Epidemiology and Psychiatric Sciences

Special Article

A comparative analysis of role attainment and impairment in binge-eating disorder and bulimia nervosa: results from the WHO World Mental Health Surveys

R.C. Kesslera1 c1, V. Shahlya1, J.I. Hudsona2, D. Supinaa3, P.A. Berglunda4, W.T. Chiua1, M. Grubera1, S. Aguilar-Gaxiolaa5, J. Alonsoa6, L.H. Andradea7, C. Benjeta8, R. Bruffaertsa9, G. de Girolamoa10, R. de Graafa11, S.E. Florescua12, J.M. Haroa13, S.D. Murphya14, J. Posada-Villaa15, K. Scotta16 and M. Xaviera17

a1 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA

a2 Psychiatric Epidemiology Research Program, McLean Hospital and Harvard Medical School, Boston, Massachusetts, USA

a3 Health Economics, Outcomes Research and Epidemiology, Shire Pharmaceuticals, Wayne, Pennsylvania

a4 University of Michigan, Institute for Social Research, Ann Arbor, Michigan, USA

a5 University of California, Davis, Center for Reducing Health Disparities, School of Medicine, CTSC Building, Sacramento, California, USA

a6 IMIM-Hospital del Mar Research Institute, Parc de Salut Mar; Pompeu Fabra University (UPF); and CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain

a7 Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil

a8 Department of Epidemiologic and Psychosocial Research, National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico

a9 Universitair Psychiatrisch Centrum – Katholieke Universiteit Leuven (UPC-KUL), campus Gasthuisberg, Leuven, Belgium

a10 IRCCS Centro S. Giovanni di Dio Fatebenefratelli Brescia, Bologna, Italy

a11 Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands

a12 National School of Public Health, Management and Professional Development, Bucharest, Romania

a13 Parc Sanitari Sant Joan de Déu, CIBERSAM, University of Barcelona, Barcelona, Spain

a14 School of Psychology, University of Ulster, Londonderry, Northern Ireland

a15 Universidad Colegio Mayor de Cundinamarca, Bogota, Colombia

a16 Department of Psychological Medicine, Otago University, Dunedin, New Zealand

a17 Department of Mental Health – CEDOC and Faculdade Ciencias Medicas, Universidade Nova de Lisboa, Lisbon, Portugal


Background. Cross-national population data from the WHO World Mental Health surveys are used to compare role attainments and role impairments associated with binge-eating disorder (BED) and bulimia nervosa (BN).

Methods. Community surveys assessed 23 000 adults across 12 countries for BED, BN and ten other DSM-IV mental disorders using the WHO Composite International Diagnostic Interview. Age-of-onset was assessed retrospectively. Ten physical disorders were assessed using standard conditions checklists. Analyses examined reciprocal time-lagged associations of eating disorders (EDs) with education, associations of early-onset (i.e., prior to completing education) EDs with subsequent adult role attainments and cross-sectional associations of current EDs with days of role impairment.

Results. BED and BN predicted significantly increased education (females). Student status predicted increased risk of subsequent BED and BN (females). Early-onset BED predicted reduced odds of current (at time of interview) marriage (females) and reduced odds of current employment (males). Early-onset BN predicted increased odds of current work disability (females and males). Current BED and BN were both associated with significantly increased days of role impairment (females and males). Significant BED and BN effects on adult role attainments and impairments were explained by controls for comorbid disorders.

Conclusions. Effects of BED on role attainments and impairments are comparable with those of BN. The most plausible interpretation of the fact that these associations are explained by comorbid disorders is that causal effects of EDs are mediated through secondary disorders. Controlled treatment effectiveness studies are needed to trace out long-term effects of BED–BN on secondary disorders.

(Received July 25 2013)

(Revised August 28 2013)

(Accepted August 28 2013)

(Online publication September 19 2013)

Key words

  • Binge eating;
  • bulimia nervosa;
  • eating disorder;
  • WHO World Mental Health Surveys


c1 Address for correspondence: R.C. Kessler, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, USA. (Email: Kessler@hcp.med.harvard.edu)