Elevated plasma lipids in patients with binge eating disorders are found only in those who are anorexic

Dietary Effects of Fasting on the Lipid Panel

INTRODUCTION

Dietary habits, such as the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH), have been shown to improve cardiac health. Another more recent popular form of dieting incorporates periods of fasting known as intermittent fasting. The two main forms are alternate-day fasting and time-restricted eating.

METHODS

PubMed search and literature review was undertaken. This review evaluates the current literature regarding the effects of the fasting dietary model and other types of fasting upon the lipid panel.

RESULTS

There have been studies that have shown that intermittent fasting does provide a benefit in cardiovascular health, weight loss, and hypertension. However, the effect on cholesterol and triglyceride levels during intermittent fasting is in question.

CONCLUSION

The effect that fasting has on one's lipid panel is unclear, there are studies that show that different forms of fasting affect the lipid panel in various ways. There are studies that show that intermittent fasting does improve one's lipid profile and provides health benefits. Randomized controlled clinical trials with a large sample size are needed to evaluate the effects that intermittent fasting has based on race, ethnicity, gender, obesity, dyslipidemia, diabetic and healthy patients, and will lead to definitive evidence of lipid panel outcomes beyond current evidence based solely upon observational cohorts with numerous and multifactorial confounding factors and biases.

Anorexia nervosa manifesting as massive ascites, hypercholesterolemia, and sequential binge eating in an 11-year-old girl: A case report

RATIONALE

Anorexia nervosa (AN) is a serious eating disorder associated with a distorted body image. Hypercholesterolemia has been found in patients with AN but the mechanism of hyperlipidemia in AN remains little known. Ascites in patients with AN has been attributed to hypoalbuminemia and liver diseases, but massive ascites without the aforementioned etiologies has never been reported in AN.

PATIENT CONCERNS

An 11-year-old girl was admitted for exclusion of organic underlying diseases due to severe body weight loss (18% within 3 weeks), poor appetite, and hypercholesterolemia (274 mg/dL). She complained of heartburn sensation, nausea, vomiting, constipation, and postprandial dull abdominal pain with fullness.

DIAGNOSES

The patient's condition met with all 3 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for diagnosing AN. On admission, her total cholesterol level was 337 mg/dL and hypocomplementemia (C3 55.5 mg/dL) was also found. Abdominal sonography and computed tomography scans showed massive ascites. However, neither proteinuria nor hypoalbuminemia was found. Upper gastroduodenal endoscopy showed chronic superficial gastritis and colonoscopy revealed negative findings. Ascites obtained by paracentesis demonstrated a transudate without bacterial infection, tuberculosis, or pancreatitis. Exploratory laparoscopy showed nonpurulent ascites. However, biopsies from the small intestine, mesentery, and liver showed chronic inflammation and fibrosis.

INTERVENTIONS

The intensive nutritional therapy by increasing total energy intake stepwise with a combination of high-energy formula and her favorite foods.

OUTCOMES

Her hypercholesterolemia, hypocomplementemia, and massive ascites resolved after her weight was restored. She developed binge eating with continuous weight gain after discharge. Her weight significantly increased to an obese level (body mass index [BMI] 25.9 kg/m) after loss to follow-up for 4 years until she returned to our emergency room due to suicide attempt.

CONCLUSION

Diagnostic crossover between subtypes in anorexia nervosa might be a potential risk factor for illness severity and poor prognosis. AN can manifest as massive ascites with normal albumin concentrations that could possibly be due to chronic inflammation of the intestinal serosa, mesentery, and peritoneal surface of the liver.

Increased lipid and lipoprotein concentrations in anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

Alterations in blood lipid concentrations in anorexia nervosa (AN) have been reported; however, the extent, mechanism, and normalization with weight restoration remain unknown. We conducted a systematic review and a meta-analysis to evaluate changes in lipid concentrations in acutely-ill AN patients compared with healthy controls (HC) and to examine the effect of partial weight restoration.

METHOD

A systematic literature review and meta-analysis (PROSPERO: CRD42017078014) were conducted for original peer-reviewed articles.

RESULTS

Forty-eight studies were eligible for review; 33 for meta-analyses calculating mean differences (MD). Total cholesterol (MD = 22.7 mg/dL, 95% CI = 12.5, 33.0), high-density lipoprotein (HDL; MD = 3.4 mg/dL, CI = 0.3, 7.0), low-density lipoprotein (LDL; MD = 12.2 mg/dL, CI = 4.4, 20.1), triglycerides (TG; MD = 8.1 mg/dL, CI = 1.7, 14.5), and apolipoprotein B (Apo B; MD = 11.8 mg/dL, CI = 2.3, 21.2) were significantly higher in acutely-ill AN than HC. Partially weight-restored AN patients had higher total cholesterol (MD = 14.8 mg/dL, CI = 2.1, 27.5) and LDL (MD = 16.1 mg/dL, CI = 2.3, 30.0). Pre- versus post-weight restoration differences in lipid concentrations did not differ significantly.

DISCUSSION

We report aggregate evidence for elevated lipid concentrations in acutely-ill AN patients compared with HC, some of which persist after partial weight restoration. This could signal an underlying adaptation or dysregulation not fully reversed by weight restoration. Although concentrations differed between AN and HC, most lipid concentrations remained within the reference range and meta-analyses were limited by the number of available studies.

Doppler Echocardiography Assessment of Aortic Stiffness in Female Adolescents with Anorexia Nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with abnormalities in biomarkers of cardiovascular risk. Arterial stiffness, as measured by pulse-wave velocity (PWV), is also a risk factor for cardiovascular disease. The aims of this study were to determine the stiffness of the aorta in female adolescents with AN and to determine if either the severity or the type of AN was associated with PWV.

METHODS

This was a retrospective case-control study. Adolescent patients with a clinical diagnosis of AN were included. Aortic diameter and pulse-wave transit time over a portion of the thoracic aorta were measured using Doppler echocardiography, and PWV was calculated.

RESULTS

There were 94 female patients with AN and 60 adolescent female control subjects. There was no significant difference in age between patients with AN and control subjects (15.5 ± 1.7 vs 15.1 ± 2.6 years, P = .220). Body mass index (16.0 ± 2.4 vs 19.7 ± 2.7 kg/m², P < .001) and body mass index percentile (9.4 ± 15.6 vs 45.5 ± 26.2, P < .001) were significantly lower for patients with AN than control subjects. PWV (443 ± 106 vs 383 ± 77 cm/sec, P < .001) was significantly higher in patients with AN than control subjects. Similar differences from control subjects were found in patients with AN with both lower and higher body mass index percentiles and also in patients with AN with the restrictive or the binge-purge subtype.

CONCLUSIONS

Female adolescents with AN have increased aortic stiffness compared with control subjects. This study suggests that patients with AN may be at increased risk for future cardiovascular disease. Future studies are required to determine the reversibility of these changes with weight restoration.

Serum Lipid Levels in Patients with Eating Disorders

Objective To evaluate some risk factors for cardiovascular diseases in feeding and eating disorders, the degree of lipid abnormalities was investigated in a large Japanese cohort of different groups of feeding and eating disorders, according to the Japan Atherosclerosis Society Guidelines for the Prevention of Atherosclerotic Cardiovascular Diseases 2012 (JAS Guidelines 2012). Methods Participants in the current study included 732 women divided into four groups of feeding and eating disorders: anorexia nervosa, restricting type (AN-R); anorexia nervosa, binge-eating/purging type; bulimia nervosa (BN); and binge-eating disorder (BED). We measured the serum levels of total cholesterol, high-density-lipoprotein (HDL) cholesterol, and triglyceride in these participants. Low-density-lipoprotein (LDL) cholesterol and non-HDL cholesterol levels were also calculated. Results The concentrations of LDL cholesterol and non-HDL cholesterol were widely distributed in all groups. When the LDL cholesterol risk was defined as ≥120 mg/dL and the non-HDL cholesterol risk as ≥150 mg/dL, according to the JAS Guidelines 2012, the proportion of LDL cholesterol risk ranged from 29.6% (BN) to 38.6% (AN-R), and the proportion of non-HDL cholesterol risk ranged from 17.8% (BN) to 30.1% (BED). Conclusion The present findings suggest the existence of LDL cholesterol risk and non-HDL cholesterol risk in all groups of eating disorders. Given the chronicity of this condition, the development of elevated concentrations of LDL cholesterol and non-HDL cholesterol at an early age may increase the risk of cardiovascular diseases.

Oxidative stress and antioxidant levels in patients with anorexia nervosa: A systematic review and exploratory meta-analysis

OBJECTIVE

To systematically review and meta-analyze oxidative stress and antioxidant markers in anorexia nervosa (AN).

METHODS

Electronic PubMed search from database inception until 12/31/2013. Out of 1062 hits, 29 studies comparing oxidative stress/antioxidant markers between patients with AN and healthy controls (HCs) with a total of 1,729 participants (AN = 895, HCs = 834) were eligible. Data about oxidative stress and antioxidant markers, independent of their source, were extracted. We calculated random effects standardized mean differences (SMDs) as effect size measures for outcomes reported in ≥5 studies; others were summarized descriptively.

RESULTS

Compared to HCs, AN patients showed significantly higher apolipoprotein B (ApoB) levels (studies = 7; n = 551; SMD = 0.75; p = .0003, I(2)  = 74%), with higher age being associated with higher ApoB (Coefficient: 0.61 ± 0.15, p < .0001), whereas BMI (p = .15) and measurement method (p = .70) did not moderate the results. Serum albumin levels were similar between AN and HCs (studies = 13; n = 509; SMD =-0.19; 95%CI: -0.62 to 0.24; p = .38; I(2)  = 81%), with neither age (p = .84) nor BMI (p = .52) being significant moderators. Lower superoxide dismutase levels were reported in 2 studies, while findings for vitamin A and its metabolites were inconclusive. In single studies, patients with AN had significantly higher catalase and nitric oxide (NO) parameter levels (platelet NO, exhaled NO and nitrites), such as lower glutathione and free cysteine levels, compared to HCs.

DISCUSSION

AN appears to be associated with some markers of increased oxidative stress. Additional research is needed to discern whether oxidative stress is a potential cause or effect of AN, and whether treatments improving oxidative stress could be useful in AN.

Bone Mineral Changes and Cardiovascular Effects among Female Athletes with Chronic Menstrual Dysfunction

Purpose

Oligo/amenorrhea, as a part of the Female Athlete Triad has adverse effects on the athlete's bone mineral density (BMD) and cardiovascular system. Hypoestrogenism, due to suppression of hypothalamus-pituitary axis (HPA) as a result of energy imbalance, is the possible cause of the Triad. This study was designed based on following up and reassessment of elite female athletes who were diagnosed as menstrual dysfunction about two years ago.

Methods

This study was conducted in three phase sections: 1) Reassess the pattern of menstrual cycle among athletes who reported menstrual dysfunction about two years ago; 2) Bone mineral density was measured twice in the same machine and same center with a two-year interval; 3) The laboratory data including blood glucose, lipid profile and inflammatory markers was assessed in phase 3.

Results

BMD of athletes did not change significantly after 25.5 months of oligomenorrhea P (spine) = 0.2, P (femur)=0.9. Mean of all cardiovascular factors was in the normal range except for high density lipoprotein (HDL) which was 49.28 (SD=9.18), however, most of the athletes had abnormalities in their lipid profile. Inverse relationship between the increase in the BMD of spine and total cholesterol (r =−0.49, P=0.04), Apolipoprotein A (r = −0.51 P=0.04), and very low density lipoprotein (VLDL) (r =−0.66, P=0.009). Also correlation between BMD of spine and HbA1C (r =−0.70, P=0.003) were significant.

Conclusion

Findings of this study show that negative changes in BMD and cardiovascular biomarkers of female athletes with functional hypothalamic menstrual dysfunction could occur if proper therapeutic intervention (including increase in calorie intake, decrease in exercise load or hormonal replacement) will not consider.

The clinical biochemistry of anorexia nervosa

In anorexia nervosa, under-nutrition and weight regulatory behaviours such as vomiting and laxative abuse can lead to a range of biochemical problems. Hypokalaemia is the most common electrolyte abnormality. Metabolic alkalosis occurs in patients who vomit or abuse diuretics and acidosis in those misusing laxatives. Hyponatraemia is often due to excessive water ingestion, but may also occur in chronic energy deprivation or diuretic misuse. Urea and creatinine are generally low and normal concentrations may mask dehydration or renal dysfunction. Abnormalities of liver enzymes are predominantly characterized by elevation of aminotransferases, which may occur before or during refeeding. The serum albumin is usually normal, even in severely malnourished patients. Amenorrhoea is due to hypogonadotrophic hypogonadism. Reduced concentrations of free T4 and free T3 are frequently reported and T4 is preferentially converted to reverse T3. Cortisol is elevated but the response to adrenocorticotrophic hormone is normal. Hypoglycaemia is common. Hypercholesterolaemia is a common finding but its significance for cardiovascular risk is uncertain. A number of micronutrient deficiencies can occur. Other abnormalities include hyperamylasaemia, hypercarotenaemia and elevated creatine kinase. There is an increased prevalence of eating disorders in type 1 diabetes and the intentional omission of insulin is associated with impaired metabolic control. Refeeding may produce electrolyte abnormalities, hyper- and hypoglycaemia, acute thiamin depletion and fluid balance disturbance; careful biochemical monitoring and thiamin replacement are therefore essential during refeeding. Future research should address the management of electrolyte problems, the role of leptin and micronutrients, and the possible use of biochemical markers in risk stratification.

Autonomic nervous system and lipid metabolism: findings in anxious-depressive spectrum and eating disorders

OBJECTIVE

To correlate lipid metabolism and autonomic dysfunction with anxious-depressive spectrum and eating disorders. To propose the lipid index (LI) as a new possible biomarker.

METHODS

95 patients and 60 controls were enrolled from the University Psychiatry Unit of Catania and from general practitioners (GPs). The patients were divided into four pathological groups: Anxiety, Depression, Anxious-Depressive Disorder and Eating Disorders [Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) official/appendix criteria]. The levels of the cholesterol, triglycerides and apolipoproteins A and B were determined. The LI, for each subject, was obtained through a mathematical operation on the values of the cholesterol and triglycerides levels compared with the maximum cut-off of the general population. The autonomic functioning was tested with Ewing battery tests. Particularly, the correlation between heart rate variability (HRV) and lipid metabolism has been investigated.

RESULTS

Pathological and control groups, compared among each other, presented some peculiarities in the lipid metabolism and the autonomic dysfunction scores. In addition, a statistically significant correlation has been found between HRV and lipid metabolism.

CONCLUSIONS

Lipid metabolism and autonomic functioning seem to be related to the discussed psychiatric disorders. LI, in addition, could represent a new possible biomarker to be considered.

Dieting frequency in obese patients with binge eating disorder: behavioral and metabolic correlates

This study examined the clinical significance of self-reported frequency of time spent dieting in obese patients with binge eating disorder (BED). A total of 207 treatment-seeking obese BED patients (57 men and 150 women) were dichotomized by dieting frequency and gender and compared on a number of historical, psychological, and metabolic variables. Frequent dieters reported significantly earlier age of onset for binge eating, dieting, and obesity, more episodes of weight cycling, greater weight suppression, and greater eating disorder pathology than infrequent dieters; no differences, however, emerged on current binge eating frequency or psychological distress. Among women but not among men, frequent dieters had consistently lower chances of abnormalities in total cholesterol, high-density lipoprotein (HDL) cholesterol, and the total/HDL cholesterol ratio while infrequent dieters had greater chances of abnormalities on these variables. Dietary restraint was inversely correlated with abnormalities in triglycerides, HDL cholesterol, and the total/HDL cholesterol ratio but was unrelated to low-density lipoprotein (LDL) cholesterol. In summary, frequent dieters of both genders had greater lifetime and current eating and weight concerns, and in women, decreased chance of metabolic abnormalities than infrequent dieters. Our findings suggest that frequent dieting attempts, particularly in women, are associated with greater eating disorder pathology but may have a beneficial effect on metabolic functioning and cardiovascular disease risk independent of actual weight status. These findings may have implications for clinical advice provided to obese BED patients.

Expression and activity of P-glycoprotein (MDR1/ABCB1) in peripheral blood mononuclear cells from patients with anorexia nervosa compared with healthy controls

OBJECTIVE

Pharmacotherapeutic strategies for treatment of anorexia nervosa (AN) are characterized by limited success. Some drugs used (antipsychotics, selective serotonin reuptake inhibitors) are transported by P-glycoprotein (P-gp), a transporter with major impact on pharmacokinetics of substrate drugs. Biochemical alterations seen in AN patients could lead to increased expression and/or activity of P-gp and therefore to diminished access of drugs to the brain. The aim of our study was to investigate expression and activity levels of P-gp in peripheral blood mononuclear cells (PBMCs) in AN patients.

METHOD

PBMCs of 16 AN patients and 16 controls were isolated. Activity of P-gp was determined by flow cytometry and expression was quantified by reverse-transcriptase-real-time-polymerase-chain-reaction.

RESULTS

Neither a significant difference in P-gp expression (AN: 0.00154 +/- 0.00088 [MDR1/beta2 mg], control: 0.00244 +/- 0.0013 [MDR1/beta2 mg], p = .138) nor a difference in P-gp activity (rhodamine 123 ratio AN: 1.79 +/- 0.73, control: 2.03 +/- 0.42, p = .20) between AN patients and healthy controls could be detected. In contrast to previous studies, expression and activity of P-gp correlated significantly (p = .0031).

CONCLUSION

Failure in pharmacotherapy with P-gp substrates in AN patients are probably neither caused by different P-gp expression nor activity levels.

Hormonal and nutritional effects on cardiovascular risk markers in young women

CONTEXT

Cardiovascular (CV) risk markers, including high-sensitivity C-reactive protein (hsCRP), are increasingly important in predicting cardiac events. A favorable CV risk profile might be expected in anorexia nervosa (AN) due to low body weight and dietary fat intake. However, women with AN have decreased IGF-I levels reflecting decreased GH action, and IGF-I deficiency is associated with elevated hsCRP. Moreover, oral estrogens, known to increase hsCRP in other populations, are commonly prescribed in AN. To date, hsCRP levels and their physiological determinants have not been reported in women with AN.

OBJECTIVE

We examined the relationship between CV risk markers, undernutrition, IGF-I, and oral estrogens, specifically hypothesizing that in the setting of undernutrition, AN would be associated with low hsCRP despite low IGF-I levels and that those women taking oral contraceptive pills (OCPs) would have higher hsCRP and lower IGF-I levels.

DESIGN AND SETTING

We conducted a cross-sectional study at a clinical research center.

STUDY PARTICIPANTS

Subjects included 181 women: 140 women with AN [85 not receiving OCPs (AN-E) and 55 receiving OCPs (AN+E)] and 41 healthy controls [28 not receiving OCPs (HC-E) and 13 receiving OCPs (HC+E)].

MAIN OUTCOME MEASURES

We assessed hsCRP, IL-6, IGF-I, low-density lipoprotein (LDL), and high-density lipoprotein (HDL).

RESULTS

Despite low weight, more than 20% of AN+E had high-risk hsCRP levels. AN+E had higher hsCRP than AN-E. AN-E had lower mean hsCRP levels than healthy controls (HC+E and HC-E). IL-6 levels were higher in AN+E with elevated hsCRP (>3 mg/liter) than in AN+E with normal hsCRP levels. IGF-I was inversely associated with hsCRP in healthy women, suggesting a protective effect of GH on CV risk. However, this was not seen in AN. Few patients in any group had high-risk LDL or HDL levels.

CONCLUSIONS

Although hsCRP levels are lower in AN than healthy controls, OCP use puts such women at a greater than 20% chance of having hsCRP in the high-CV-risk (>3 mg/liter) category. The elevated mean IL-6 in women with AN and high-risk hsCRP levels suggests that increased systemic inflammation may underlie the hsCRP elevation in these patients. Although OCP use in AN was associated with slightly lower mean LDL and higher mean HDL, means were within the normal range, and few patients in any group had high-risk LDL or HDL levels. IGF-I levels appear to be important determinants of hsCRP in healthy young women. In contrast, IGF-I does not appear to mediate hsCRP levels in AN.

Administration of recombinant human growth hormone normalizes GH-IGF1 axis and improves malnutrition-related disorders in patients with anorexia nervosa

High serum level of GH in the presence of low plasma level of insulin-like growth factor-I (IGF-I) is one of the endocrinological features of anorexia nervosa (AN). Whether the amount of endogenous GH is not enough to increase IGF-I is not certain. We studied the effect of recombinant human growth hormone (rhGH) on the GH-IGF-I axis and on malnutrition-related disorders in this syndrome. Twenty patients with AN were divided into two groups; one (N = 13) was given rhGH (0.33 mg/day), and the other (N = 7) was given placebo for 6 or 12 months, respectively. During each treatment, levels of serum GH, plasma IGF-I, serum thyroid hormones, serum cholesterol, fasting plasma glucose and cardiac function were monitored. Changes in body mass index (BMI) and calorie taken were also evaluated. Plasma IGF-I level increased from 74.4 +/- 41.9 to 269.0 +/- 31.2 microg/L (P<0.001) during administration of rhGH, which associated with a decrease in serum GH level from 17.0 +/- 15.0 to 1.6 +/- 0.8 microg/L (P<0.001). Administration of rhGH increased BMI, body temperature, fasting plasma glucose level, and food intake. Serum level of triiodothyronine, but not thyroxine, increased during treatment with rhGH. The treatment decreased serum levels of both total and HDL-cholesterol. Studies with echocardiography showed an increase in cardiac output during the treatment with rhGH. These improvements were not observed in patients treated with placebo. Administration of rhGH is recommended as one of the methods of managing the patients with AN.

Overconsumption of dietary fat and alcohol: mechanisms involving lipids and hypothalamic peptides

The studies described in this report provide interesting animal models for exploring some of the metabolic and neural antecedents to the over-consumption of fat and alcohol. The results provide strong support for the existence of positive feedback loops that involve a close relation between circulating lipids and orexigenic peptides in dorsal regions of the hypothalamus. The peptides involved in these circuits include galanin, enkephalin, dynorphin and orexin. These peptides are expressed in the paraventricular nucleus and perifornical lateral hypothalamus, and they have very different functions from peptides expressed in the arcuate nucleus. Through mechanisms involving circulating lipids that rise on energy-dense diets, these peptides in the dorsal hypothalamus are each increased by the consumption of fat and ethanol; these nutrients, in turn, stimulate further production of these same peptides that promote overeating and excess drinking. These mechanisms involving non-homeostatic, positive feedback circuits may be required under conditions when food supplies are scarce and periods of gorging are essential to survival. However, they have pathological and sometimes life-threatening consequences in modern society, where fat-rich foods and alcoholic drinks are abundantly available and are contributing to the marked rise over the past 25 years in obesity and diabetes in both children and adults.

Uncoupling of cardiovascular risk markers in adolescent girls with anorexia nervosa

OBJECTIVE

Cardiovascular (CV) risk begins in childhood, and low body weight should result in a favorable risk profile. However, adolescents with anorexia nervosa (AN) have alterations in many hormonal factors that mediate CV risk. We hypothesized that in AN, growth hormone (GH) resistance and hypercortisolemia would increase CV risk through effects on pro-inflammatory cytokines and lipid status despite low weight.

STUDY DESIGN

We examined CV risk markers (high sensitivity C-reactive protein [hsCRP], interleukin-6 [IL-6], apolipoprotein-B [Apo-B], and lipid profile) in 23 subjects with AN and in 20 control subjects 12 to 18 years of age, in whom GH, cortisol, leptin, and triiodothyronine (T3) had been previously determined.

RESULTS

Subjects with AN had higher Apo-B (P < .0001), IL-6 (P = .03), Apo-B/high-density lipoprotien (HDL) (P = .01), and Apo-B/low-density lipoprotein (LDL) (P < .0001) and lower hsCRP (P = .01) than controls. Triglycerides were lower and HDL higher in subjects with AN. IGF-I predicted hsCRP in controls but not in AN. Log hsCRP correlated positively with GH and inversely with leptin. On regression modeling, the most significant predictor of log hsCRP was leptin; T3 predicted log IL-6, log Apo-B, log Apo-B/HDL, and Apo-B/LDL; and cortisol independently predicted log Apo-B. IL-6 decreased with weight gain.

CONCLUSION

CV risk markers are uncoupled in AN, with increased Apo-B and IL-6 and decreased hsCRP, related to hormonal alterations. IL-6 normalizes with weight gain.

Etiology of hypercholesterolemia in patients with anorexia nervosa

OBJECTIVE

Hypercholesterolemia is common in patients with anorexia nervosa (AN) despite emaciation. The objective of this study was to clarify the mechanism of hypercholesterolemia in AN.

METHOD

We measured serum lipids in 39 patients with AN and analyzed serum lipid profiles in the 24 patients in comparison with five age-matched controls.

RESULTS

Mean serum levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), ketone bodies, apolipoprotein (apo)-A1, B, C2, C3, E, and cholesterol ester transfer protein (CETP) activity were significantly higher in patients with AN than in controls. No significant difference in serum free fatty acid (FFA) levels was observed between patients with AN and controls. CETP was accelerated in patients with AN with hypercholesterolemia. No correlation was apparent between serum levels of cholesterol and thyroid hormones.

CONCLUSION

Serum levels of cholesterol, CETP, and apolipoproteins decreased after weight gain, indicating that cholesterol metabolism is accelerated in patients with AN with normal serum levels of FFA.

Dermatologic signs in patients with eating disorders

Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN. Cutaneous manifestations are the expression of the medical consequences of starvation, vomiting, abuse of drugs (such as laxatives and diuretics), and of psychiatric morbidity. These manifestations include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, generalized pruritus, acquired striae distensae, slower wound healing, prurigo pigmentosa, edema, linear erythema craquele, acral coldness, pellagra, scurvy, and acrodermatitis enteropathica. The most characteristic cutaneous sign of vomiting is Russell's sign (knuckle calluses). Symptoms arising from laxative or diuretic abuse include adverse reactions to drugs. Symptoms arising from psychiatric morbidity (artefacta) include the consequences of self-induced trauma. The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the 'hidden' signs of these disorders in patients who tend to minimize or deny their disorder, and to avoid over-treatment of conditions which are overemphasized by patients' distorted perception of skin appearance. Even though skin signs of eating disorders improve with weight gain, the dermatologist will be asked to treat the dermatological conditions mentioned above. Xerosis improves with moisturizing ointments and humidification of the environment. Acne may be treated with topical benzoyl peroxide, antibacterials or azaleic acid; these agents may be administered as monotherapy or in combinations. Combination antibacterials, such as erythromycin with zinc, are also recommended because of the possibility of zinc deficiency in patients with eating disorders. The antiandrogen cyproterone acetate combined with 35 microg ethinyl estradiol may improve acne in women with AN and should be given for 2-4 months. Cheilitis, angular stomatitis, and nail fragility appear to respond to topical tocopherol (vitamin E). Russell's sign may decrease in size following applications of ointments that contain urea. Regular dental treatment is required to avoid tooth loss.

Enhanced serum cholesterol and triglyceride levels in bulimia nervosa: relationships to psychiatric comorbidity, psychopathology and hormonal variables

Increased levels of cholesterol have been reported in patients with bulimia nervosa (BN), but all but one of the published studies were performed on non-fasting subjects, which limits the interpretation of this finding. Moreover, the relationships between serum lipids and comorbid psychiatric disorders or bulimic psychopathology have scarcely been investigated. We measured serum levels of total cholesterol, triglycerides, glucose, 17beta-estradiol and thyroid hormones in 75 bulimic women and 64 age-matched healthy females after an overnight fast. Compared with healthy women, bulimic patients exhibited significantly enhanced serum levels of cholesterol and triglycerides, but similar values of glucose, 17beta-estradiol, FT3 and FT4. No significant differences emerged in these variables between patients with or without comorbid depression, borderline personality disorder or lifetime anorexia nervosa. Circulating cholesterol was positively correlated to the patients' drive for thinness, ineffectiveness, enteroceptive awareness and impulse regulation sub-item scores of the Eating Disorder Inventory-2. These findings confirm that BN is associated with increased levels of serum lipids. This alteration may be involved in the pathophysiology of certain psychopathological characteristics of BN and cannot be explained by the co-occurrence of other psychiatric disorders.

Chemical-physical properties of lipoproteins in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN), a psychosomatic disorder, has serious negative effects on multiple organs and systems of the human body. Anorexia nervosa usually runs a chronic course and is associated with significant morbidity and mortality. In order to elucidate the role played by lipids in AN, in the present study we compared the plasma lipid profile and the chemical-physical properties of lipoproteins obtained from subjects affected by AN.

MATERIALS AND METHODS

The study was performed on lipoproteins of AN subjects and of age-matched healthy subjects used as controls. We tested the susceptibility to oxidative stress in vitro, the fatty acid content, the fluidity using 2-dimethylamino-(6-lauroyl)-naphthalene (Laurdan) and 1,6-difenil-1,3,5-esatriene (DPH) probes.

RESULTS

Present results indicate that AN patients present a deep alteration of the composition and of chemical-physical properties in circulating lipoproteins, even in the absence of significant modifications to clinical metabolic parameters. A significantly decreased body mass index (BMI) was found in AN patients in comparison with controls. Anorexia nervosa patients showed a significant modification of phospholipids to protein ratio and a significantly increased percentage of unsaturated fatty acids compared with control subjects as well as a decreased fluidity, a significantly increased percentage of liquid-crystalline phase in VLDL, and a significantly reduced susceptibility to oxidative stress, more pronounced in LDL.

CONCLUSIONS

These results confirm the hypothesis that anorexia is accompanied by changes of lipid metabolism in the central nervous system (CNS).

Lipoprotein metabolism in patients with anorexia nervosa: a case-control study investigating the mechanisms leading to hypercholesterolaemia

Hypercholesterolaemia is a common finding in patients with anorexia nervosa (AN). To investigate the type, frequency and pathophysiological mechanisms of changes in lipoprotein metabolism in AN we performed a cross-sectional study in fifty-eight female patients (mean age 24.2 years, BMI 15.3 (sd 1.5) kg/m(2)) and fifty-eight healthy age-matched controls (CO; BMI 22.2 (sd 1.7) kg/m(2)). Total cholesterol and LDL-cholesterol were higher in AN (5.5 (sd 1.3) v. 5.0 (sd 0.8) mmol/l, P=0.023; 3.6 (sd 1.1) v. 3.2 (sd 0.7) mmol/l, P=0.025 respectively). LDL particles were significantly more enriched in cholesterol and triacylglycerol in AN. In multiple regression analysis with LDL-cholesterol as the dependent and BMI, total body fat ( %), lathosterol:cholesterol ratio (endogenous cholesterol synthesis), 7alpha-hydroxy-4-cholesten-3-one (bile acid synthesis), non-esterified glycerol, free triiodothyronine and free thyroxine as independent variables, BMI was the only significant predictor in CO (R(2) 0.36, overall P=0.001). In AN the variability of LDL-cholesterol was significantly predicted by total body fat, free thyroxine, BMI, free triiodothyronine and non-esterified glycerol (R(2) 0.55, overall P<0.001). Subgroup analysis between restricting (AN-R) and binge-eating-purging patients (AN-B) indicated that in AN-R changes in lipoproteins, BMI and total body fat were more pronounced. AN-R patients had lower bile acid synthesis than AN-B (P=0.02). We conclude that elevated cholesterol concentrations in AN are generally due to an increase in LDL-cholesterol, which is mostly determined by the severe loss of body fat and the resulting changes in thyroid hormones, increased lipolysis and decreased endogenous cholesterol synthesis with resulting decrease in LDL removal. The clinical subtype of AN plays a major role in the mechanisms leading to hypercholesterolaemia.

Dietary polyunsaturated fatty acids and anorexia nervosa: is there a link?

There has been little research examining the link between dietary fat intake and the symptoms and consequences of anorexia nervosa. In this selective literature review, the potential significance of poly-unsaturated fatty acids is discussed. It is hypothesised that dietary restriction causes essential fatty acid deficiencies and poly-unsaturated fatty acid abnormalities, which might contribute to the physical and mental symptoms and the maintenance of the disorder. The examination of epidemiology, symptoms, co-morbidity, and consequences suggest that poly-unsaturated fatty acid and phospholipid abnormalities are significant in anorexia nervosa. This will be an important area for future research, and may lead to the development of new interventions.

Total serum cholesterol and suicidality in anorexia nervosa

OBJECTIVE

No published study has evaluated the relationship between serum cholesterol and suicidality in anorexia nervosa (AN).

AIMS

To assess psychiatric and nutritional correlates of serum cholesterol in a sample of AN patients.

METHODS

Serum cholesterol and nutritional status were evaluated in a sample of 74 AN patients, before starting any type of refeeding. All subjects underwent a structured clinical interview and completed the Hopkins Symptom Checklist.

RESULTS

Subjects who reported previous suicide attempts, impulsive self-injurious behavior, or current suicidal ideation showed significantly lower cholesterol levels than subjects without suicidality. Cholesterol levels were negatively correlated with the severity of depressive symptoms in all the patients with the exception of those with recurrent binge eating. A multivariate analysis showed that the relationships between cholesterol levels and suicidal behavior and ideation do not seem to be affected by the nutritional and metabolic factors considered in the study.

CONCLUSIONS

Notwithstanding the influence of important metabolic factors affecting cholesterolemia in AN, our research tends to confirm previous studies that have found an association between low cholesterol levels and suicidality.

Opposite changes in circulating adiponectin in women with bulimia nervosa or binge eating disorder

Adiponectin is a recently discovered peripheral peptide that is secreted exclusively by differentiated adipocytes. It has been shown to enhance insulin sensitivity, control body weight, regulate lipid homeostasis, and prevent atherosclerosis. Dysregulation of both lipid and glucose metabolism and changes in body weight and body fat mass have been reported in bulimia nervosa (BN) and/or binge eating disorder (BED); hence, investigation of adiponectin secretion is of obvious interest in these eating disorders. To this purpose, we measured plasma levels of adiponectin, glucose, cholesterol, triglycerides, and thyroid hormones in 60 drug-free women, including 20 patients with BN, 20 patients with BED, and 20 healthy controls. Compared with healthy women, BN women exhibited significantly increased circulating adiponectin levels (P < 0.002) and cholesterol concentrations (P < 0.005), whereas BED women had significantly reduced plasma levels of adiponectin (P < 0.005) and increased concentrations of glucose (P < 0.01), cholesterol (P < 0.05), and triglycerides (P < 0.02). Moreover, plasma levels of adiponectin were significantly correlated to the frequency of binge/vomiting episodes (r = 0.65, P = 0.002) in bulimics but not to the frequency of bingeing in BED patients. Because we did not include a group of obese patients who did not binge eat, the specificity of our findings in the BED should be considered cautiously. However, on the basis of present results, it is tempting to speculate that the increased production of adiponectin in BN may represent a compensatory mechanism to counteract the possible development of insulin resistance, whereas the decreased secretion of adiponectin in individuals with BED may be a risk factor for the development of glucose intolerance.