Journal of Adolescent Health xxx (2022) 1e4

www.jahonline.org

Adolescent health brief

The Prevalence of Preadolescent Eating Disorders in the

United States
Stuart B. Murray, D.Clin.Psych., Ph.D. a, Kyle T. Ganson, Ph.D., M.S.W. b, Jonathan Chu c,
Kay Jann, Ph.D. d, and Jason M. Nagata, M.D., M.Sc. c, *
a
Department of Psychiatry & Behavioral Sciences, University of Southern California, Los Angeles, California
b
Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
c
Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
d
USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, California

Article history: Received May 13, 2021; Accepted November 23, 2021
Keywords: Eating disorders; Child eating disorders; Anorexia nervosa; Bulimia nervosa; Binge; Eating disorder

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: The prevalence of eating disorders (EDs) in young children remains relatively unknown.
Here, we aimed to assess the prevalence of anorexia nervosa (AN), bulimia nervosa (BN), binge ED
This study suggests that
(BED), and their subclinical derivatives, among 10- to 11-year-old children in the United States. full threshold eating dis-
Methods: Cross-sectional data from the year 1 sample of the nationwide Adolescent Cognitive orders are relatively un-
Brain Development study were extracted, and unadjusted prevalence of EDs was reported, as per common among 10- to 11-
DSM-5 criteria. year-olds in the United
Results: Among 10- to 11-year-old children in the United States, no cases of AN were reported. The States. Of all eating disor-
prevalence of BN was negligible, whereas the prevalence of BED was 1.1%. The prevalence of der phenotypes, binge
subclinical AN, BN, and BED was 6%, 0.2%, and 0.5%, respectively. eating disorder is the most
Discussion: BED is the most prevalent ED subtype among preadolescent children in the United prevalent. Subclinical
States, although subclinical markers for all ED subtypes are evident in this age range. eating disorders are more
Ó 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open common, where some but
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). not all diagnostic criteria
are met.

Eating disorders (EDs) are a constellation of burdensome,
costly, and treatment refractory psychiatric disorders which
portend elevated mortality and morbidity [1]. Although most
commonly developing in mid-adolescence, the prevalence of EDs
in younger children has remained largely unknown. This is a
particularly important concern given the greater prognosis
afforded by early detection and intervention [2], with those
treated within 3 years of illness onset showing a three-fold
greater likelihood of weight normalization within 12 months
Conflicts of interest: The authors have no conflicts of interest to declare.
* Address correspondence to: Jason M. Nagata, M.D., M.Sc., 550 16th Street,
4th Floor, Box 0110, San Francisco, CA 94158.
E-mail address: jason.nagata@ucsf.edu (J.M. Nagata).
[3], and the noted elevation in psychiatric and medical morbidity
in younger patients with EDs [4]. To date, one nationally repre-
sentative study in the United States reported the prevalence of
EDs to be 0.1% in children aged 8e11 years of age [5], although
crucially, this study reflected DSM-IV diagnostic criteria, and did
not delineate prevalence trends by ED subtype. A recent study
reporting on the first wave of the Adolescent Brain Cognitive
Development (ABCD) study reported the prevalence of EDs,
delineated by subtype, in 9- to 10-year-old children, reporting
prevalence rates of 0.1% for anorexia nervosa (AN), 0.0% for
bulimia nervosa (BN), 0.6% for binge ED (BED), and 0.6% for other
specified feeding and EDs [6]. However, these findings were
based on a fraction (approximately a third) of the baseline
sample of the ABCD data set. This study aims to build on previous

1054-139X/Ó 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jadohealth.2021.11.031
2 S.B. Murray et al. / Journal of Adolescent Health xxx (2022) 1e4
Table 1
An overview of the criteria used to determine eating disorder classifications
Eating disorder
Anorexia nervosa (AN) (binge eating/purging
subtype)
Anorexia nervosa (AN) (restricting subtype)
Bulimia nervosa (BN)
Binge eating disorder (BED)
Other specified feeding or eating disorder
(subclinical AN)
Other specified feeding or eating disorder
(subclinical BN)
Other specified feeding or eating disorder
(subclinical BED)
BMI ¼ body mass index.
findings and report ED prevalence estimates (delineated by
subtype and as per DSM-5 criteria [7]) and the bodyweight of
those afflicted, from the entire year 1 sample (ages 10e11 years)
of the nationwide ABCD study.
Methods
Cross-sectional data of children aged 10e11 years from the
ABCD Study, a large, diverse, population-based sample, at year 1
(2017e2019, release 3.0) were analyzed in 2021. Institutional
review board approval was obtained from the University of
California, San Diego, and at each study site (N ¼ 21), and
caregivers provided written informed consent. ED diagnosis
was determined using parent/caregiver responses to the
computerized Kiddie Schedule for Affective Disorders and
Schizophrenia (KSADS-5), based on DSM-5 criteria [7], and
subclinical EDs were determined by the presence of some but
not all diagnostic criteria for AN, BN, and BED (Table 1). Unad-
justed prevalence of EDs was estimated. Analyses were con-
ducted using Stata 15.1, incorporating propensity weights,
which matched key sociodemographic ABCD study variables to
those of the American Community Survey, which is a large
probability sample of US households. Although not designed to
be nationally representative, the use of propensity weights
Diagnostic criteria
 Fear surrounding becoming obese
 Emaciation
B <Fifth percentile of the BMI for age and sex
 Sense of self-worth connected to weight
 Use of weight control vomiting or other weight control methods or eating binges in the last
2 weeks
 Fear surrounding becoming obese
 Emaciation
 Sense of self-worth connected to weight
 Absence of use of weight control vomiting or other weight control methods or eating binges in the
last 2 weeks
 Presence of binge eating episodes
 Use of weight control vomiting or other weight control methods in the last 2 weeks
 Frequent use of weight control methods in the last 12 weeks
 Frequent binge eating episodes in the last 12 weeks
 Sense of self-worth connected to weight
 Presence of eating binges
 Frequent binge eating episodes
 Duration over the last 12 weeks
 Feelings of distress surrounding binge eating
 Absence of compensatory behaviors
 Absence of BN or AN diagnosis
 Presence of emaciation AND absence of current AN or current AN in partial remission
B Applies only if fear of becoming obese and sense of self-worth connected to weight are absent
OR
 Presence of fear surrounding becoming obese, presence of sense of self-worth connected to
weight, presence of emaciation (no more than 1 BMI point over cutoff) AND absence of current AN
or current AN in partial remission
 Presence of eating binges
 Presence of weight control methods
 Sense of self-worth connected to weight
 Absence of diagnosis for current AN, current AN in partial remission, current BN, current BN in
partial remission
 Presence of eating binges
 Frequent binge eating episodes
 Presence of at least 1 of characteristics of binge eating
 Feelings of distress surrounding binge eating
 Absence of diagnosis for any other current eating disorder
allows for results to be closely matched to the US population of
10- to 11-year-olds [8]. Results are based on this weighted
sample [8].
Results
Among the sample of 11,082 10- to 11-year-old children,
51.3% were boys. The sample was racially and ethnically
diverse (53.9% non-Hispanic White, 19.5% Hispanic, 16.5% non-
Hispanic Black, 5.6% non-Hispanic Asian/Pacific Islander, 3.2%
Native American, and 1.4% other race/ethnicity). No cases of
AN were present in this sample. The prevalence of BN was
negligible. The prevalence of BED was 1.1% overall (1.2% in
boys and 1.0% in girls) (Table 2). Among children with BED,
the mean body mass index was 26.5 (standard deviation 5.5)
kg/m2 and the mean body mass index percentile was 92.1
(standard deviation 14.3).
The prevalence of subclinical BN was marginally greater
than full threshold prevalence, at 0.2% in boys and girls. In
contrast, the prevalence of subclinical BED was marginally less
than that of full threshold presentations, at 0.6% in boys and
girls. The prevalence of subclinical AN was substantially
greater than that of full threshold presentations, at 6.5% in
boys and 6% in girls.
 S.B. Murray et al. / Journal of Adolescent Health xxx (2022) 1e4 3

Table 2
Prevalence of eating disorders among 11,082 10- to 11-year-old US children in the Adolescent Brain Cognitive Development study

Count Population count Prevalence 95% CI Adjusted Fa p value

Anorexia nervosa
Total 0 0 0.0% – – –
Boys 0 0 0.0% –
Girls 0 0 0.0% –
Bulimia nervosa
Total 6 2,826 0.0% 0.0%e0.0% 0.46 .50
Boys 3 1,052 0.0% 0.0%e0.0%
Girls 3 1,774 0.0% 0.0%e0.2%
Binge-eating disorder
Total 105 82,152 1.1% 0.9%e1.3% 0.47 .49
Boys 60 44,829 1.2% 0.9%e1.5%
Girls 45 37,323 1.0% 0.7%e1.4%
Other specified feeding and eating disorder: anorexia nervosa
Total 728 475,064 6.3% 5.8%e6.8% 1.00 .32
Boys 392 253,700 6.5% 5.8%e7.3%
Girls 336 221,364 6.0% 5.3%e6.8%
Other specified feeding and eating disorder: bulimia nervosa
Total 20 15,960 0.2% 0.1%e0.3% 0.16 .69
Boys 10 8,950 0.2% 0.1%e0.5%
Girls 10 7,010 0.2% 0.1%e0.4%
Other specified feeding and eating disorder: binge-eating disorder
Total 60 47,039 0.6% 0.5%e0.8% 0.06 .81
Boys 33 24,903 0.6% 0.4%e0.9%
Girls 27 22,136 0.6% 0.4%e0.9%

ABCD propensity weights were applied based on the American Community Survey from the US Census.
CI ¼ confidence interval.
a
The adjusted F statistic is a variant of the second-order Rao-Scott adjusted chi-square statistic.

Discussion subclinical markers may be substantially greater than the prev-

Among 10- to 11-year-old children in the United States, BED is
the most prevalent full threshold ED subtype. Broader evidence
relating to the onset of EDs suggests that BED most commonly
onsets in young adulthood [9]dthe latest among all ED
phenotypesdalthough our findings indicate that BED is evident
in children as young as 10 years of age. One potential source of
the discrepancy between our findings and broader epidemio-
logical findings may relate to the inclusion of parental reports in
arriving at diagnoses. A diagnosis of BED rests on an adequate
understanding of complex cognitive processes, such as what
constitutes a loss of control, and an adequate appraisal as to what
represents an ‘abnormally large volume of food’ [7]. To that end,
the inclusion of parental reports in informing diagnoses in the
present study may facilitate an earlier detection of BED, given the
abstract concepts involved in diagnosis.
Notably, and despite being linked the subsequent develop-
ment of obesity and cardiometabolic complications in adulthood
[10], our data indicate that even at 10e11 years of age, BED is
most prevalent among overweight and obese children. These
data serve to underscore the importance of early screening for
BED, and may potentially augment efforts to curb pediatric
obesity, and related sequelae, throughout later adolescence. In
keeping with previous findings from earlier waves of the ABCD
study [6], we note that the prevalence of EDs is not skewed to-
ward females, as has been widely reported in the ED field [11].
Cumulatively, these findings illustrate that screening for EDs in
children, and for BED in particular, ought to extend to all genders
and include parental observations of child behavior.
The prevalence of subclinical ED presentations is noteworthy.
Data relating to BN and BED suggest that subclinical markers may
be evident in children as young as 10e11 years of age and in boys
and girls alike. In the context of AN, these data suggest that
alence of full threshold diagnoses. However, the determination of
subclinical AN in this data set may (i) include those with low
weight status without the cognitive markers of AN, and the
extent to which this conflates subclinical AN with constitution-
ally thin yet nonpathological children is unclear, and (ii) exclude
those with atypical AN whose weight is above the fifth percen-
tile. Nevertheless, this greater preponderance of subclinical
markers of AN in boys discords with literature suggesting a
greater prevalence of AN in girls and women, and data suggest-
ing a heightened preference for muscular body types in young
boys [11], and warrants further investigation.
Limitations of our study include the inability to assess other
ED subtypes, some of which are known to onset earlier than
other ED phenotypes (e.g., avoidant and restrictive food intake
disorder), and the noted ambiguities around the prevalence of
subclinical ED behaviors in this age group.
Funding Sources
S.B.M. was supported by the National Institutes of Health (K23
MH115184). J.M.N. was supported by the National Institutes of
Health (K08HL159350) and the American Heart Association
Career Development Award (CDA34760281). Data used in the
preparation of this article were obtained from the ABCD Study
(https://abcdstudy.org), held in the NIMH Data Archive (NDA).
This is a multisite, longitudinal study designed to recruit more
than 10,000 children aged 9e10 years and follow them over
10 years into early adulthood. The ABCD Study was supported by
the National Institutes of Health and additional federal partners
under award numbers U01DA041022, U01DA041025,
U01DA041028, U01DA041048, U01DA041089, U01DA041093,
U01DA041106, U01DA041117, U01DA041120, U01DA041134,
U01DA041148, U01DA041156, U01DA041174, U24DA041123, and
4 S.B. Murray et al. / Journal of Adolescent Health xxx (2022) 1e4
U24DA041147. A full list of supporters is available at https://
abcdstudy.org/nihcollaborators. A listing of participating sites
and a complete listing of the study investigators can be found at
https://abcdstudy.org/principal-investigators.html. ABCD con-
sortium investigators designed and implemented the study and/
or provided data but did not necessarily participate in analysis or
writing of this report.
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