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Table of Contents
Year : 2023  |  Volume : 37  |  Issue : 1  |  Page : 14-20

Studies on eating disorders in Taiwan: Measurements, epidemiology, comorbidities, and health-care use

1 Department of Psychiatry, National Taiwan University Hospital, Yunlin Branch, Yunlin; Department of Psychiatry, National Taiwan University College of Medicine, Taipei, Taiwan
2 Department of Psychiatry, National Taiwan University College of Medicine, Taipei; Department of Psychiatry, Shuang Ho Hospital, Taipei Medical University, New Taipei City; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan

Date of Submission01-Nov-2022
Date of Decision14-Dec-2022
Date of Acceptance16-Dec-2022
Date of Web Publication28-Mar-2023

Correspondence Address:
Mei-Chih Meg Tseng
No. 291, Zhongzheng Road, Zhonghe District, New Taipei City 235041
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TPSY.TPSY_2_23

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Background: Eating disorder (ED) is a disease entity with substantial physical and psychosocial morbidity, while it has remained underdetected by clinicians in Taiwan. To improve the detection and treatment of EDs by health-care professionals in Taiwan, we reviewed ED studies in Taiwan, including epidemiology, measurements, correlates, comorbidities, and health-care use. Methods: A literature review was done using PubMed. The main inclusion criteria were studies that focused on EDs and disordered eating attitudes/behaviors and were done in Taiwan. Results: Several frequently used ED measurements had well-established Mandarin Chinese versions, and they all had sound psychometric properties. Disordered eating attitudes/behaviors have been prevalent in Taiwanese adolescents and college students, but EDs were detected at an older age compared to that in Western countries. Having a diagnosis of ED and higher ED symptom severity are associated with increased comorbidity burden. All patients with anorexia nervosa (AN) and bulimia nervosa (BN) have sought treatment for physical problems while less than half have sought treatment for mental health problems. Studies have also shown a 2–4-fold higher total costs in patients with AN/BN than individuals without EDs. Conclusion: More effort is needed to detect individuals with AN and BN at a younger age in Taiwan. Programs targeting at the influence of family, peers, and media on the body image of children/adolescents and young adults await establishment. We also need to build more educational programs to improve ED literacy in both health-care professionals and the general public for early detection and timely treatments of EDs by mental health professionals.

Keywords: anorexia nervosa, bulimia nervosa, comorbidities, eating behaviors

How to cite this article:
Tu CY, Tseng MCM. Studies on eating disorders in Taiwan: Measurements, epidemiology, comorbidities, and health-care use. Taiwan J Psychiatry 2023;37:14-20

How to cite this URL:
Tu CY, Tseng MCM. Studies on eating disorders in Taiwan: Measurements, epidemiology, comorbidities, and health-care use. Taiwan J Psychiatry [serial online] 2023 [cited 2023 Jun 11];37:14-20. Available from: http://www.e-tjp.org/text.asp?2023/37/1/14/372639

  Introduction Top

Eating disorders (EDs), including anorexia nervosa (AN), bulimia nervosa (BN), and binge-ED, have been recognized as a disease entity associated with substantial physical and psychosocial morbidity [1],[2]. In addition to abnormalities in eating behaviors, EDs are characterized by abnormalities in perception and attitude toward weight and shape [3]. EDs were once considered to be a cultural-bound syndrome, which is mostly found in industrialized Western countries, but clinical and school cohort studies from Asia-Pacific regions supported that EDs are increasingly common in Asia but are underdetected in health-care settings [4].

ED studies in Taiwan had not been presented in the literature until the late 1980s, and they involved a few clinical or case series studies [5],[6] and psychometric studies of ED measurements written in Mandarin Chinese [7],[8]. More studies of the prevalence and correlates of disordered eating behaviors [9],[10], eating attitudes [11],[12],[13], and EDs [14],[15],[16],[17],[18] have been published in English journals since 2000, and this has continued in the 2020s. A few investigators studied psychopathology and psychiatric comorbidities [19],[20],[21],[22]. Studies using the National Health Insurance data in recent years further provided the grasp of ED illness burden including the trend of incidence [23],[24] and prevalence [23], health-care use [25],[26],[27], health-care costs [28],[29], and mortality [30] and morbidity [31] of AN and BN in Taiwan.

In the past two decades, with its complex display in physical and mental symptoms, EDs remained disease entities underdetected by clinicians in Taiwan [26],[27]. In this review, we intended to include studies that focused on EDs and disordered eating attitudes/behaviors and were done in Taiwan. PubMed database was searched, using the following key terms: (eating disorder OR anorexia nervosa OR bulimia nervosa OR eating behavior) AND (prevalence OR incidence OR screening OR psychopathology OR sociocultural OR biological OR comorbid OR help-seeking OR healthcare) AND Taiwan. Articles relevant to the topic in question were reviewed to provide a qualitative summary. The review is categorized into the following domains: (a) epidemiological studies; (b) development and establishment of psychometric properties of measurements for EDs; (c) clinical presentations, comorbidity, and help-seeking behaviors; (d) cost of illness and physical outcomes of patients with EDs; and (e) neuroendocrine, neurophysiology, and neuroimaging correlates of eating behaviors. We hope that our work may stimulate Taiwanese health-care professionals and attract mental health workers' attentions on EDs, resulting in improving the detection and treatment of EDs in Taiwan.

  Psychometric Properties of Eating Disorder-related Measures Top

Investigators who are interested in ED studies may find several psychometrically sound Mandarin Chinese versions of ED-related measures. The ED Inventory (EDI) is a multidimensional self-report questionnaire that is used to assess the cognition, behaviors, and psychological traits relevant to ED patients [32]. This measure has been widely used to identify AN, BN, and those who are at risk for EDs. The Mandarin Chinese EDI (C-EDI) has good internal consistency and convergent and discriminant validities [33]. The first-order eight-factor structure and the second-order two-factor structure are adequately fitted to Taiwanese ED patients' data, and C-EDI has been proven valid cross-culturally [33]. Of note, patients with restricting-type AN tend to score their drive for thinness and other eating and general psychopathologies at a lower level than binge-purging-type AN or BN patients but at a comparable level with nonpatient students. Poor discrimination between restricting-type AN patients and female students using the C-EDI suggests that its usefulness for detecting eating pathology in Taiwanese restricting-type AN patients is limited. The Eating Attitudes Test (EAT) and the Bulimic Investigatory Test Edinburgh (BITE) are among the most frequently used copy of self-report questionnaire to screen for EDs. The BITE was designed specifically to identify binge-eating behaviors [7]. The Chinese version of the EAT and BITE both has good internal consistency and test–retest reliability [15],[34]. In addition, Tseng et al. found that the BITE has better performance than the EAT in detecting ED in the nonclinical population (both dance and nondance students) [35]. The SCOFF, composed of five dichotomous questions, is a brief questionnaire to screen EDs [36]. Liu et al. showed that the Mandarin Chinese version of SCOFF has good convergent and discriminant validity [37]. The optimal cutoff scores for detecting EDs in the psychiatric setting are 2 (sensitivity/specificity = 86%/74%) and 3 (sensitivity/specificity = 80%/86%) for men and women, respectively [37]. Other Chinese versions of self-administered questionnaire such as the ED Examination Questionnaire and the Body Shape Questionnaire have also been widely used in ED studies in Taiwan [14],[38],[39]. The Three-factor Eating Questionnaire (TFEQ), another self-administered questionnaire that evaluates eating behaviors, has been translated into Chinese and validated in a Taiwanese adolescent sample [40]. In recent research to assess the psychometric properties of its shortened form (TFEQ-21), the investigators found that the questionnaire is reliably measuring adolescent eating behaviors [41].

Night eating syndrome (NES) is a lately defined ED [42] and was listed as one of the specified EDs in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [3]. The self-administered Night Eating Questionnaire (NEQ) consists of 14 items assessing the characteristics of NES, including morning anorexia, evening hyperphagia, nocturnal eating, and associated sleep and mood symptoms [43]. The internal consistency, reliability, and concurrent validity of the Mandarin Chinese version of the NEQ have been examined, and the diagnostic performance has been excellent [38]. Two structured interview tools, Structured Interview on Anorexic and Bulimic Disorder, Expert-Assessment (SIAB-EX) [18],[19] as well as the NES History and Inventory (NESHI) [21], have been translated and applied in ED studies in Taiwan.

  Prevalence and Incidence of Disordered Eating Behaviors and Eating Disorders in Taiwan Top

Many studies indicated that disordered eating behaviors/EDs have been a prevalent mental health condition among different populations in Taiwan. Community epidemiological studies in Taiwan included surveys of disordered eating attitudes/behaviors in different age groups, including elementary school students, adolescents, and college students. The lifetime prevalence of the DSM-5 defined AN in a nationally representative sample of 8–14-year-old Taiwanese youths in Taiwan's National Epidemiological Study of Child Mental Disorders was 0.2% (95% confidence interval [CI] = 0.0–0.4) [44], which is comparable to the 0.3% (95% CI = 0.18–0.42) in a representative sample of 13–18-year-old US adolescents (National Comorbidity Survey Replication Adolescent Supplement, NCS-A) [45]. An earlier study using two-phase survey method had demonstrated that the lifetime prevalence of AN and BN was 0.1% (95% CI = 0.0–0.4) and 1% (95% CI = 0.5–1.8), respectively, among high school female students [14]. The prevalence of AN in Taiwan seemed no less than that in the NCS-A study according to the overlapping 95% CI. Of note, the data need to be interpreted cautiously because the small sample size of AN cases might prevent us from making reliable estimates. The prevalence of BN in Taiwan is comparable to that of Western countries (1%) (95% CI = 0.59–1.21) [14].

EAT-26 and Children's EAT-26 were used to investigate disordered eating in these populations. The prevalence of having a high risk of developing EDs in 4–6 graders and middle school students was 10.1%–12.3% [9],[46] and 8.6%–17.1% [47],[48],[49], respectively. Among female college students, 43.2% of them are at risk of developing EDs as evaluated by the EDI-3 Referral Form [10]. Thirteen percent of teenagers reported having used self-induced vomiting to lose weight [50], and the prevalence of BN defined by scoring 26 or above on the BITE was 1.8% in high school students [51], similar to that in Western countries. The rates of having anorexia symptoms and bulimia symptoms identified by the Adult Self-Report Inventory-4 in the college student population are 10.4% and 1.1%, respectively, which are also comparable to those of Western countries [17].

The prevalence of EDs has also been assessed in high-risk people, such as high school dance students, weight reduction program participants, and psychiatric outpatients. The overall rate of EDs was four times more among the dance students than that of the nondance students, with 8% and 2%, respectively [14]. The prevalence of EDs at 1-year follow-up (15%) is higher than that in the 1st year (8%) [52]. Among the dance students who did not have EDs at baseline, 17.1% of them (35/204) develop an ED at 1-year follow-up, while 43.9% (18/41) are remitted [53]. Interestingly, increased BITE scores have been found in students in grades 10 and 11 (aged 15–16 years) but not in grade 12 students (aged over 17 years) over a 1-year period. In contrast, a consistent decline in abnormal eating attitudes (measured by the EAT) is noted among students in all grades. This finding is partially consistent with the observation that gradually increased dieting and binge-eating are more consistently found throughout adolescence [54] but binge-eating behaviors significantly decreased from adolescence to adulthood [55]. The prevalence of probable binge eaters, defined by a BITE score above 20, ranged from 10.6% to 15.9% in obese participants of hospital-based weight reduction programs [15],[56]. Among patients, aged 18–45, who visited the psychiatric clinics and were assessed by the ED module of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Patient Version (SCID-I/P), the prevalence of EDs is 22.6% and 6.4% for women and men, respectively [18].

Studies using the National Health Insurance Research Database (NHIRD) showed that the incidence of AN ranges 1.1–1.3 per 100,000 person-years [23],[24] and that of BN range 6.1–7.5 per 100,000 person-years in the outpatient, emergency, and inpatient department using different case enrollment criteria and during different enrollment periods [23],[24]. The incidence of AN is low compared with that of Western countries (ranging from 4.7 to 18.8/100,000) [57],[58],[59],[60],[61], but the incidence of BN is in the lower range of 3.2 to 20.7 per 100,000 that was reported in the literature [58],[59],[60],[61]. The age at first-time diagnoses of AN and BN is peaked at 20–29 years in our study [24], which is older than that in most Western countries [58],[59],[60],[61]. No change is found in the overall incidence for AN across the study period (2002-2013) [Figure 1], but an increase in AN incidence is found in the age groups of 10–14 and 30–39 years. No change in the overall BN incidence is found over the whole period, while the overall incidence of BN increased before 2009 and then decreased. The incidences of BN among the age groups of 20–29, 30–39, and 40–49 years and among the females are in line with the trend in the increased overall incidences of BN in the initial years of the study period [24] [Figure 1]. The trend in the increased incidence of BN before 2009 in this study corresponds with the observed increases in binge-eating and vomiting features and the BN proportion of EDs in other Asian areas during the 21st century [62],[63]. The findings of the older age in onset and the trends in the increased incidence of AN and BN among adults rather than adolescents suggest that more effort is needed to detect individuals with AN and BN at a younger age in Taiwan.
Figure 1: Annual percentage change (APC) in the age-specific incidence rates (per 100,000 persons) of detected AN (a) and BN (b) in Taiwan, 2002–2013. Multiple joinpoint models depict observed (plotted as symbols) and modeled (shown as color lines) time trends. Line of the incidence rate of the 10–14 years age group among BN cases is absent in (b) because APC is not calculated. Average annual percentage change (AAPC) values for each age group in AN and BN are also shown. *The APC and AAPC are statistically significant at an alpha of 0.05 [24]. AN, anorexia nervosa; BN, bulimia nervosa.

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The prevalence of overall EDs (including AN, BN, and ED not otherwise specified, defined as receiving a primary diagnosis of an ED (International Classification of Diseases, Ninth Revision, Clinical Modification codes 307.1, 307.50, 307.51, and 307.59) either twice at the outpatient department or once during hospitalization in the NHIRD), is 3.54 and 38.72/100,000 in males and females, respectively, in a population consisting of individuals utilizing ambulatory care or hospitalization [23]. Among the subjects enrolled in this study (aged 11–34), the incidence of EDs in females and males peaked at the 20–24 and 25–29 age groups, respectively; and the pattern has similarly been found for the prevalence of EDs. Over the study period (2002–2012), the incidence of AN has shown an increased trend in females, while a trend of decrease was found in males. The incidences of BN are increased in both females and males. But the increase was more prominent in females, with a 1.9- to 2.5-fold increased incidence in 2007–2012 compared with that in 2001–2003.

  Associated Risk Factors and Sociocultural Influences Top

Body image disturbance is one of the core symptoms of EDs. The thin ideal that prevailed in developed countries might have encouraged extreme weight control behaviors [64]. Several studies in Taiwan investigated the relationship between disturbed eating attitudes/behaviors, body image disturbance, and psychological characteristics [12],[46],[47],[48],[49],[65]. In female high school students, disturbed eating attitudes/behaviors are associated with weight dissatisfaction and weight/shape-related teasing experiences [48],[49]. Yen et al. found that higher-level concern over weight and dieting is associated with depression and low self-esteem in adolescents [12]. Another study showed that adolescent girls with disordered eating behaviors are more likely to have moderate-to-severe depressed mood, low peer acceptance, and stress from family/friends due to weight than their counterparts without disordered eating behaviors; in addition, girls more frequently have preoccupation with fatness and the desire to be thinner than boys do [65]. Higher concern about body shape, body image dissatisfaction, and history of being teased for being overweight is associated with a higher risk of being diagnosed with EDs (AN, BN, or ED not otherwise specified) in overall high school students and dance students [14],[52].

Some studies showed that body dissatisfaction is positively associated with the level of external control, the influence of significant others, the impact of media, and the internalization of thin ideal [9],[66],[67]. In addition, caregivers' evaluation of the children's body size is correlated with children's evaluation of their body size [68]. In short, environmental context, particularly familial and sociocultural factors, plays a role in the development of EDs not only in Western countries but also in Taiwan. Of note, clinical patients with restricting-type AN have been found to have lower levels of “drive for thinness” than binge-eating/purging-type AN and BN as well as their Western counterparts [33]. [Table 1] summarizes the psychological and sociocultural risk factors for disturbed eating attitudes/behaviors and EDs in Taiwan.
Table 1: Psychological and sociocultural risk factors for disturbed eating attitudes/behaviors and eating disorders in Taiwan

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  Comorbid Psychiatric Symptoms/Disorders among Eating Disorder Population Top

Multiple studies have shown elevated rates of comorbid psychiatric illness in individuals with EDs [69]. The risk of comorbid anxiety disorders and mood disorders is significantly higher in high school dance students diagnosed with EDs compared to those without EDs in Taiwan (OR: 2.75 [1.46–5.15] and (OR: 2.15 (1.24–3.74), respectively) [52]. In addition, higher ED symptom severity is associated with more severe co-occurring symptoms of anxiety disorders, obsessive–compulsive disorders, depressive disorders, and somatoform disorders in college students [17]. In the psychiatric outpatient setting, the co-occurring rate of major depressive disorder and bipolar disorder in patients with different ED subtypes was 41.3%–66.7% and 16.7%–49.3%, respectively [19]. Patients with EDs and comorbid bipolar disorder had more severe weight dysregulation, impulsivity, emotional lability, and higher rates of co-occurring alcohol use disorders than those without comorbid bipolar disorder [19],[20]. In a sample from psychiatric clinics at a university hospital, the lifetime prevalence of deliberate self-harm and suicide attempts among ED patients was 32.7% and 18.1%, respectively, while the rate of having any impulsive behavior was similar to that of non-ED psychiatric patients (64.8% vs. 60.6%) [70]. Patients with EDs who have pre-existing major depressive disorder and substance use disorder have 1.8- and 2.6-fold, respectively, elevated risk for suicide compared with those without any psychiatric comorbidity (major depressive disorder, substance use disorder, bipolar disorder, schizophrenia, anxiety disorder, or personality disorder) [30].

  Clinical Presentations, Health-care Use, and Costs of Patients with Eating Disorders Top

Evidence showed that barriers exist in clinical diagnosis and treatment of EDs as well as high medical and economic burdens of care for individuals with AN and BN in Taiwan. Tseng et al. conducted a cross-sectional survey to investigate the prevalence and correlates of ED among a large sample of psychiatric outpatients using a two-phase survey method [18]. In the same study, the investigators were interested in the presenting symptoms of patients with EDs – whether they include eating/weight concerns when seeking professional help. They found that the top three leading reasons for patients with EDs to visit psychiatric clinics are eating/weight concerns (46.0%), emotional problems (41.3%), and sleep disturbances (19.3%). Patients who had more impulsive behaviors and poorer functioning were less likely to report eating problems at presentation. In other words, patients with these characteristics tend to seek help for their mood, sleep, and behavioral symptoms, while they tend not to disclose their eating conditions [18]. These findings suggest that clinicians should be alert to the hidden ED morbidity, especially in patients with complex psychopathology, and include ED screening in clinical assessments among the high-risk population.

In the year preceding the diagnosis of AN or BN, all patients with AN and BN have sought treatment for physical problems, while less than half have sought treatment for mental health problems [27]. Individuals with AN and BN, as well as the control group (schizophrenia), are all underdetected by nonpsychiatric medical professionals. BN was less likely to be recognized by both psychiatrists and other medical professionals compared with AN and schizophrenia [27]. Research based on the data from the NHIRD of Taiwan showed that female patients with AN/BN have more outpatient service utilization than did the non-ED controls [26],[28]. Patients with AN have more than three times higher total costs and patients with BN have two times higher total costs than individuals without EDs. Comorbidity of depressive disorders and older age increase health-care costs among both individuals with AN and BN [28]. Patients with both ED and depression had higher health-care service costs than those who had depression only. The difference was primarily contributed by the higher outpatient psychiatric service costs of the ED with depression group compared with the depression-only group [25].

  Physical Comorbidity and Outcome of Eating Disorders in Taiwan Top

In earlier conducted studies, 54.1% of patients with AN have intermediate/poor outcomes or are dead during a period of follow-up for 6.4 years (on average) after the first encounter [5], and 56% of the patients with BN still meet a diagnosis of EDs after follow-up 4.7 years (on average) [71]. The percentage of recovery is similar to that in Western countries [72],[73].

Few studies have investigated the associations between EDs and physical disorders. One study found that patients with EDs had a 5.3-fold and 4.6-fold increased risk of esophageal and stomach cancers, respectively, compared with the controls without EDs. But patients with EDs did not have an increased risk of other cancers compared with the controls in the same study [31].

  Neuroendocrine, Neurophysiology, and Neuroimaging Studies Top

Ko et al. investigated the leptin level, caloric intake, and eating behaviors of women with premenstrual dysphoric disorder (PMDD) and found a lower late-luteal leptin level, a higher caloric intake, and higher uncontrolled eating in normal-weight women with PMDD than normal-weight controls. In addition, blood leptin levels are higher in overweight women with PMDD than in normal-weight women with PMDD [74]. A more recent study showed that women with PMDD have a higher BMI and higher blood leptin level in the luteal phase compared with controls. In the same study, they also demonstrated that women having PMDD had higher sweat craving and uncontrolled eating in the late luteal phase than in the early luteal phase; however, these eating behaviors are not correlated with change in blood leptin or ghrelin levels [75]. Another study showed that women with obesity and sweet food addiction have higher impulsivity and lower activation when processing response inhibition as shown by the functional magnetic resonance imaging [76]. Chang et al. examined the correlation between disordered eating and physiological responses to high-calorie food measured using the heart rate variability. They showed that low-frequency power to high-frequency power (LF/HF) (an indicator of the balance of sympathetic and parasympathetic activity) is negatively correlated with the severity of disordered eating attitudes/behaviors and that BMI moderated the association of food stimuli and LF/HF [77].

  Conclusion Top

EDs are associated with high morbidity and mortality and often cause a great disease burden. Prevention and early interventions are key to improve outcomes. Disordered eating behaviors and EDs are prevalent in Taiwan, but prevention programs and campaigns targeting at for ED are still scarce. High levels of concern about weight/shape and interpersonal stress related to weight/shape issues can increase the risk of disordered eating, suggesting that the rôle of body image disturbance in EDs is a cross-cultural phenomenon. Programs targeting the influence of family, peers, and media on the body image of children/adolescents and young adults can prevent the development of disordered eating attitudes/behaviors. Considering that patients with AN or BN are more likely to seek help at medical clinics rather than at psychiatric clinics, educational programs designed to improve the ED literacy in health-care professionals (especially family physicians and gynecologists, the top two types of specialists that the AN and BN patients had ever consulted) and the general public might facilitate early detection and timely treatments of EDs by mental health professionals. Finally, patients with EDs frequently have other psychiatric comorbidities and may seek mental health services due to problems else than eating/weight concerns. Hence, psychiatrists should also be sensitive to the hidden ED morbidity among clinical psychiatric patients.

  Financial Support and Sponsorship Top

This study was supported by grants from Taipei Medical University (TMU111-AE1-B01).

  Conflicts of Interest Top


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