Onset of adolescent eating disorders: population based cohort study over 3 years

Abstract Objective: To study the predictors of new eating disorders in an adolescent cohort. Design: Cohort study over 3 years with six waves. Subjects: Students, initially aged 14-15 years, from 44 secondary schools in the state of Victoria, Australia. Outcome measures: Weight (kg), height (cm), dieting (adolescent dieting scale), psychiatric morbidity (revised clinical interview schedule), and eating disorder (branched eating disorders test). Eating disorder (partial syndrome) was defined when a subject met two criteria for either anorexia nervosa or bulimia nervosa according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Results: At the start of the study, 3.3% (29/888) of female subjects and 0.3% (2/811) of male subjects had partial syndromes of eating disorders. The rate of development of new eating disorder per 1000 person years of observation was 21.8 in female subjects and 6.0 in male subjects. Female subjects who dieted at a severe level were 18 times more likely to develop an eating disorder than those who did not diet, and female subjects who dieted at a moderate level were five times more likely to develop an eating disorder than those who did not diet. Psychiatric morbidity predicted the onset of eating disorder independently of dieting status so that those subjects in the highest morbidity category had an almost sevenfold increased risk of developing an eating disorder. After adjustment for earlier dieting and psychiatric morbidity, body mass index, extent of exercise, and sex were not predictive of new eating disorders. Conclusions: Dieting is the most important predictor of new eating disorders. Differences in the incidence of eating disorders between sexes were largely accounted for by the high rates of earlier dieting and psychiatric morbidity in the female subjects. In adolescents, controlling weight by exercise rather than diet restriction seems to carry less risk of development of eating disorders. Key messages Adolescent females who diet at a severe level are 18 times more likely to develop an eating disorder than those who do not diet, and those who diet at a moderate level are five times more likely to develop an eating disorder High levels of psychiatric morbidity in females increase the risk of developing eating disorders by sevenfold Around two thirds of new cases of eating disorder arise in females who have dieted moderately The predominance of eating disorders in females is largely explained by the higher rates of earlier dieting and psychiatric morbidity Daily exercise seems to be a less risky strategy for controlling weight in adolescents