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Original Investigation
October 16, 2019

Association of Bulimia Nervosa With Long-term Risk of Cardiovascular Disease and Mortality Among Women

Author Affiliations
  • 1School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
  • 2Bureau d’information et d’études en santé des populations, Institut National de Santé Publique du Québec, Montreal, Canada
  • 3Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
  • 4Innovation Hub, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
  • 5Division of Cardiology, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
  • 6Department of Psychiatry, McGill University, Montreal, Quebec, Canada
  • 7Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada
JAMA Psychiatry. Published online October 16, 2019. doi:https://doi.org/10.1001/jamapsychiatry.2019.2914
Key Points

Question  Is bulimia nervosa associated with a long-term risk of cardiovascular disease and mortality among women?

Findings  In this longitudinal cohort study of 416 709 women in Canada (including 818 women hospitalized for bulimia nervosa and 415 891 for pregnancy-related events) who were followed up for 12 years, women with a diagnosis of bulimia nervosa had a significantly increased risk of hospitalization for cardiovascular disease and death up to 8 years after the index bulimia-related hospitalization.

Meaning  This study’s findings suggest that women diagnosed with bulimia nervosa may benefit from closer management of this condition for prevention of cardiovascular risk factors and disease.

Abstract

Importance  Bulimia nervosa is associated with short-term cardiovascular complications in women, but its long-term consequences on cardiovascular health are unknown.

Objective  To study the association of bulimia nervosa with the long-term risk of cardiovascular disease and mortality in women.

Design, Setting, and Participants  In this longitudinal cohort study, 416 709 women hospitalized in Quebec, Canada, including women hospitalized for bulimia nervosa and those for pregnancy-related events as a comparison group, were followed up for 12 years from 2006 to 2018 to identify incidences of cardiovascular disease and death.

Exposures  At least 1 hospitalization for bulimia nervosa.

Main Outcomes and Measures  The study participants were followed up to identify future incidences of cardiovascular disease and deaths. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% CIs to assess the association of bulimia nervosa with future outcomes after adjustment for patient characteristics.

Results  The study population comprised 818 women who were hospitalized for bulimia nervosa (mean [SD] age, 28.3 [13.4] years) and 415 891 hospitalized for pregnancy-related events (mean [SD] age, 28.3 [5.4] years). Patients were followed up for a total of 2 957 677 person-years. The women hospitalized for bulimia nervosa had a greater incidence of cardiovascular disease compared with those hospitalized for pregnancy-related events (10.34 [95% CI, 7.77-13.76] vs 1.02 [95% CI, 0.99-1.06] per 1000 person-years). Incidence of future cardiovascular disease was even higher for women with 3 or more bulimia admissions (25.13 [95% CI, 13.52-46.70] per 1000 person-years). Women hospitalized for bulimia nervosa had 4.25 (95% CI, 2.98-6.07) times the risk of any cardiovascular disease and 4.72 (95% CI, 2.05-10.84) times the risk of death compared with women hospitalized for pregnancy-related events. Bulimia nervosa was found to be associated with ischemic heart disease (HR, 6.63; 95% CI, 3.34-13.13), atherosclerosis (HR, 6.94; 95% CI, 3.08-15.66), and cardiac conduction defects (HR, 2.99; 95% CI, 1.57-5.71). Bulimia was also associated with 21.93 (95% CI, 9.29-51.74) times the risk of myocardial infarction at 2 years of follow-up and 14.13 (95% CI, 6.02-33.18) times the risk at 5 years of follow-up.

Conclusions and Relevance  This study’s findings suggest that bulimia nervosa may be associated with the long-term risk of any cardiovascular disease, such as ischemic cardiac events and conduction disorders, as well as with death among women. The findings also suggest that women with a history of bulimia nervosa should be screened regularly for ischemic cardiovascular disease and may benefit from prevention of and treatment for cardiovascular risk factors.

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