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柳葉刀-精神病學(xué) | 進(jìn)食障礙的部分疾病負(fù)擔(dān)仍不為人知

《柳葉刀-精神病學(xué)》(The Lancet Psychiatry)近日發(fā)表一篇基于2019全球疾病負(fù)擔(dān)(GBD)研究的進(jìn)食障礙的患病率研究。作者指出,2019全球疾病負(fù)擔(dān)(GBD)研究低估了進(jìn)食障礙的患病率,暴食癥患者和其他特定的喂食或進(jìn)食障礙患者或被忽略。本文相關(guān)評論的作者建議GBD納入回避性/限制性食物攝入障礙、反芻障礙和異食癖的患病率估計;并取得與所有DSM-5喂食和進(jìn)食障礙相關(guān)傷殘的直接測量數(shù)據(jù)。

識別二維碼訪問柳葉刀GBD資源中心

《柳葉刀-精神病學(xué)》(The Lancet Psychiatry近日發(fā)表了Damian Santomauro及其團(tuán)隊[1]提出了一個令人震驚的觀點(diǎn):2019全球疾病負(fù)擔(dān)(GBD)研究[2]低估了進(jìn)食障礙的患病率,未被計入的患病人數(shù)高達(dá)4190萬(95% 置信區(qū)間 [UI] 27.9–59.0)。

GBD2019僅關(guān)注進(jìn)食障礙的冰山一角——神經(jīng)性厭食癥和神經(jīng)性貪食癥,因而忽略了1730萬(95% UI 11.3-24.9)暴食癥患者和2460萬(14.7-39.7)其他特定的喂食或進(jìn)食障礙(OSFED)患者,這些患者在2019年的傷殘調(diào)整壽命年(DALY)合計高達(dá)370萬(2.0-6.5)[1]。這篇具有里程碑意義的論文強(qiáng)調(diào),進(jìn)食障礙的患病率比之前認(rèn)為的要多4倍,并且與加倍的傷殘負(fù)擔(dān)相關(guān)。研究結(jié)果顯示,暴食癥和進(jìn)食障礙的流行率尤其會隨著年齡的增長而升高,該文章也更全面地描述了進(jìn)食障礙在男性中的疾病負(fù)擔(dān),打破了進(jìn)食障礙只影響瘦弱的年輕白人女性這一不準(zhǔn)確但根深蒂固的刻板印象。該研究應(yīng)用創(chuàng)新、嚴(yán)謹(jǐn)、可重復(fù)的方法,充分利用全球數(shù)據(jù),挑戰(zhàn)了GBD中所代表各國對進(jìn)食障礙罕見性的誤解。盡管如此,毋庸置疑的是,進(jìn)食障礙的全球負(fù)擔(dān)比它們本就已經(jīng)顯著的研究結(jié)果所揭示的更大,原因有兩個:

首先,作者指出,回避性/限制性攝食障礙、反芻障礙和異食癖(Pica)無法被納入其分析中,因?yàn)檫@些疾病的患病率不詳。的確,關(guān)于精神障礙診斷與統(tǒng)計手冊第五版(DSM-5)全譜系喂食和進(jìn)食障礙的嚴(yán)格流行病學(xué)研究很少,但越來越多來自學(xué)校和社區(qū)樣本的證據(jù)表明,這些障礙十分常見。在一項(xiàng)針對瑞士1444名8–13歲小學(xué)生的研究中,3.2%的兒童在自評問卷中認(rèn)可符合回避性/限制性攝食障礙癥狀,其特征是由于以下一種或多種原因限制食物攝入:感覺敏感、對厭惡性后果的恐懼、對進(jìn)食或食物缺乏興趣[3]。類似的是,在新加坡一項(xiàng)針對797名21–77歲成年人的問卷調(diào)查研究中,4.1%篩查出存在回避性/限制性攝食障礙[4]。在同一項(xiàng)針對瑞士學(xué)齡兒童的研究中,1.7%認(rèn)可存在與反芻障礙一致的行為(反芻食物后咀嚼、再吞咽或吐出),3.8%認(rèn)可存在與Pica一致的行為(攝入非營養(yǎng)性、非食物性物質(zhì)),1.1%認(rèn)可存在與這兩種障礙一致的行為[5]。回避性/限制性食物攝入障礙尤其會帶來精神疾?。ㄈ缱詺6])和醫(yī)療(如低骨密度[7])并發(fā)癥風(fēng)險,表明其在DALY方面的負(fù)擔(dān)可能是實(shí)質(zhì)性的。

第二,為了估計DALY,Santomauro及其團(tuán)隊假設(shè)閾值以下進(jìn)食障礙(例如,閾值以下的神經(jīng)性貪食癥)的損害程度只有其全閾值對應(yīng)的進(jìn)食障礙(例如,神經(jīng)性貪食癥)的一半,而非典型的神經(jīng)性厭食癥(即個體限制其食物攝入量,但無體重過低)的傷殘影響相當(dāng)于神經(jīng)性厭食癥減去體重過低的影響。這種方法在數(shù)學(xué)運(yùn)算上是有意義的,而且也可以說是作者在其樣本中估計DALY的唯一方法。然而,毫無疑問的是,這種方法低估了疾病負(fù)擔(dān)。閾值以下的進(jìn)食障礙患者在進(jìn)食病理、普通精神病理學(xué)或身體健康方面通常與全閾值的患者沒有差別[8]。此外,無論其行為癥狀的頻率如何,全閾值和閾值以下的進(jìn)食障礙患者都存在相同的潛在認(rèn)知精神病理(cognitive psychopathology),而認(rèn)知精神病理與臨床損傷密切相關(guān)[9]。與神經(jīng)性厭食癥患者類似,非典型神經(jīng)性厭食癥患者往往也經(jīng)歷了體重的急劇下降,所以絕對的體重指數(shù)(BMI)不是必須的有效傷殘標(biāo)志。例如,對于存在限制性進(jìn)食的少女,即使沒有達(dá)到通常引用的厭食癥體重截止值,其骨密度仍然比健康女孩低得多,因而前者的骨折風(fēng)險更高。[10]

綜上所述,Santomauro及其團(tuán)隊對GBD2019進(jìn)行了鞭辟入里的重新分析,清楚地表明進(jìn)食障礙是常見且有害的。他們的文章提出了振聾發(fā)聵的警示,要求將暴食癥和OSFED納入GBD的未來版本。我們完全贊同并希望進(jìn)一步推動這一進(jìn)程。我們建議GBD納入回避性/限制性食物攝入障礙、反芻障礙和Pica的患病率估計;并取得與所有DSM-5喂食和進(jìn)食障礙相關(guān)傷殘的直接測量數(shù)據(jù)。如果他們真的付諸實(shí)踐,其報告的全球疾病負(fù)擔(dān)將更大,這突出強(qiáng)調(diào)了增加資金投入的明確需要,以研究、預(yù)防和治療這些使人身體衰弱的疾病。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

*中文翻譯僅供參考,所有內(nèi)容以英文原文為準(zhǔn)。

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