Women with bulimia nervosa may have higher CVD risk

Bulimia nervosa may be associated with increased risks of cardiovascular disease (CVD) and death among women, according to findings from a longitudinal cohort study conducted in Quebec, Canada.

Women who had ≥1 hospitalization for bulimia nervosa had a 4.25-fold (95 percent confidence interval [CI], 2.98 to 6.07) and 4.72-fold (95 percent CI, 2.05 to 10.84) increase in the risk of any CVD and death compared with women hospitalized for pregnancy-related events. The risk of CVD increased progressively with the number of admissions for bulimia nervosa, with a 7.39-fold (95 percent CI, 3.42 to 15.97) increase in risk for those with ≥3 admissions. [JAMA Psychiatry 2020;77:44-51, doi: 10.1001/jamapsychiatry.2019.2914]

When associations were plotted over time, the association between bulimia nervosa and risk of any CVD decreased over time. Specifically, bulimia nervosa was found to be associated with a 6.77 times (95 percent CI, 4.77 to 9.61) and a 5.13 times (95 percent CI, 3.70 to 7.12) increase in the risk of any CVD at 2 years and 5 years of follow-up, respectively, compared with women hospitalized for pregnancy-related events.

Bulimia nervosa was shown to have significant associations with many CVDs. At 12 years of follow-up, women hospitalized for bulimia nervosa had increased risks of myocardial infarction (MI) (hazard ratio [HR], 5.48; 95 percent CI, 1.80 to 16.70), other ischaemic heart disease (IHD) (HR, 6.63; 95 percent CI, 3.34 to 13.13), atherosclerosis (HR, 6.94; 95 percent CI, 3.08 to 15.66) and conduction disorder (HR, 2.99; 95 percent CI, 1.57 to 5.71) compared with women hospitalized for pregnancy-related events, after adjustment of covariates.

In terms of incidence rates, women hospitalized for bulimia nervosa had a higher incidence of CVD (10.34 vs 1.02 per 1,000 person-years) and death (3.21 vs 0.10 per 1,000 person-years) compared with women with pregnancy-related hospitalizations. The incidence of CVD was the highest among women who had ≥3 admissions for bulimia nervosa (25.13 per 1,000 person-years; 95 percent CI, 13.52 to 46.70) and those aged ≥40 years at first admission (1.92 per 1,000 person-years; 95 percent CI, 1.61 to 2.30).

Sensitivity analyses yielded consistent results for both gravid and nongravid women diagnosed with bulimia nervosa, in those aged 10 years at cohort entry, as well as in those who were first hospitalized before 2013 when the definition of bulimia was stricter.

In this longitudinal cohort study, 416,709 women (mean age, 28.3 years) hospitalized in Quebec, Canada, for bulimia nervosa (n=818) or pregnancy-related events (n=415,891; comparison group) were followed up for 12 years. Data were retrieved from the Study of Hospital Clientele registry. Diagnosis of bulimia nervosa and CVD was based on codes from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and Canadian Classification of Health Interventions.

Bulimia nervosa is one of the most common psychiatric diseases in women. The condition is characterized by episodes of binge eating followed by compensatory purging, which may potentially affect CVD stability. In addition to immediate electrolyte imbalance, damages to cardiac myocytes may occur, leading to CVD development. The condition is also associated with psychological stress, which further aggregates its development. [Lancet 2010;375:583-593; Dialogues Clin Neurosci 2018;20:31-40; J Eat Disord 2015;3:12; Am J Hypertens 2015;28:1295-1302]

Results of the study showed that bulimia nervosa is significantly associated with increased risks of CVDs, including MI, other ischaemic heart disease, atherosclerosis and conduction disorders. The risks were the highest in the first 5 years after the index bulimia nervosa-related hospitalization and decreased thereafter. “The findings also suggest that women with a history of bulimia nervosa should be screened regularly for ischaemic CVD and may benefit from prevention of and treatment of CVD risk factors,” the researchers concluded.