Attention paid to the economic burden of eating disorders (EDs) has been increasing, particularly over the last 15 years or so [1]. Given the high degree of morbidity and mortality associated with EDs, attempts have been made to estimate cost-of-illness, covering both direct costs (e.g., meetings with a therapist, transportation) and indirect costs (e.g., absence from work), often referred to as taking a societal perspective [2]. Such estimates detail the economic burden that EDs impose on society, as well as informing service delivery, policies, and assuring value-for-money in healthcare [3].
Reviews of cost-of-illness studies in EDs have underlined heterogeneity in samples and methods used, resulting in wide variation in estimated costs (e.g., [1, 4]; see also [5]) and questionable generalisability [5, 6]. There has been limited consideration of wider costs, such as those not directly associated with treatment [4], and studies have underestimated the societal impact in economic terms [1], rarely taking into account factors such as absence from work. A large proportion of recent studies originate from North America and many obtain cost information from health insurance databases (see also [7]). As well as posing a risk in terms of sampling bias, such studies are influenced by the fact that “a considerable percentage of the [US] population is uninsured or has no insurance at all” ([4], p. 487) and “research taking a societal perspective continues to be sparse and incomplete” ([1], p. 60).
Comparatively little is known about individuals with regular binge eating who are not underweight, with a shortage of published studies from the UK and Europe, where approaches to healthcare differ. This group represents the majority of those residing in the community [8] and those presenting for outpatient treatment [9] but is often overlooked in cost-of-illness studies. Existing work has tended to focus on one particular illness rather than considering a range of ED presentations [1, 7, 10–13], with studies of anorexia nervosa particularly common, and there has been limited exploration of factors associated with healthcare costs [7], which can help inform both healthcare and research priorities.
Healthcare usage for non-underweight individuals who report regular binge eating is higher than that for individuals without EDs (e.g., [12, 14, 15]), even when accounting for comorbidities (e.g., [7, 16]). When examining economic impact, these studies have generally focused on healthcare costs, with annual estimates for BN in the range of €888 to €18,823, and €1762 to €2902 for individuals with BED [17], with societal costs seldom reported (cf. [18]). Data on individuals with subthreshold and atypical EDs (e.g., Other Specified Feeding and Eating Disorders [OSFED]) are notably lacking given that “these disorders are more prevalent and thus have contributed substantially to the total cost of EDs” ([19], p. 1).
Although some studies have looked at the influence of demographic factors such as age and gender (e.g., [7, 13]), few have explored whether common ED symptoms, such as binge eating, are associated with costs. Looking at a sample of women seeking treatment for regular binge eating, Dickerson et al. [20] found that baseline binge eating frequency was not associated with costs, although age was positively related to both medication costs and total healthcare costs. Higher body mass index (BMI) was associated with medication costs (see also [5]).
Looking at the impact of EDs at a national level, a 2015 report commissioned by a UK ED charity [21] suggested an annual cost of between £2.6 billion and £3.1 billion to sufferers and carers, with costs to the National Health Service (NHS) of between £3.9 billion and £4.6 billion. A report of societal costs to the US in 2018-19 [5, 22] assumed a prevalence of 1.66% and estimated costs in excess of $64 billion (equivalent to $11,808 [approximately €9,784] for each person with an ED). Similar estimates have been made in other countries (e.g., [23]). Such figures provide an overview of the significant financial burden of EDs although further work is required to explore these findings and triangulate estimates [23].
The current study aims to provide an estimate of societal costs in a group of non-underweight individuals referred for specialist outpatient treatment for regular binge eating, using a ‘bottom-up’, prevalence-based approach. Additionally, the study will look at associations between costs and demographic factors, as well as exploring diagnostic differences (e.g., [15, 16, 24]) and associations with binge eating frequency.