柳叶刀-精神病学 | 进食障碍的部分疾病负担仍不为人知

《柳叶刀-精神病学》（The Lancet Psychiatry）近日发表一篇基于2019全球疾病负担（GBD）研究的进食障碍的患病率研究。作者指出，2019全球疾病负担（GBD）研究低估了进食障碍的患病率，暴食症患者和其他特定的喂食或进食障碍患者或被忽略。本文相关评论的作者建议GBD纳入回避性/限制性食物摄入障碍、反刍障碍和异食癖的患病率估计；并取得与所有DSM-5喂食和进食障碍相关伤残的直接测量数据。

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《柳叶刀-精神病学》（The Lancet Psychiatry）近日发表了Damian Santomauro及其团队[1]提出了一个令人震惊的观点：2019全球疾病负担（GBD）研究[2]低估了进食障碍的患病率，未被计入的患病人数高达4190万（95% 置信区间 [UI] 27.9–59.0）。

GBD2019仅关注进食障碍的冰山一角——神经性厌食症和神经性贪食症，因而忽略了1730万（95% UI 11.3-24.9）暴食症患者和2460万（14.7-39.7）其他特定的喂食或进食障碍（OSFED）患者，这些患者在2019年的伤残调整寿命年（DALY）合计高达370万（2.0-6.5）[1]。这篇具有里程碑意义的论文强调，进食障碍的患病率比之前认为的要多4倍，并且与加倍的伤残负担相关。研究结果显示，暴食症和进食障碍的流行率尤其会随着年龄的增长而升高，该文章也更全面地描述了进食障碍在男性中的疾病负担，打破了进食障碍只影响瘦弱的年轻白人女性这一不准确但根深蒂固的刻板印象。该研究应用创新、严谨、可重复的方法，充分利用全球数据，挑战了GBD中所代表各国对进食障碍罕见性的误解。尽管如此，毋庸置疑的是，进食障碍的全球负担比它们本就已经显著的研究结果所揭示的更大，原因有两个：

首先，作者指出，回避性/限制性摄食障碍、反刍障碍和异食癖（Pica）无法被纳入其分析中，因为这些疾病的患病率不详。的确，关于精神障碍诊断与统计手册第五版（DSM-5）全谱系喂食和进食障碍的严格流行病学研究很少，但越来越多来自学校和社区样本的证据表明，这些障碍十分常见。在一项针对瑞士1444名8–13岁小学生的研究中，3.2%的儿童在自评问卷中认可符合回避性/限制性摄食障碍症状，其特征是由于以下一种或多种原因限制食物摄入：感觉敏感、对厌恶性后果的恐惧、对进食或食物缺乏兴趣[3]。类似的是，在新加坡一项针对797名21–77岁成年人的问卷调查研究中，4.1%筛查出存在回避性/限制性摄食障碍[4]。在同一项针对瑞士学龄儿童的研究中，1.7%认可存在与反刍障碍一致的行为（反刍食物后咀嚼、再吞咽或吐出)，3.8%认可存在与Pica一致的行为（摄入非营养性、非食物性物质），1.1%认可存在与这两种障碍一致的行为[5]。回避性/限制性食物摄入障碍尤其会带来精神疾病（如自杀[6]）和医疗（如低骨密度[7]）并发症风险，表明其在DALY方面的负担可能是实质性的。

第二，为了估计DALY，Santomauro及其团队假设阈值以下进食障碍（例如，阈值以下的神经性贪食症）的损害程度只有其全阈值对应的进食障碍（例如，神经性贪食症）的一半，而非典型的神经性厌食症（即个体限制其食物摄入量，但无体重过低）的伤残影响相当于神经性厌食症减去体重过低的影响。这种方法在数学运算上是有意义的，而且也可以说是作者在其样本中估计DALY的唯一方法。然而，毫无疑问的是，这种方法低估了疾病负担。阈值以下的进食障碍患者在进食病理、普通精神病理学或身体健康方面通常与全阈值的患者没有差别[8]。此外，无论其行为症状的频率如何，全阈值和阈值以下的进食障碍患者都存在相同的潜在认知精神病理（cognitive psychopathology），而认知精神病理与临床损伤密切相关[9]。与神经性厌食症患者类似，非典型神经性厌食症患者往往也经历了体重的急剧下降，所以绝对的体重指数（BMI）不是必须的有效伤残标志。例如，对于存在限制性进食的少女，即使没有达到通常引用的厌食症体重截止值，其骨密度仍然比健康女孩低得多，因而前者的骨折风险更高。[10]

综上所述，Santomauro及其团队对GBD2019进行了鞭辟入里的重新分析，清楚地表明进食障碍是常见且有害的。他们的文章提出了振聋发聩的警示，要求将暴食症和OSFED纳入GBD的未来版本。我们完全赞同并希望进一步推动这一进程。我们建议GBD纳入回避性/限制性食物摄入障碍、反刍障碍和Pica的患病率估计；并取得与所有DSM-5喂食和进食障碍相关伤残的直接测量数据。如果他们真的付诸实践，其报告的全球疾病负担将更大，这突出强调了增加资金投入的明确需要，以研究、预防和治疗这些使人身体衰弱的疾病。END

JJT has received funding from the US National Institute of Mental Health (R01MH108595, R01MH116205, and R01MH103402), Hilda and Preston Davis Foundation, and Lawrence J and Anne Rubenstein Charitable Foundation; speaking honoraria from the Australia and New Zealand Academy for Eating Disorders, Universidad de Monterrey (San Pedro Garza García, Mexico), University of California San Diego (San Diego, CA, USA), Rhode Island College (Providence, RI, USA), Emory University (Atlanta, GA, USA), Recovery Record, and Walden Behavioral Care; consulting fees from Guidepoint and Park Nicollett Healthcare System; and honoraria from the US National Institutes of Health for serving as a grant reviewer, from the US Department of Defense for grant reviews, from John Wiley & Sons for service as an associate editor of the International Journal of Eating Disorders, and from the Academy for Eating Disorders for travel to meetings of the Board of Directors. JJT also receives book royalties from Harvard Health Publications, Hazelden, and Cambridge University Press. KRB has received funding from the National Institute of Mental Health (F32 MH111127 and K23MH125143), Hilda and Preston Davis Foundation, Global Foundation for Eating Disorders, and Harvard Medical School (Boston, MA, USA); speaking honoraria from the Australia and New Zealand Academy for Eating Disorders, University of California San Diego, and the Hispanic and Latin American Academy for Eating Disorders; honoraria from the US Department of Defense for grant reviews. KRB also receives book royalties from Cambridge University Press. Both authors are employed and receive income from the Massachusetts General Hospital. KRB receives additional income from her private psychotherapy practice. The interests of authors were reviewed and are managed by Massachusetts General Hospital in accordance with their conflict-of-interest policies.

References

1.Santomauro DF Melen S Mitchison D Vos T Whiteford H Ferrari AJ. The hidden burden of eating disorders: an extension of estimates from the Global Burden of Disease Study 2019.Lancet Psychiatry. 2021; (published online March 3.) https://doi.org/10.1016/S2215-0366(21)00080-8

2.Vos T Lim SS Abbafati C et al.Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.

Lancet. 2020; 396: 1204-1222

3.Kurz S Van Dyck Z Dremmel D Munsch S Hilbert A. Early-onset restrictive eating disturbances in primary school boys and girls. Eur Child Adolesc Psychiatry. 2015; 24: 779-785

4.Chua SN Fitzsimmons-Craft EE Austin SB Wilfley DE Taylor CB. Estimated prevalence of eating disorders in Singapore.Int J Eat Disord. 2021; 54: 7-18

5.Murray HB Thomas JJ Hinz A Munsch S Hilbert A. Prevalence in primary school youth of pica and rumination behavior: the understudied feeding disorders. Int J Eat Disord. 2018; 51: 994-998

6.Kambanis PE Kuhnle MC Wons OB et al.revalence and correlates of psychiatric comorbidities in children and adolescents with full and subthreshold avoidant/restrictive food intake disorder.Int J Eat Disord. 2020; 53: 256-265

7.Aulinas A Marengi DA Galbiati F et al.Medical comorbidities and endocrine dysfunction in low-weight females with avoidant/restrictive food intake disorder compared to anorexia nervosa and healthy controls. Int J Eat Disord. 2020; 53: 631-636

8.Thomas JJ Vartanian LR Brownell KD. The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM.Psychol Bull. 2009; 135: 407-433

9.Bohn K Doll HA Cooper Z O'Connor M Palmer RL Fairburn CG. The measurement of impairment due to eating disorder psychopathology.Behav Res Ther. 2008; 46: 1105-1110

10.Kandemir N Becker K Slattery M et al.Impact of low-weight severity and menstrual status on bone in adolescent girls with anorexia nervosa.Int J Eat Disord. 2017; 50: 359-369

题图 Copyright © 2020 Florent Vergnes/AFP/Getty Images

*中文翻译仅供参考，所有内容以英文原文为准。

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