Bulimia May Contribute to Premature CVD in Women

Women with a history of bulimia may be at increased risk of cardiovascular disease and death years after their initial eating-disorder diagnosis, a new study suggests. The researchers say the findings point to the need to follow these women closely with screening and treatment of risk factors.

“Bulimia is known to have a short-term impact on arrythmias and other acute cardiovascular issues during the eating-disorder event, but the long-term impact hasn't been studied,” senior author Nathalie Auger, MD (Institut National de Santé Publique du Québec, Montreal, Canada), told TCTMD.

Auger’s study, led by Rasmi M. Tith, RD, MPH (University of Waterloo, Canada), found that hospitalization for bulimia was associated with a fourfold increased risk of any cardiovascular disease and death over 12-year follow-up. The risk was highest among those with multiple hospital admissions for bulimia, the researchers report in their paper published October 16, 2019, online ahead of print in JAMA Psychiatry.

Although the finding is simply an association at this point, Riti Patel, MD (Lankenau Heart Institute, Main Line Health, Philadelphia, PA), who was not involved in the study, said it’s a needed step toward shedding more light on cardiac issues in women with eating disorders. The existing literature is sparse, with much of it focusing on anorexia rather than bulimia, Patel noted. Importantly, across the entire spectrum of psychiatric illness, eating disorders are associated with the highest mortality rate.

“We don’t necessarily understand why, but it's thought that a good number of those [deaths], up to a third, are related to cardiovascular issues,” she added.

Higher Risk in Proximity to Bulimia Admission

Using Quebec registry data, Tith and colleagues compared 818 women who were hospitalized for bulimia and 415,891 women hospitalized for pregnancy-related events such as delivery of a live or stillborn infant, abortion, and ectopic pregnancy. The mean age of women in both groups was 28 years. The researchers say the control group was chosen because they were believed to reflect the majority of women of that age in Quebec, and because data sources were limited.

Compared with controls, women hospitalized for bulimia had a higher incidence per 1,000 person-years of both cardiovascular disease (10.34 vs 1.02) and death (3.21 vs 0.10) over the 12-year follow-up. Cardiovascular disease risk was highest in the early years after the bulimia hospitalization, with a 6.77-times greater risk at 2 years, 5.13-times greater risk at 5 years, and 4.25-times greater risk at 12 years. The increased risks applied to MI, conduction disorder, pulmonary vascular disease, cerebrovascular disease, atherosclerosis, and other ischemic and CV diseases, as well as to admission to a coronary care unit.

The pattern was similar for any death, with a 13.09-times greater risk at 2 years, 8.27-times greater risk  5 years, and 4.72-times greater risk at 12 years.

“We saw the risk peaking at anywhere up to 4 years after the hospitalization, remaining high after that period but notably strongest in those first 4 or 5 years,” Auger said. She and her colleagues say that information may be useful for determining how to follow women for cardiovascular screening and preventive measures.

To TCTMD, Auger said the findings highlight the importance of using the bulimia hospitalization as "an opportunity to inform women, first of all, because many of them might not know about these risks. The women should all ideally quit smoking and adopt healthier behaviors like physical activity and better nutrition.”

‘You Have to Start Someplace’

In an accompanying editorial, Katie M. O’Brien, MSPH, PhD, and Alexander P. Keil, MSPH, PhD (both National Institute of Environmental Health Sciences, Research Triangle Park, NC), note that the while registry data such as those used in this study are useful when data sources are limited, more research is needed to “refine these estimates, especially with a well-defined target population, to estimate the true effect of bulimia on CVD.”

Similarly, Patel said the control group used by the investigators was not ideal. “If you're going to do a study like this and you have a control group, you basically want patients who have no medical issues and who are not hospitalized,” she said. “[This was] not the ideal group, but I still think it's important that they were able to get this data. You have to start someplace.”

She added that severity of the bulimia and how long the patient has had the disorder may be a better indicator of future risk than waiting until the person has been hospitalized to screen them for CVD risk factors. Additionally, Patel said many patients cycle in and out of eating disorders, making it difficult to know for sure if a patient hospitalized for bulimia has bulimia alone or has anorexia tendencies that complicate their risk profile.

Patel also noted that the finding of an association between bulimia and ischemic heart disease is potentially important, since rhythm disturbances and autonomic dysfunction, such as blood pressure fluctuations related to taking diuretics, are more common findings than atherosclerotic disease in this population.

She said the study is “a good start” to putting the topic on the radar of cardiologists, since eating disorders are something that most have little experience with and may even feel uncomfortable discussing with patients.

“The hope is that more and more clinicians will become aware of what they need to do for their patients with bulimia or how to inform their patients about these risks,” Auger added.