Review of the Prevalence and Incidence of Eating Disorders

Hans Wijbrand Hoek1,2* and Daphne van Hoeken1

2

Parnassia Psychiatric Institute, The Hague, The Netherlands Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
Accepted 26 January 2003

Abstract: Objective: To review the literature on the incidence and prevalence of eating disorders. Methods: We searched Medline using several key terms relating to epidemiology and eating disorders and we checked the reference lists of the articles that we found. Special attention has been paid to methodologic problems affecting the selection of populations under study and the identification of cases. Results: An average prevalence rate for anorexia nervosa of 0.3% was found for young females. The prevalence rates for bulimia nervosa were 1% and 0.1% for young women and young men, respectively. The estimated prevalence of binge eating disorder is at least 1%. The incidence of anorexia nervosa is 8 cases per 100,000 population per year and the incidence of bulimia nervosa is 12 cases per 100,000 population per year. The incidence of anorexia nervosa increased over the past century, until the 1970s. Discussion: Only a minority of people who meet stringent diagnostic criteria for eating disorders are seen in mental health care. # 2003 by Wiley Periodicals, Inc. Int J Eat Disord 34: 383396, 2003. Key words: prevalence; incidence; epidemiology; methodology; anorexia nervosa; bulimia nervosa; binge eating disorder; health care; general practice

INTRODUCTION
Prevalence and incidence are the basic measures of disease frequency. The prevalence is the total number of cases in the population. The point prevalence is the prevalence at a specific point in time. The 1-year period prevalence rate is the point prevalence rate plus the annual incidence rate. The prevalence rate is the most useful rate for planning facilities, as it indicates the demand for care. The incidence is the number of new cases in the population over a specified period of time (usually 1 year) and is commonly expressed per 100,000 of the population per year. Incidence rates for eating disorders represent the situation at the moment of detection,
Correspondence to: Prof. Dr. Hans W. Hoek, Parnassia Psychiatric Institute, Mangostraat 15, 2552 KS The Hague, The Netherlands. E-mail: w.hoek@parnassia.nl Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.10222
#

2003 by Wiley Periodicals, Inc.

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which is not necessarily the moment when the disorder actually began. There have been no studies on the incidence of eating disorders in the general population. The incidence rates available have been based on cases presented to health care facilities. Incidence rate differences between groups are better clues to etiology than are prevalence rate differences, because they relate to fairly new cases of an eating disorder. Several reviews have been written on the epidemiology of eating disorders (Fairburn & Beglin, 1990; Fombonne, 1995; Hsu, 1996; Szmukler, 1985). The current article is based on a selection of the literature on epidemiology and updates and incorporates our previous reviews (Hoek, 1993; Hoek, 2002; Hoek, van Hoeken, & Katzman, 2003; van Hoeken, Lucas, & Hoek, 1998; van Hoeken, Seidell, & Hoek, 2003).

METHOD
We searched the literature in Medline using several key terms relating to epidemiology and eating disorders. We also checked the reference lists of the articles that we found. Methodologic Problems The validity of many epidemiologic studies of eating disorders is questioned because there is a number of methodologic problems concerning the selection of populations and the identification of cases (Hoek, 1993; Hsu, 1996; van Hoeken et al., 2003; Szmukler, 1985). Specific problems are the low prevalence of eating disorders in the general population and the tendency of eating disorder subjects to conceal their illness and avoid professional help. These factors make it necessary to study a large number of subjects from the general population to achieve enough differential power for the cases. This can be a highly time and cost-intensive task. Several strategies have been used to circumvent this problem, in particular case register and other record-based studies, two-stage studies, and studies of special populations. The limitations of record-based studies are considerable (Hsu, 1996). Register-based frequencies represent cases detected in inpatient and occasionally outpatient care. Treated cases represent only a minority of all cases (Hoek, 1993). Findings from case registers and hospital records are of limited value for generating hypotheses on the etiology of disease because there is no direct access to the subjects and the additional information that is available is usually limited and of a demographic nature only. Currently, the two-stage screening approach is the most widely accepted procedure for the identification of prevalent cases. First, a large population is screened for the likelihood of an eating disorder by means of a screening questionnaire that identifies an at-risk population (first stage). Second, definite cases are established on the basis of a personal interview with subjects from this at-risk population and from a randomly selected sample of subjects not at risk (second stage; Williams, Tarnopolsky, & Hand, 1980). Methodologic problems of two-stage studies are poor response rates, the sensitivity and specificity of the screening instrument, and the restricted size of the groups interviewed, particularly of those not at risk (Fairburn & Beglin, 1990). Studies of special populations address a particular segment of the general population, selected a priori for being at increased risk (e.g., high school girls, female university students, athletes, or a particular age cohort). The major methodologic problem associated with this type of study is the generalizability of the findings to the general population.

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Classification In the sections on anorexia nervosa and bulimia nervosa, we discuss only studies that use strict definitions of these eating disorders as defined by the American Psychiatric Association (APA, 1980, 1987, 1994), the World Health Organization (WHO, 1978, 1992), Russell (1979), and Feighner et al. (1972). Another category, the eating disorders not otherwise specified (EDNOS), includes a variety of patients who do not meet all criteria for anorexia nervosa or bulimia nervosa but who do have symptoms severe enough to qualify them as having a clinically significant eating disorder. This heterogeneity makes it a difficult category on which to base a search for possible etiologic factors. As a result, there is hardly any reliable epidemiologic information available for this category of patients. Therefore, EDNOS subjects are not included in this review. In DSM-IV, a provision is made for a separate eating disorder category to be researched further, binge eating disorder (BED). Although there is only limited epidemiologic information available, we will briefly review the epidemiology of this disorder.

RESULTS
Anorexia Nervosa Prevalence The current standard for the assessment of the prevalence of eating disorders is the two-stage screening approach. Table 1 summarizes the two-stage surveys of young females with anorexia nervosa. All two-stage studies obtained response rates of 85% or higher, except Meadows, Palmer, Newball, and Kenrick (1986), who achieved a response rate of 70%. These twostage surveys found a prevalence rate of 0%0.9% for strictly defined anorexia nervosa among young females. Most studies found much higher prevalence rates for partial syndromes of anorexia nervosa. Two-stage surveys in Europe using DSM-IV criteria for anorexia nervosa identical to DSM-III-R criteriareported an average prevalence rate of 0.29% for anorexia nervosa. A review of studies before 1993 using DSM-III criteria revealed a similar finding, namely, an average prevalence rate of 0.28% (Hoek, 1993). Another study is discussed here because it was not confined to high-risk populations and it provided prevalence rates for the entire population. Lucas, Beard, OFallon, and Kurland (1991) used an extensive case-finding method, which included all medical records of health care providers, general practitioners, and specialists in the community of Rochester, Minnesota. They also screened records that mentioned diagnostic terms that could refer to nondetected cases. They found an overall sex and age-adjusted point prevalence rate of 0.15% (95% confidence interval [CI]: 0.12%0.18%) on January 1, 1985. The Rochester, Minnesota, study included probable and possible cases. Definite cases constituted only 39% (82 of 208 cases) of all incident cases identified in the period 19351989 (Lucas, Crowson, OFallon, & Melton, 1999). If this rate is applied to the point prevalence of 0.15%, an estimated point prevalence of 0.06% is obtained for definite cases in the Rochester population on January 1, 1985. Incidence The incidence studies of anorexia nervosa used psychiatric case registers, medical records of hospitals in a circumscribed area, registrations by general practitioners, or medical records of health care providers in a community. All record-based studies will

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Table 1.
Subjects Source College Private schools State schools General practice Schoolgirls General practice Schoolgirls High school General practice Schoolgirls and case register Schoolgirls Schoolgirls Schoolgirls Schoolgirls 1120 1416 1417 1518 1221 517 747 276 3,100 2,862 1318 1635 2,544 540 1635 15 539 2,136 1416 1,010 EAT EAT Growth chart and questionnaire EAT Questionnaire EAT EAT EDE-S EAT EAT 1622 1419 1419 1822 446 1,331 1,676 584 EAT EAT EAT EAT Age N Screening Criteria Feighner Russell Russell DSM-III Russell Russell DSM-III-R DSM-III DSM-III-R DSM-III-R DSM-III-R DSM-III-R DSM-IV DSM-IV Methods

Two-stage surveys of prevalence of anorexia nervosa in young females

Study

Prevalence (%) 0.2 0.8 0.2 0.2a 0 0 0.70 0.3 0.2 0.58 0 0.7 0.9 0.3

Button and Whitehouse (1981) Szmukler (1983) Szmukler (1983) Meadows, Palmer, Newball, and Kenrick (1986) Johnson-Sabine, Wood, Patton, Mann, and Wakeling (1988) King (1989) stam, Gillberg, and Garton (1989) Ra

Whitaker et al. (1990) Whitehouse, Cooper, Vize, Hill, and Vogel (1992) Rathner and Messner (1993) Wlodarczyk-Bisaga and Dolan (1996) Steinhausen, Winkler, and Meier (1997) Nobakht and Dezhkam (2000) Gual et al. (2002)

Note: EAT Eating Attitudes Test; EDE-S Eating Disorders ExaminationScreening Version; DSM-III, DSM-III-R, DSM-IV 3rd, 3rd Rev. ed., and 4th ed., respectively, of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980, 1987, 1994 [see reference list]). a Not found by screening (EAT score below threshold).

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grossly underestimate the incidence in the community, because not all subjects will be referred to (mental) health care or be hospitalized. Therefore, it is unclear whether the increase in cases reported to the health care facilities reflects an actual increase in the incidence in the community. The increase might also be due to improved methods of case detection or to the wider availability of services. Table 2 shows all studies that reported overall incidence rates of anorexia nervosa for the total population. The overall rates vary considerably, ranging from 0.10 per 100,000 population per year in a hospital recordsbased study in Sweden in the 1930s to 12.0 per 100,000 population in a medical recordsbased study in the United States in the 1980s. Incidence rates derived from general practitioners on average represent eating disorders that started more recently than those based on other medical records (e.g., Hoek et al., 1995; Turnbull, Ward, Treasure, Jick, & Derby, 1996). In the study conducted in The Netherlands (Hoek, 1991; Hoek et al., 1995), general practitioners using DSM-III-R criteria recorded the rate of eating disorders in a large (N 151,781) representative sample (1.1%) of the Dutch population. The incidence rate of anorexia nervosa was 8.1 per 100,000 person-years (95% CI: 6.110.2) during the period 19851989. During the study period, 63% of the incident cases were referred to mental health care, yielding an incidence rate of anorexia nervosa in mental health care of 5.1 per year per 100,000 population. In the period 19951996, the incidence of patients with anorexia nervosa referred to mental health care was 5.4 per year per 100,000 population (Hoek, van Hoeken, & Bartelds, 2000). Turnbull et al. (1996) searched the UK General Practice Research Database (which covers 550 general practitioners and 4 million patients) for

Table 2.

Incidence of anorexia nervosa per year per 100,000 population

Study Region Southern Sweden Source Hospital records Period 19311940 19411950 19511960 (19311960) 19561958 19631965 19731975 19831985 19931995 19601969 19701976 19651971 19601969 19781982 19741982 1970 1988 1989 19851989 1993 19351949 19501959 19601969 19701979 19801989 (19351989) Incidence 0.10 0.20 0.45 (0.24) 0.38 0.55 1.12 1.43 1.17 0.37 0.64 0.66 1.60 4.06 5.0 0.42 1.36 1.17 8.1 4.2 9.1 4.3 7.0 7.9 12.0 (8.3)

Theander (1970)

Willi and Grossmann (1983) Willi, Giacometti, and Limacher (1990) Milos et al. (in press) Jones, Fox, Babigian, and Hutton (1980)

Zurich, Switzerland Hospital records

Zurich, Switzerland Hospital records Zurich, Switzerland Hospital records Monroe County, NY Case register and hospital records Kendell, Hall, Hailey, and Babigian (1973) Camberwell, UK Case register Kendell, Hall, Hailey, and Babigian (1973) Northeast Scotland Case register Szmukler, McCance, McCrone, and Northeast Scotland Case register Hunter (1986) Hoek and Brook (1985) Assen, Netherlands Case register Mller-Madsen and Nystrup (1992) Denmark Case register Hoek et al. (1995) Turnbull, Ward, Treasure, Fick, and Derby (1996) Lucas, Crowson, OFallon, and Melton (1999) The Netherlands England, Wales Rochester, MN General practitioners General practitioners Medical records

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first diagnoses of anorexia nervosa in the period 19881993. A randomly selected subset of cases was checked with DSM-IV criteria, from which estimates of adjusted incidence rates were made. They reported an age and sex-adjusted incidence rate of 4.2 (95% CI: 3.45.0) per 100,000 population for anorexia nervosa in 1993. Lucas et al. (1991, 1999) used an extensive case-finding method. Over the period of 19351989, they reported an overall age and sex-adjusted incidence rate of anorexia nervosa of 8.3 per 100,000 person-years (95% CI: 7.19.4). Time Trends There has been considerable debate regarding whether the incidence of eating disorders is, or has been, increasing. Various studies have reported diverging incidence rates, which may be due to methodologic problems. Long-term epidemiologic studies are sensitive to changes in methods, such as variations in registration policy, demographic differences between the populations, inclusion of readmissions, the particular methods of detection used, or the availability of services (Fombonne, 1995; Williams & King, 1987). Studies based on long study periods (Lucas et al., 1999; Willi, Giacometti, & Limacher, 1990; Willi & Grossmann, 1983) have revealed an upward trend in the incidence of anorexia nervosa since the 1950s. The increase is most substantial among 1524-yearold females. Lucas et al. (1999) found that the age-adjusted incidence rates of anorexia nervosa among 1524-year-old females showed a highly significant linear increasing trend from 1935 to 1989, with an estimated rate of increase of 1.03 per 100,000 personyears per calendar year. A rise in incidence also has been observed among 1014-year-old females for each decade since the 1950s. The rates for men and for women older than 25 years old have remained relatively low. Despite the use of different methods, we have attempted to combine the results of various studies on the incidence of anorexia nervosa in mental health care in Northern Europe (Sweden, Northeast Scotland, and The Netherlands) to derive a figure over a long period (Figure 1). Figure 1 and the studies in Switzerland (see Table 2) show that until the 1970s, there was an increase over time of the registered incidence of anorexia nervosa in Europe. After the 1970s, the incidence of anorexia nervosa in Europe stabilized (Hoek, 1993; Hoek et al., 2000; Milos et al., in press). The debate still continues about the extent to which there has been an increase in the true incidence (i.e., the incidence in the community) of anorexia nervosa in the 20th century. However, there has been a definite increase in the incidence of registered cases and, as a result, an increased demand for care. Age Incidence rates for anorexia nervosa are the highest for females in the 1519 age group. This age group constitutes approximately 40% of all identified cases. For example, Lucas et al. (1999) reported an incidence of 73.9 per 100,000 person-years for 1519-year old women over the period of 19351989, with a continual rise since the 1930s to a top rate of 135.7 for the period 19801989. They reported incidence rates of 9.5 for 3039-year-old women, 5.9 for 4049-year-old women, 1.8 for 5059-year-old women, and 0.0 for women 60 years and older. Males Anorexia nervosa also occurs in men, but few studies report incidence rates for this section of the population. The incidence of anorexia nervosa among males is below 1.0 and probably even below 0.5 per 100,000 population per year (Hoek et al., 1995; Lucas et al.,

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Figure 1. Yearly incidence of anorexia nervosa in mental health care in Northern Europe in the 20th century.

1999; Turnbull et al., 1996) and the female-to-male ratio is more than 10:1 (Hoek et al., 1995; van Hoeken et al., 2003). Bulimia Nervosa Prevalence In 1990, Fairburn and Beglin provided a review of the prevalence studies on bulimia nervosa. The Fairburn/Beglin review yielded the generally accepted prevalence rate of 1% among young females for bulimia nervosa diagnosed according to the prevailing criteria at that time (DSM-III, DSM-III-R, and Russell). Table 3 summarizes the two-stage surveys of bulimia nervosa in young females that have been published since the review by Fairburn and Beglin. The aggregated prevalence rate according to DSM-III-R and DSM-IV criteria remains 1%. In a random, stratified, nonclinical community sample, based on a structured interview for the whole sample, the lifetime prevalence of bulimia nervosa was 1.1% among women and 0.1% among 1565-year-old men using DSM-III-R criteria (Garfinkel et al., 1995). The prevalence of subclinical bulimia nervosa among young females is substantially higher than that of full-syndrome bulimia nervosa (e.g., Whitehouse, Cooper, Vize, Hill, & Vogel, 1992: 1.5% for full-syndrome and 5.4% for partial-syndrome bulimia nervosa). Incidence Only a few incidence studies of bulimia nervosa have been reported in the literature. The most obvious reason for this was the lack of criteria for bulimia nervosa. Most case registers use the International Classification of Diseases (ICD-10; WHO, 1992). ICD-9 (WHO, 1978) and previous versions did not provide a separate code for bulimia nervosa. Bulimia nervosa was first distinguished as a separate disorder by Russell in 1979 and the APA in 1980 (DSM-III). Before 1980, the term bulimia in medical records denoted symptoms of heterogeneous conditions manifested by overeating, but not the syndrome, as it

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Table 3.
Subjects Source Household census DIS 777 2,544 416 224 540 517 359 747 276 3,100 2,862 EAT EAT EAT EDE-S EAT EAT 1824 DIS DSM-III DSM-III Age N Screening Criteria Methods

Two-stage surveys of prevalence of bulimia nervosa in young females

Study

Prevalence (%) 4.5

Bushnell, Wells, Hornblow, Oakley-Browne, and Joyce (1990) Household census Household census High school Schoolgirls College General practice 1120 16 1416 1417 1518 1221 1635 1936 EAT EAT, BCDS, ANIS EAT, BCDS, ANIS Questionnaire 2544 (1844) 1318 1418

Whitaker et al. (1990) and Tu ry (1991) Szabo

and Tu ry (1991) Szabo

Whitehouse, Cooper, Vize, Hill, and Vogel (1992) Rathner and Messner (1993) Schoolgirls and case register Schoolgirls Schoolgirls Schoolgirls Schoolgirls Schoolgirls

DSM-III DSM-III DSM-III-R DSM-III DSM-III-R DSM-III-R DSM-III-R DSM-IV DSM-III-R DSM-III-R DSM-IV DSM-IV

2.0 (2.6) 4.2 0 0 4.0 1.3 1.5 0 0.5 0 0.5 3.2 0.8

Santonastaso et al. (1996) Wlodarczyk-Bisaga and Dolan (1996) Steinhausen, Winkler, and Meier (1997) Nobakht and Dezhkam (2000) Gual et al. (2002)

Note: ANIS Anorexia Nervosa Inventory Scale; BCDS Bulimic Cognitive Distortions Scale; DIS Diagnostic Interview Schedule; DSM-III, DSM-III-R, DSM-IV 3rd, 3rd Rev. ed., and 4th ed., respectively, of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980, 1987, 1994 [see reference list]); EAT Eating Attitudes Test; EDE-S Eating Disorder ExaminationScreening Version.

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is known today. Therefore, it is difficult to evaluate trends in the incidence of bulimia nervosa or a possible shift from anorexia nervosa to bulimia nervosa. Three studies reported the incidence rate of bulimia nervosa in Rochester, MN (Soundy, Lucas, Suman, & Melton, 1995), The Netherlands (Hoek et al., 1995), and the United Kingdom (Turnbull et al., 1996). The methodology used by Soundy et al. was similar to that employed by Lucas et al. (1991) in their long-term study of anorexia nervosa in the same area. They screened all medical records of health care providers, general practitioners, and specialists in Rochester over the period of 19801990 for a clinical diagnosis of bulimia nervosa and related symptoms. In The Netherlands, Hoek et al. (1995) evaluated the incidence rate of bulimia nervosa using DSM-III-R criteria. This general practice study was representative of the population and covered the period 1985 1989. Turnbull et al. (1996) screened the UK General Practice Research Database, covering a large, representative sample of the English and Welsh populations, for first diagnoses of anorexia nervosa and bulimia nervosa in 1993. These three studies reported an annual incidence of approximately 12 per 100,000 population for bulimia nervosa: 13.5 in Rochester, MN (Soundy et al., 1995), 11.5 for The Netherlands (Hoek et al., 1995), and 12.2 in the United Kingdom (Turnbull et al., 1996). Another general population study was performed by Pagsberg and Wang (1994) on the island of Bornholm, Denmark. This study is mentioned briefly because the population under study was relatively small (less than 50,000 inhabitants). Pagsberg and Wang found an incidence of 6.8 per year per 100,000 population during the period 19851989. Time Trends The yearly incidence rates in Rochester rose sharply from 7.4 per 100,000 females in 1980 to 49.7 in 1983. Then they remained relatively constant at approximately 30 per 100,000 females until 1990 (Soundy et al., 1995). This would seem to be related to the publication, and to the subsequent implementation in the field, of the DSM-III, whereby bulimia nervosa was recognized as an official diagnostic category. Turnbull et al. (1996) reported a significant and threefold increase in the bulimia nervosa incidence rates for 1039-year-old women during the period 19881993: from 14.6 in 1988 to 51.7 in 1993. These incidence rates of bulimia nervosa can only serve as minimum estimates of the true incidence rate. The reasons are the lack of data, the greater taboo surrounding bulimia nervosa, and its lower perceptibility compared with anorexia nervosa. Age For the group at highest risk (i.e., 2024-year-old females), Soundy et al. (1995) reported an incidence rate of 82.7 per 100,000 and Hoek et al. (1995) reported an incidence rate of 82.1 per 100,000. Turnbull et al. (1996) reported an annual incidence of 1.7 per 100,000 person-years (men and women) aged 40 and over. Males Both Soundy et al. (1995) and Hoek et al. (1995) reported an incidence of bulimia nervosa of 0.8 for males per 100,000 person-years. BED In DSM-IV, BED is referred to as a diagnostic category in need of further research. A general problem with the comparison of studies of BEDand of bulimia nervosais

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the definition of a binge. Studies may differ in the boundaries set for a binge, resulting in subject groups that are not fully comparable. In the literature, only Cotrufo, Barretta, Monteleone, and Maj (1998) used a two-stage procedure to evaluate the prevalence of BED. They identified two cases of BED in a group of 1319-year-old females (N 919), a prevalence rate of 0.2%. This low rate may be due to the relatively young age of the population investigated. In addition, the sample size is rather small for a low-frequency disorder. As in the case of anorexia nervosa and bulimia nervosa, we would have preferred to focus on prevalence studies using a two-stage case identification procedure in the general population. Because such studies are lacking, we described other prevalence studies. Ghaderi and Scott (2001) used questionnaires on two occasions to evaluate a random sample of 1,157 females aged 1830 in the Swedish population. They found a prevalence of BED of 1.2%. Hay (1998) conducted interviews to determine the prevalence of bulimic-type eating disorders in all subjects in a large general population sample (3,001 interviews). The mean age of the subjects was 35.2 years. Using DSM-IV criteria, a point prevalence of 1% was found for BED. Using a broader definition by Fairburn and Cooper (1993), the prevalence was estimated to be 2.5%. A weakness of the study was that diagnoses were based on a limited number of questions (two gating questions, and three further probes). No information was given regarding the sensitivity and specificity of the instrument. In the United States, a rate of 4.5% for recurrent binge eating (two episodes per week during the previous 3 months) was reported among a sample of 1840-year-old Black women (N 1,628) and a rate of 2.6% was found among 5,741 White women of the same age group (Striegel-Moore, Wilfley, Pike, Dohm, & Fairburn, 2000). A noteworthy finding in that study is that Black and White women differed significantly on a number of eating disorder features. For example, Black women with BED reported less concern about weight, shape, and eating compared with White women with BED (Pike, Dohm, Striegel-Moore, Wilfley, & Fairburn, 2001).

DISCUSSION
We reviewed more epidemiologic studies from the United States and Western Europe than from other parts of the world because these researchers were able to use more thorough methods, such as two-stage procedures. To achieve a broader understanding of the epidemiology of eating disorders, we also reviewed cross-cultural studies (for reviews, see Hoek et al., 2003; Nasser, 1997; Nasser, Katzman, & Gordon, 2001). Transcultural studies in the 1970s and 1980s showed that anorexia nervosa was rare in nonWestern countries (Ballot et al., 1981; Buchan & Gregory, 1984; Buhrich, 1981; Famuyiwa, 1988; King & Bhugra, 1989; Lee, Chiu, & Chen, 1989). However, more recent studies have demonstrated that abnormal eating attitudes and eating disorders, in particular BED and bulimia nervosa, frequently occur in traditional as well as in developing countries and among Whites as well as among Blacks and Asians (Ghazal, Agoub, Moussaoui, & Battas, 2001; Hoek, van Harten, van Hoeken, & Susser, 1998; Huon, Mingyi, Oliver, & Xiao, 2002; Lee & Lee, 1996; Mumford, Whitehouse, & Choudry, 1992; Nakamura et al., 2000; Nobakht & Dezhkam, 2000). Health policy makers need to know the number of patients in care. Despite the variety of methods used in these studies, we have tried to combine the different rates of anorexia

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Table 4. 1-year period prevalence rates per 100,000 young females at different levels of care
Level of morbidity Community (0) Primary care (1) Mental health care (2) Anorexia Nervosa 370 160 127 Bulimia Nervosa 1,500 170 87

nervosa and bulimia nervosa into one model to discuss the morbidity at different levels of care (Hoek, 1993, 2002). Table 4 shows the 1-year period prevalence rates per 100,000 young females at three different levels. The 1-year period prevalence is given by point prevalence plus annual incidence rate. Level 0 represents the community. Our knowledge about this level is derived from the two-stage surveys of eating disorders. We calculated that the mean point prevalence rate for anorexia nervosa is 290 and for bulimia nervosa is 1,000 per 100,000 young females. We do not know the incidence rates in the community. In previous studies, we used primary care figures as estimates for the incidence in the community (Hoek, 1991, 1993). Using these estimates, we calculated the 1-year period prevalence rates in the community to be 370 for anorexia nervosa and 1,500 for bulimia nervosa per 100,000 young females (Hoek, 1993). Level 1 consists of patients identified as having an eating disorder by their primary care physicians. These rates are derived from the general practice study in The Netherlands (Hoek et al., 1995). Patients attending outpatient and inpatient services of mental health care represent Level 2. The rates for eating disorders were derived from the number of patients referred to mental health care by the general practitioner according to the studies in The Netherlands (Hoek, 1991; Hoek & Brook, 1985; Hoek et al., 1995, 2000). In spite of the methodologic differences of the community studies and the fact that the data on Levels 1 and 2 are from one country only (The Netherlands), Table 4 shows that approximately one third of the anorexia nervosa patients in the community receive mental health care. Only about 6% of subjects with bulimia nervosa receive mental health care.

CONCLUSIONS
Many of the epidemiologic studies on eating disorders in Western Europe and the United States yield consistent prevalence rates. For anorexia nervosa, an average prevalence rate of 0.3% was found for young females. The reported prevalence rate of bulimia nervosa was 1% in young women, which seems accurate. A tentative conclusion is that the prevalence of BED is at least 1%. It must be assumed that even the studies with the most complete case-finding methods yield an underestimate of the true incidence. On the basis of our review, we conclude that the overall incidence of anorexia nervosa is at least 8 per 100,000 population per year and the incidence of bulimia nervosa is at least 12 per 100,000 population per year. The incidence rate of anorexia nervosa, particularly in 1524-year-old females, definitely increased over the past century, until the 1970s. Whereas eating disorders are rare in the general population, they are relatively common among adolescent girls and young women. Unfortunately, only a minority of the

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people who meet stringent diagnostic criteria for eating disorders receive mental health care. This means that the majority of persons with a severe eating disorder lack adequate treatment.

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