited due to poor health, fair or poor overall health, and any chronic health
problems during early adulthood (Table 2). These associations remained significant after age, sex, co-occurring
psychiatric disorders, corresponding health problems during adolescence, parental
income, BMI, and worries about health during early adulthood were controlled
statistically. Eating disorders were not associated with risk for diabetes,
which was present in 3 individuals.
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Table 2. Eating Disorders During Adolescence and Chronic Health Problems
During Early Adulthooda
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ADOLESCENT EATING DISORDERS AND MENTAL HEALTH OUTCOMES DURING EARLY
ADULTHOOD
Eating disorders during adolescence were associated with an increased
risk for anxiety disorders, depressive disorders, and suicide attempts during
early adulthood (Table 3). These
associations remained significant after age, sex, co-occurring psychiatric
disorders, corresponding psychiatric conditions during adolescence, parental
income, BMI, and worries about health during early adulthood were controlled
statistically. Twenty-five (62%) of the adolescents with eating disorders
had 2 or more chronic physical health problems during early adulthood. In
comparison, 22% of the adolescents without psychiatric disorders and 32% of
the adolescents without eating disorders who had other psychiatric disorders
had multiple chronic physical health problems during early adulthood (22 = 34.34, P<.001).
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Table 3. Eating Disorders During Adolescence and Psychiatric Conditions
During Early Adulthooda
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ADOLESCENT WEIGHT LOSS BEHAVIORS AND HEALTH PROBLEMS DURING EARLY ADULTHOOD
Fasting, frequently exercising to lose weight, self-induced vomiting,
and strict dieting during adolescence were associated with health problems
during early adulthood after age, sex, co-occurring psychiatric disorders,
corresponding health problems during adolescence, parental income, and worries
about health during early adulthood were controlled statistically (Table 4). Several of the associations between
weight loss behaviors and subsequent health problems remained significant
after adolescent eating disorders, co-occurring eating or weight problems,
and BMI were controlled statistically. Because all of the adolescents who
reported self-induced vomiting met the criteria for bulimia nervosa or eating
disorder not otherwise specified, co-occurring eating disorders could not
be controlled in the analyses involving self-induced vomiting. The use of
medications to lose weight was not significantly associated with any subsequent
physical or mental health problems. A low body weight during adolescence was
associated with an elevated risk for respiratory illnesses during adulthood
(OR, 4.44; 95% CI, 2.07-9.62). This association remained significant after
age, sex, co-occurring psychiatric disorders, corresponding health problems
during adolescence, parental income, adolescent eating disorders, and worries
about health during early adulthood were controlled statistically. A low body
weight during adolescence was not independently associated with any other
adult health problems after these covariates were controlled.
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Table 4. Significant Associations Between Weight Loss Behaviors During
Adolescence and Health Problems During Early Adulthooda
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ADOLESCENT BEHAVIORS ASSOCIATED WITH WEIGHT PROBLEMS AND ADULT HEALTH
PROBLEMS
Eating alone to conceal unusual eating behavior, eating a large amount
of food, and frequent fluctuations in weight during adolescence were associated
with early adulthood health problems after age, sex, co-occurring psychiatric
disorders, corresponding health problems during adolescence, parental income,
and worries about health during early adulthood were controlled statistically
(Table 5). Several of the associations
between these behaviors and subsequent health problems remained significant
after adolescent eating disorders, co-occurring eating or weight problems,
and BMI were controlled. Adolescent obesity was associated with an elevated
risk for fair or poor health during adulthood (OR, 4.31; 95% CI, 1.39-13.33).
This association remained significant after age, sex, co-occurring psychiatric
disorders, corresponding health problems during adolescence, parental income,
adolescent eating disorders, and worries about health during early adulthood
were controlled. Adolescent obesity was not independently associated with
any other adult health problems after these covariates were controlled.
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Table 5. Significant Associations Between Behaviors Associated With
Weight Problems During Adolescence and Health Problems During Early Adulthooda
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COMMENT
The present findings indicate that adolescents with eating disorders
are at an elevated risk for a broad range of physical and mental health problems
during early adulthood. Our findings are consistent with the findings of cross-sectional
and treatment outcome studies26-33,50-51
indicating that eating disorders tend to be associated with poor physical
and mental health outcomes. However, to our knowledge, these are the first
systematic findings from a community-based longitudinal investigation to demonstrate
that adolescent eating disorders are associated with the risk for the development
of physical and mental disorders after preexisting health problems are controlled
statistically. Because most individuals with eating disorders are not appropriately
diagnosed or treated,34-35 it
seems that greater effort should be devoted to the recognition and treatment
of eating disorders among adolescents in the community. The administration
of screening questionnaires to patients with eating or weight problems may
help primary care physicians, pediatricians, and other practitioners to increase
the recognition of eating disorders.52 Referring
adolescents with eating disorders to appropriate treatment specialists may
help to prevent the development of potentially serious health problems.
The present findings also indicate that specific problems with eating
or weight during adolescence are associated with an increased risk for physical
and mental disorders during early adulthood. Our findings are of particular
interest because they indicate that youths with eating or weight problems
may be at an elevated risk for health problems during adulthood, even if their
problems with eating or weight are not severe enough to warrant an eating
disorder diagnosis. Because problems with eating and weight are so common
among adolescents in the general population, it would seem important to develop
and implement educational and public health interventions that inform parents
and youths about the potentially harmful long-term consequences of eating
and weight problems during adolescence.53
The present findings also indicate that problematic behaviors associated
with eating and weight tend to be more strongly associated with risk for subsequent
health problems than body weight itself. Particularly noteworthy are our findings
indicating that self-induced vomiting is strongly associated with various
adverse health outcomes. Future research should investigate the biological
and psychological processes that may mediate the associations between specific
problems with eating and weight and the development of physical and mental
disorders. Numerous factors, including disruptions in hormonal, neurotransmitter,
cytokine, peptide, immunologic, and metabolic functioning, may underlie these
associations.50-51,54-58
An increased understanding of the mechanisms that govern the association between
eating or weight problems and adverse health outcomes may facilitate the development
of more effective treatment interventions.
Although effective treatments are available for youths with eating disorders,23-33
the present findings from this upstate New York sample are consistent with
previous findings35 indicating that relatively
few adolescents with eating disorders receive these kinds of specialized treatment
services. Because eating and weight problems are associated with a wide range
of adverse health outcomes, the present findings suggest that greater effort
should be made to promote increased recognition and treatment of eating and
weight problems by pediatricians, primary care physicians, and other health
professionals. Our findings also suggest that specialized treatment programs
should be made more widely available to adolescents with eating disorders.
Limitations of the present study merit consideration. There were not
enough cases to permit analyses regarding associations between specific types
of adolescent eating disorders and adult health problems. Therefore, we investigated
associations between specific eating or weight problems and health problems
during early adulthood. In this respect, the present findings provide a uniquely
detailed and systematic contribution to the scientific literature. Health
outcomes were assessed by interview and could not be independently verified.
However, adolescent problems with eating or weight were associated with poor
adult health outcomes after worries about health during early adulthood were
controlled statistically. Because sufficiently detailed data regarding treatment
were not available, treatment outcomes could not be systematically investigated.
Few male subjects had eating disorders; however, many male subjects had eating
or weight problems, and it was of interest to investigate the health problems
that were associated with these problems. There were relatively few subjects
with certain health outcomes, such as cardiovascular symptoms, chronic fatigue,
and neurological symptoms. This would have been a concern if adolescent problems
with eating or weight did not predict these health outcomes. However, problems
with eating or weight during adolescence did predict several of the health
outcomes that were low in prevalence.
The present study also has numerous methodological strengths, including
the use of a large representative sample, the use of a longitudinal design,
the systematic assessment of a wide range of psychiatric disorders and health
problems from adolescence through early adulthood based on data that were
obtained from the youths and their mothers, and the use of statistical procedures
to control for the effects of age, sex, socioeconomic status, co-occurring
psychiatric disorders, preexisting health problems, and worries about health
during early adulthood. For these reasons, the present findings promise to
increase our understanding of the association between eating disorders and
health problems during early adulthood.
AUTHOR INFORMATION
Submitted for publication February 28, 2001; final revision received
August 16, 2001; accepted September 11, 2001.
This study was supported by grant MH-36971 from the National Institute
of Mental Health, Rockville, Md (Dr Cohen); and grant DA-03188 from the National
Institute on Drug Abuse, National Institutes of Health, Bethesda, Md (Dr Brook).
Corresponding author: Jeffrey G. Johnson, PhD, New York State Psychiatric
Institute, 1051 Riverside Dr, Campus Box 60, New York, NY 10032 (e-mail: jjohnso{at}pi.cpmc.columbia.edu).
From the Departments of Psychiatry, Columbia University and the New
York State Psychiatric Institute (Drs Johnson, Cohen, and Kasen) and The Mount
Sinai Medical Center (Dr Brook), New York, NY.
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