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Eating Disorders
Enza Gucciardi*1, Nalan Celasun2, Farah Ahmad3 and Donna E Stewart4

Address: 1University Health Network Women's Health Program, University of Toronto, 657 University Avenue, Toronto, Canada, 2University
Health Network Women's Health Program, University of Toronto, 657 University Avenue, Toronto, Canada, 3University Health Network Women's
Health Program, University of Toronto, 657 University Avenue, Toronto, Canada and 4University Health Network Women's Health Program,
University of Toronto, 657 University Avenue, Toronto, Canada
Email: Enza Gucciardi* - Enza.Gucciardi@uhn.on.ca; Nalan Celasun - Nalan.celasun@uhn.on.ca; Farah Ahmad - farah.ahmad@uhn.on.ca;
Donna E Stewart - donna.stewart@uhn.on.ca
* Corresponding author

from Women's Health Surveillance Report

Published: 25 August 2004

BMC Women's Health 2004, 4(Suppl 1):S21 doi:10.1186/1472-6874-4-S1-S21
This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S21
<supplement> <title> <p>Women's Health Surveillance Report</p> </title> <editor>Marie DesMeules, Donna Stewart, Arminée Kazanjian, Heather McLean, Jennifer Payne, Bilkis Vissandjée</editor> <sponsor> <note>The Women's Health Surveillance Report was funded by Health Canada, the Canadian Institute for Health Information (Canadian Population Health Initiative) and the Canadian Institutes of Health Research</note> </sponsor> <note>Reports</note> <url>http://www.biomedcentral.com/content/pdf/1472-6874-4-S1-info.pdf</url> </supplement>

Abstract
Health Issue: Eating disorders are an increasing public health problem among young women.
Anorexia and bulimia may give rise to serious physical conditions such as hypothermia,
hypotension, electrolyte imbalance, endocrine disorders, and kidney failure.
Key Issues: Eating disorders are primarily a problem among women. In Ontario in 1995, over 90%
of reported hospitalized cases of anorexia and bulimia were women. In addition to eating disorders,
preoccupation with weight, body image and self-concept disturbances, are more prevalent among
women than men.
Women with eating disorders are also at risk for long-term psychological and social problems,
including depression, anxiety, substance abuse and suicide. For instance, in 2000, the prevalence of
depression among women who were hospitalized with a diagnosis of anorexia (11.5%) or bulimia
(15.4 %) was more than twice the rate of depression (5.7 %) among the general population of
Canadian women. The highest incidence of depression was found in women aged 25 to 39 years
for both anorexia and bulimia.
Data Gaps and Recommendations: Hospitalization data are the most recent and accessible
information available. However, this data captures only the more severe cases. It does not include
the individuals with eating disorders who may visit clinics or family doctors, or use hospital
outpatient services or no services at all. Currently, there is no process for collecting this
information systematically across Canada; consequently, the number of cases obtained from
hospitalization data is underestimated. Other limitations noted during the literature review include
the overuse of clinical samples, lack of longitudinal data, appropriate comparison groups, large
samples, and ethnic group analysis.

Background failure. Women with eating disorders are also at risk of

Eating disorders are an increasing public health problem long-term psychological and social problems, including
among young women[1]: they may give rise to serious depression, anxiety, substance abuse and suicide. The
physical problems such as hypothermia, hypotension, costs in terms of quality of life, loss of productivity, seri-
electrolyte imbalance, endocrine disorders and kidney ous medical problems and mortality are high. [2]

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Clinical eating disorders include anorexia nervosa and western Ontario and Charlottetown, more than 25% from
bulimia nervosa. [3] Anorexia is characterized by a each grade reported not eating breakfast every day, and
severely calorie-restricted diet, resulting in a body weight there was a sharp increase among girls beginning in grade
that is at least 85% below that expected for age and height. 7.[18] Unhealthy eating patterns in childhood can
[3] Bulimia is identified by frequent fluctuations in weight adversely affect health, contribute to chronic disease in
and recurrent episodes of compulsive bingeing followed later life, and often persist into adolescence and adult-
by self-induced vomiting, purging, fasting, laxative use hood, since change is difficult once eating patterns are
and/or excessive exercise in attempts to avoid weight established.[18]
gain.[3] Eating disorders not otherwise specified include
behaviours such as chronic dieting, purging and binge- Morbidity
eating, which do not meet the full criteria for a specific eat- The starvation associated with anorexia and the chronic
ing disorder,[3] they are two to five times as common as vomiting frequently associated with bulimia can cause
the clinical eating disorders. serious medical problems, such as hypothermia, hypoten-
sion, anemia, osteoporosis, endocrine abnormalities,
Eating disorders are, by and large, a problem among dehydration, kidney stones, metabolic alkalosis and den-
women. From the data collected in the Ontario Health tal caries.[1] Girls and women with eating disorders are
Survey, Mental Health Supplement, the lifetime preva- also at increased risk of menstrual irregularities such as
lence of bulimia (according to the criteria of the Diagnos- amenorrhea, infertility, [19,20] miscarriages and fetal
tic and Statistical Manual, 3rd revision [DSM-III-R]) complications such as prematurity, low birth weight, mal-
among women aged 15 to 65 was estimated as 1.1% in formations and low Apgar scores.[1,20-23]
1990.[4] In 1995, 95% of reported hospitalized cases of
anorexia and more than 90% of hospitalized cases of Mothers who have or have had an eating disorder may
bulimia in Ontario were women.[5] also create abnormal behavioural patterns when feeding
their children, such as irregular feeding schedules,
In addition to eating disorders, preoccupation with detached non-interactive mealtimes, and use of food for
weight and body image, and self-concept disturbances, are non-nutritive purposes, which may lead to second-gener-
more prevalent among women than men.[4,6-9] Per- ation eating problems. [24-27]
sonal, behavioural and socio-environmental factors, such
as negative body image, low self-esteem, fear of becoming Psychological Morbidity
fat, chronic dieting and social pressures to be thin, are In addition to depression, anxiety and obsessive-compul-
identified risk factors.[1,6,10-13] sive disorders, eating disorders are also associated with
diminished libido, altered sleeping patterns, irritability
Body Image and suicide attempts.[3,28,29] Ontario women with
Body image concerns and preoccupation with body bulimia have higher levels of anxiety, depression and
weight and shape increase as girls become older and more alcohol abuse than those without bulimia.[3,4,29,30]
aware of the idealized societal preference for a thin body Smoking and substance abuse are much more prominent
shape.[14] The images of women in the media and popu- among teenaged girls with eating disorders than among
lar culture place pressure on vulnerable young girls and those with healthy eating habits. [3,17,28] In a recent
women to live up to these expectations, regardless of their analysis of the 1997 Ontario Student Drug Use Survey,
natural body shape.[8,9] In British Columbia, it was adolescent females who perceived themselves as over-
found that by age 18, 80% of girls at all weights reported weight were almost 50% more likely to smoke than those
that they would like to weigh less.[15,16] A school-based who considered themselves of average weight or too thin,
population study involving 1,739 adolescent women whereas weight perceptions were not associated with
aged 12 to 18 years in Toronto, Hamilton and Ottawa smoking among males.[31] Several studies have suggested
found that current dieting to lose weight was reported by an association between a traumatic experience (sexual or
23% of participants, binge-eating by 15%, self-induced physical abuse) and later self-injury. A recent study found
vomiting by 8.2% and the use of diet pills by 2.4%.[17] that among patients with eating disorders there is a more
than 30% lifetime risk of self-injurious behaviour.[32]
Body shape dissatisfaction and preoccupation with weight
are not limited to adolescents but also occur in children. Mortality
A recent Canadian school-based study concluded that The rate of death from anorexia is higher than from
34% of prepubescent girls, 36% of early pubescent girls bulimia because of the complications of starvation and
and 76% of post-pubescent girls were dissatisfied with electrolyte imbalances, or suicide.[33,34] A recent review
their body shape.[11] In a survey of eating and smoking reported a mortality rate of 0.6% for anorexia as com-
behaviours among boys and girls in grades 4 to 8 in south- pared with 0.3% for bulimia.[35] A longitudinal U.S.

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study (21-year follow-up) of 84 women with anorexia (BMI < 20), acceptable weight (BMI 20–25), some excess
reported that 14 women (16.7%) had died, and 12 of the weight (BMI 25–27) and overweight (BMI > 27).
14 had died of causes directly related to anorexia; the
observed death rate was 9.8 times greater than CIHI
expected.[6] From the CIHI database, any separations from hospital
with an ICD-9 code of 307.1 for anorexia and 307.5 for
Socio-Economic Status bulimia and other unspecified disorders of eating from
Although previous studies in Canada and the United 1994 to 1999 were extracted. Crude hospitalization rates,
States have demonstrated differences in education and age-specific rates, and age-standardized hospitalization
socio-economic status (SES) in the prevalence of obesity, rates per 100,000 separations across provinces and territo-
[36-38] the relation between eating disorders and SES is ries were examined. Furthermore, age-specific rates for the
still unclear.[17,39] Jones et al[17] observed that SES was comorbidity of depressive disorder (ICD-9 code of 311)
not significantly associated with disturbed eating behav- among those with a hospital separation for an eating dis-
iours in a school-based Ontario population (n = 530), order were also examined for the year 2000.
findings that are consistent with those of previous studies
and may reflect the pervasive influence of the media on all Results
SES groups.[39] Prevalence
The prevalence of eating disorders is difficult to ascertain,
Ethnic Subgroups since many people may not even be aware that they have
Cultural beliefs and attitudes are identified as significant an eating disorder, are reluctant to seek medical care or
contributing factors in the development of eating disor- have not been hospitalized. Although epidemiologic
ders.[40] Canadian research on eating disorders and eth- research can approximate the prevalence of eating disor-
nic background, however, is extremely limited. ders within a population, the lack of standard methodol-
ogies and community samples results in conflicting
A few studies propose that cultural beliefs may actually estimates.
protect ethnic groups against eating disorders, but their
effect may be eroded as adolescents face pressures of Hospitalization data are the most recent and accessible
acculturation.[41] A recent study of Mexican-American information available, but only the more severe cases are
women across generations reported that second-genera- captured and not the individuals with eating disorders
tion women displayed the most disordered eating pat- who may visit clinics or family doctors, use hospital out-
terns and the highest degree of acculturation to patient services or use no services at all. Currently, there is
mainstream U.S. culture.[42] Experiences of cultural no process for collecting this information systematically
change (such as those of immigrants, for example) may across Canada; consequently, the number of cases
also increase vulnerability to eating disorders.[43,44] obtained from hospitalization data is an underestimate.

This Study Inpatient crude hospital separations in Canada for any

This study presents data from the NPHS and national diagnosis of anorexia, bulimia and other unspecified eat-
databases to investigate the burden of eating disorders in ing disorders appear to have increased somewhat (by
Canada and to explore the differences in attitude to 4.7%), from 10.2 to 10.7 per 100,000 women between
weight between men and women. 1994 and 1999 (Figure 1). Although the rates among men
were notably lower, they also increased slightly (4.8%)
Methods during the same period, from 0.6 to 0.7 per 100,000 men
NPHS (Figure 1). These increases may be due to better awareness
Within the NPHS, 1996–1997 (see Appendix A for details and detection of eating disorders and improved special-
about the methods of data collection for the NPHS), the ized inpatient treatment programs.
population selected for this analysis consisted of women
and men aged 20 to 64, excluding pregnant women and Across Canada, age-standardized hospital separation rates
people less than 3 feet (0.9 metres) or greater than 6 feet for eating disorders were highest among women in British
11 inches (2.1 metres) in height. All data were weighted to Columbia (15.9 per 100,000 women) and New Bruns-
represent the total population at the date of each survey. wick (15.1), and lowest in Saskatchewan (8.6) and
Alberta (8.6) (Figure 2).
Respondents who perceived themselves to be either
underweight or overweight were asked to state their Differences between Men and Women
desired weight. The responses were analyzed according to The 1996–1997 NPHS data suggest that more women
four categories of body mass index (BMI) – underweight than men wished to weigh much less than their actual

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FigureSpecified,
Canadian
100,000
erwise 1for
Inpatient
Anorexia,
1994–1999
Crude
Bulimia
Hospital
and Eating
Separation
Disorder
RatesNot
perOth- Figureand
Desired
egory 3Mean
Sex Weight Gain or Loss by Body Mass Index Cat-
Canadian Inpatient Crude Hospital Separation Rates Desired Mean Weight Gain or Loss by Body Mass
per 100,000 for Anorexia, Bulimia and Eating Disor- Index Category and Sex Source: Statistics Canada,
der Not Otherwise Specified, 1994–1999 Source: Cana- National Population Health Survey 1996–1997
dian Institute for Health Information

Figure
Inpatient
Anorexia,
fied by Canadian
2Crude
BulimiaHospital
Province,
and Eating
Separation
1994–1999
DisorderRates
Notper
Otherwise
100,000 Speci-
for Figure
Canadian
Among
Not Otherwise
Women
4 Inpatient
Specified,
with
Age-specific
Anorexia,
2000 Prevalence
Bulimia andfor
Eating
Depression
Disorder
Inpatient Crude Hospital Separation Rates per Canadian Inpatient Age-specific Prevalence for
100,000 for Anorexia, Bulimia and Eating Disorder Depression Among Women with Anorexia, Bulimia
Not Otherwise Specified by Canadian Province, and Eating Disorder Not Otherwise Specified, 2000
1994–1999 Source: Canadian Institute for Health Source: Canadian Institute for Health Information
Information

weight (see Figure 3). Among those who had an accepta- Depression
ble BMI, between 20 and 25, women wanted to lose an In 2000, the prevalence of depression among women who
average of 5.3 kg, whereas men wanted to gain an average were hospitalized with a diagnosis of anorexia (11.54%)
of 2.2 kg. Among those with a BMI between 25 and 27 or or bulimia (15.36%) was more than twice the prevalence
greater than 27, women wished to achieve a higher aver- of depression (5.7%) in the general population of
age weight loss than men (8.7 kg versus 5.2 kg and 17.2 kg women, according to the 1998–1999 NPHS.[45] (For
versus 12.4 kg, respectively). Similarly, among those who depression rates of the general population please see the
were underweight, with a BMI of less than 20, the average chapter on "Depression".) The highest prevalence of
desired weight gain was smaller for women than for men depression was found among women between 25 and 39
(3.6 versus 8.9 kg). years of age for both anorexia and bulimia (see Figure 4).

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subgroups such as disabled, immigrant and visible minor-

ity women.

• Cross-cultural and longitudinal evaluations of attitudes

and behaviours towards disordered eating should be con-
ducted in large community samples to monitor trends,
examine protective and non-protective factors, and assist
in the development and planning of preventive and treat-
ment programs.

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