Bulimia Tied to Increased CVD, Early Death Risk

Pauline Anderson

October 28, 2019

Women with bulimia serious enough to require hospitalization have about a fourfold increased risk for cardiovascular disease (CVD) and premature death, new research shows.

Nathalie Auger, MD

Clinicians should be aware that bulimia is not something that goes away once treated, study investigator Nathalie Auger, MD, physician researcher at University of Montreal Hospital Research Center, Quebec, Canada, told Medscape Medical News.

"This is a long-standing problem that impacts women throughout their lives," she said.

Psychiatrists would benefit from working with clinicians, including cardiologists, to identify women with bulimia and the "best strategies to help them improve their cardiovascular profile," Auger added.

The study was published online October 16 in JAMA Psychiatry.

Lack of Follow-up

Characterized by episodes of binge eating followed by purging, including self-induced vomiting, laxative use, excessive exercise, or restricted food intake, bulimia is one of the most common psychiatric disorders among women, affecting an estimated 1.5% of the population.

After initial treatment, women with bulimia are often not followed up over time to monitor their outcomes, Auger noted.

"There are known acute cardio effects of eating disorders, but the long-term relationship of eating disorders with cardiovascular disease or mortality is much more poorly understood," she said.

Using a provincial health registry in Quebec, investigators collected data on 818 women hospitalized for bulimia between 2006 and 2016.

Patients were hospitalized for conditions such as electrolyte imbalances, gastrointestinal or pulmonary complications, or psychiatric disorders including suicide attempts.

The investigators compared cardiovascular outcomes and all-cause mortality between women with bulimia and 415,891 women hospitalized for a pregnancy-related event such as giving birth or having an abortion. The mean age of study participants was 28.3 years. The study's mean follow-up period was 12 years.

Adjusted analyses showed that compared with hospitalization for a pregnancy-related event, hospitalization for bulimia was associated with increased risk of any CVD (hazard ration [HR], 4.25; 95% confidence interval [CI], 2.98 - 6.07), and death (HR, 4.72; 95% CI, 2.05 - 10.84). This risk increased with more than one admission for bulimia.

Bulimia was associated with increased risk for all cardiovascular outcomes. For example, compared with the control group, women hospitalized with bulimia had 5.48 times the risk of myocardial infarction, 6.63 times the risk of other ischemic heart disease, and 6.94 times the risk of atherosclerosis.

Surprising Findings

The results were somewhat surprising since the women in the study were "quite young," said Auger. "It really suggests that bulimia is an important problem in terms of the overall impact on life functioning and common conditions like cardiovascular diseases."

The risk of any CVD was greatest in the first few years following initial bulimia hospitalization and decreased over time to the point that it was almost equal to that of the control group at 12-year follow-up. The same was true for mortality risk.

A phenomenon called "depletion of susceptibles" may help explain this phenomenon, said Auger. Since women in the study had bulimia severe enough to require hospitalization, they may develop cardiovascular outcomes more rapidly, leaving fewer women available to acquire cardiovascular disease.

Several factors may explain why women with bulimia are at higher risk of CVD. Auger noted there's an element of depression, stress, or anxiety involved with bulimia and that mental illnesses are linked to increased CVD risk.

Many women with bulimia have metabolic alterations such as hypercholesterolemia, and they typically have low estrogen levels, which may also negatively affect cardiovascular health, the authors note.

In addition, they may engage in unhealthy behaviors including smoking, as well as drug and alcohol use, which are significant contributors to CVD.

A limitation of the study was that there was no available information on the duration of bulimia and or binge-eating disorder, which shares features of bulimia but doesn't include purging.

In addition, there were no data on electrolytes, serum cholesterol or triglycerides, diet quality, or physical activity.

Secret Symptoms

Commenting on the findings for Medscape Medical News, Scott Crow, MD, University of Minnesota, who has researched eating disorders and CVD, said the study is important as it helps clarify/quantify bulimia's mortality risk.

Crow noted that many previous studies focused on anorexia nervosa, which, unlike bulimia, is a noticeable disorder because of extreme weight loss.

"When people have bulimia, symptoms are usually secretive for some length of time," which could lead to an underestimation of mortality risk, said Crow, who is also director of the Midwest Regional Postdoctoral Training Program in Eating Disorders Research.

Using pregnancy-related conditions as a comparator is "a nice control" for determining mortality compared with the population of young women as a whole, said Crow. However, he noted, the study doesn't "completely make clear" whether the risk is related to bulimia or comorbid psychopathology, such as anxiety or mood disorders.

Auger and Crow have disclosed no relevant financial relationships.

JAMA Psych. Published online October 16, 2019. Abstract

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