History of anorexia nervosa in bulimic patients: its influence on body composition

Body composition assessment in adult females with anorexia nervosa and bulimia nervosa - a cross-sectional study comparing dual-energy X-ray absorptiometry scan and isotopic dilution of deuterium

BACKGROUND

Eating disorders (EDs) compromise individuals' nutritional status, affecting among other organs and systems, bone health.

OBJECTIVE

This study aimed to assess and compare bone mineral density (BMD) from dual-energy x-ray absorptiometry (DXA) scan and deuterium (D₂O) dilution of adult females with anorexia nervosa (AN) and bulimia nervosa (BN).

METHODS

This was a cross-sectional study with 53 female participants (18-49 years) with a diagnosis of AN (N = 25) or BN (N = 28). DXA scan was performed to assess BMD, fat mass, and fat-free mass, and D₂O dilution was used to assess total body water (TBW), fat mass, and fat-free mass. Interviews/questionnaires were used to assess symptoms, illness trajectory, and physical activity. T-test, Chi-squared test, Pearson's linear correlation, linear regressions, and Bland-Altman analyses were performed, with a significance level of 5%.

RESULTS

TBW below the recommended level for adult females (≥ 45%) was more frequent in BN (60%) compared with AN (21%; P = 0.013). FMI (soft tissue only) (t-test P = 0.06), and FFMI (t-test P = 0.08) agreed between DXA scan and D₂O dilution. Only FFMI did not show systematic bias of proportion (β:-0.2, P = 0.177). The diagnosis of BN, binge-eating episodes, and physical activity in AN were associated with the differences in the methods' results. FMI was positively associated with BMD in AN, and both FMI and FFMI were positively associated with BMD in BN.

CONCLUSION

In adult females with EDs, DXA scan and D₂O dilution achieved agreement for FMI and FFMI. Changes in fat mass and fat-free mass are important in understanding the mechanisms behind bone loss in EDs. Protocols for body composition assessment in EDs can help to minimize the effect of the ED diagnosis, ED behaviors (i.e., excessive exercise and purging behaviors) and weight on the accuracy of measurements.

So similar and so different: Circulating androgens and androgen origin in bulimic women

Hyper androgen state frequently can be diagnosed in bulimic women. Eating disorder not otherwise specified (EDNOS) recognized as a less severe form of bulimia nervosa (BN). The objective of the study was to determine whether androgen levels and androgen origin differs in bulimic women compared to control subjects. Forty-six women with bulimia nervosa (BN), 31 with eating disorder not otherwise specified, purging type (EDNOS P) and 56 matched healthy controls were studied with respect to serum testosterone (T), 5alpha-dihydrotestosterone (DHT), sex hormone-binding globulin (SHBG), deyhydroepiahndrosterone sulfate (DHEAS) and luteinizing hormone (LH) and to ovarian morphology. Despite all groups had almost identical androgen and SHBG levels; there were differences in the origin of circulating T and DHT. Correlation analysis suggest major differences in the formation of circulating testosterone (T) and 5α-dihydrotestosterone (DHT) with BN being more like the control subjects with peripheral formation from 4-androsterne-3,17-dione (A-4), dehydroepiandrosterone sulfate (DHEAS) and also from T. While in EDNOS group a possible direct ovarian T secretion and a DHEAS modulating action of androgens on pituitary gonadotropin secretion is present. The origin of circulating T and DHT differs between bulimics. Our findings do probably not reflect direct actions of circulating DHT on pituitary LH secretion in the women with EDNOS, but rather the effect of A-4, T via conversion to DHT in the central nervous system, indicating psych/endocrine differences between the two groups of bulimic women.

Body composition and physical fitness in women with bulimia nervosa or binge-eating disorder

OBJECTIVE

Knowledge about physical fitness in women with bulimia nervosa (BN) or binge-eating disorder (BED) is sparse. Previous studies have measured physical activity largely through self-report, and physical fitness variables are mainly restricted to body mass index (BMI) and bone mineral density. We expanded the current knowledge in these groups by including a wider range of physical fitness indicators and objective measures of physical activity, assessed the influence of a history of anorexia nervosa (AN), and evaluated predictive variables for physical fitness.

METHOD

Physical activity, blood pressure, cardiorespiratory fitness (CRF), muscle strength, body composition, and bone mineral density were measured in 156 women with BN or BED, with mean (SD) age 28.4 years (5.7) and BMI 25.3 (4.8) kg m-2 .

RESULTS

Level of physical activity was higher than normative levels, still <50% met the official physical activity recommendation. Fitness in women with BN were on an average comparable with recommendations or normative levels, while women with BED had lower CRF and higher BMI, VAT, and body fat percentage. We found 10-12% with masked obesity. A history of AN did not predict current physical fitness, still values for current body composition were lower when comparing those with history of AN to those with no such history.

DISCUSSION

Overall, participants with BN or BED displayed adequate physical fitness; however, a high number had unfavorable CRF and body composition. This finding calls for inclusion of physical fitness in routine clinical examinations and guided physical activity and dietary recommendations in the treatment of BN and BED.

Clinical utility of subtyping binge eating disorder by history of anorexia or bulimia nervosa in a treatment sample

OBJECTIVE

This study examined whether having a history of anorexia nervosa (AN) or bulimia nervosa (BN) is associated with response to treatment in adults with binge eating disorder (BED).

METHOD

Data from 189 adults diagnosed with BED who were randomly assigned to one of three group cognitive-behavioral (CBT) treatments were analyzed to compare those with and without a history of AN/BN.

RESULTS

A total of 16% of the sample had a history of AN/BN. The BED subgroup with a history of AN/BN presented with higher rates of mood disorders and greater eating-related symptom severity at baseline. Participants with a history of AN/BN also had higher global eating disorder (ED) symptoms at end of treatment (EOT), and more frequent objective binge-eating episodes at EOT and 12-month follow-up.

DISCUSSION

These findings suggest that in adults with BED, a history of AN/BN is predictive of greater eating-related symptom severity following group-based CBT and poorer short- and long-term binge-eating outcomes. These findings suggest that considering ED history in the treatment of adults with BED may be clinically useful.

The efficacy of Bioelectrical Impedance Analysis (BIA) in monitoring body composition changes during treatment of restrictive eating disorder patients

REVIEWS

Treating restrictive eating disorder patients is metabolically and psychologically complex. Determining body composition is an important diagnostic and treatment option for these patients, because it ascertains whether the acquisition of body mass during refeeding is metabolically appropriate - ideally an approximate 20/80% - 25/75% fat/lean body mass ratio. The purpose of this paper is to evaluate the efficacy of Bioelectrical Impedance Analysis (BIA) during the treatment period of patients with restrictive eating disorders. The search engines PubMed, Medline, and MSN were utilized using combinations of key words, "Bioimpedance Analysis", "body composition determination", "eating disorders", and "anorexia".

CONCLUSIONS

The literature indicates that the use of Bioelectrical Impedance Analysis (BIA) in eating disorder patients to be efficacious in determining body composition during the treatment period, and that only assessing weight changes does not necessarily reflect specific changes in various body compartments. Also, utilizing BIA has the advantage of using each patient as his/her own "control", potentially allowing for a more individualized nutrition regimen according to the body composition changes observed during treatment.

Trait-level and momentary correlates of bulimia nervosa with a history of anorexia nervosa

OBJECTIVE

Some investigators have suggested subtyping bulimia nervosa (BN) by anorexia nervosa (AN) history. We examined trait-level and momentary eating-related and psychosocial factors in BN with and without an AN history.

METHOD

Interview, questionnaire, and ecological momentary assessment data of eating-related and psychological symptoms were collected from 122 women with BN, including 43 with (BN+) and 79 without an AN history (BN-).

RESULTS

Body mass index (kg/m(2) ) was lower in BN+ than BN- (p = 0.001). Groups did not differ on trait-level anxiety, shape/weight concerns, psychiatric comorbidity, or dietary restraint; or on momentary anxiety, dietary restriction, binge eating, purging, or exercise frequency, or affective patterns surrounding binge/purge behaviors. Negative affect increased prior to exercise and decreased thereafter in BN+ but not BN-, although groups did not statistically differ.

DISCUSSION

Results do not support formally subtyping BN by AN history. Exercise in BN+ may modulate negative affect, which could have important treatment implications.

Thigh circumference as a useful predictor of body fat in adolescent girls with anorexia nervosa

BACKGROUND/AIM

Girls with anorexia nervosa (AN) demonstrate severe depletion of body fat. The aim of this study was to determine an accurate anthropometric measurement for clinical assessment of fat depletion in girls with AN in connection with body composition measured by dual-energy X-ray absorptiometry (DXA).

METHODS

In 64 female AN patients aged 12.8-23.1 years (mean 16.0 ± 1.8), body mass index (BMI), skinfold thickness (subscapular, abdominal and triceps), mid-upper arm and thigh circumference, fat mass (FM) and lean mass were determined and compared with the data of 71 controls.

RESULTS

Girls with AN had lower anthropometric traits and were fat depleted compared to controls (14.9 ± 7.3 vs. 27.4 ± 6.4% of FM using DXA; all p < 0.001). BMI, thigh circumference and subscapular skinfold thickness demonstrated a very similar predictive value for DXA assessment of body fat. Based on the receiver-operating characteristic curve analysis and the determination of the positive predictive value, thigh circumference appeared the most specific and sensitive anthropometric predictor of fatness discriminating between AN and healthy girls, with the AUC value reaching 0.95 (95% CI = 0.92-0.97). Using a cutoff value of 49.6 cm, accuracy was 90.6%, sensitivity 93% and specificity 88.7%.

CONCLUSIONS

Thigh circumference strongly correlates with DXA-FM and demonstrates a slight clinical advantage over BMI. This simple measurement might also serve as a useful predictor of body fatness in adolescent girls with AN and should therefore be further evaluated in independent cohort studies.

Bulimia nervosa with history of anorexia nervosa: could the clinical subtype of anorexia have implications for clinical status and treatment response?

OBJECTIVE

To investigate whether the subtype of anorexia nervosa (AN) could influence the bulimic syndrome and treatment response in bulimia nervosa (BN) patients with a history of AN (BN/AN+).

METHOD

Seventy female BN patients were assessed for eating disorder, psychopathology and personality, and treated for 6 months.

RESULTS

BN/AN+ patients retained some traits of their past condition: lower body weight, higher perfectionism, and higher reward dependence. They also had more severe symptoms, longer evolution time, and worse response to treatment. A history of restricting AN was associated to higher age, longer evolution time, higher impulsivity, and greater tendency to use diet pills and diuretics. A history of binge-purging AN was associated to more severe vomiting, lower body dissatisfaction and less depressive symptoms, as well as better outcome.

DISCUSSION

The influence of the AN subtype in BN/AN+ patients is worthy of further study as it might have clinical implications.

Investigation of factors associated to crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa and comparison of bulimia nervosa patients with or without previous ANR or ANBP

OBJECTIVE

To characterize factors associated to diagnostic crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa (BN) and to compare BN individuals with initial ANR or ANBP to subjects with stable BN.

METHOD

Two hundred thirty-eight patients with current and lifetime diagnosis of AN or BN underwent diagnostic, psychopathological, and historical examinations by means of ad hoc clinical interviews and rating scales.

RESULTS

One hundred twenty-three individuals had a stable BN. Seventy patients had a diagnosis of ANR and 45 of ANBP at the time of disease onset; 24 ANR patients and 23 ANBP subjects developed BN, whereas 46 ANR patients and 22 ANBP subjects did not crossover. Although the rate of diagnostic crossover was higher in the ANBP group than in the ANR one, the difference was not statistically significant. Longer illness duration, higher maximum past body mass index (BMI), higher novelty seeking, and lower self-directedness resulted significantly associated to crossover from ANR to BN, whereas higher maximum past BMI, higher desired body weight, higher novelty seeking, and lower harm avoidance were significantly associated to crossover from ANBP to BN. As compared to stable BN subjects, BN patients with initial ANR exhibited lower minimum past BMI, lower desired body weight, higher drive for thinness, ascetism, and social insecurity scores; BN patients with initial ANBP exhibited lower minimum past BMI and decreased enteroceptive awareness scores.

CONCLUSIONS

Different clinical and personality factors seem to be associated to crossover from ANR and ANBP to BN. Moreover, BN with initial ANR seems to differ clinically from stable BN. These findings may have therapeutic and prognostic implications.

Revisiting differences in individuals with bulimia nervosa with and without a history of anorexia nervosa: Eating pathology, personality, and maltreatment

OBJECTIVE

Early research in subtyping bulimia nervosa (BN) by history of anorexia nervosa (AN) generally found more similarities than differences, but recent research and limitations of the early work suggest the need to revisit this approach. We examine differences between women with BN with and without a history of AN regarding eating pathology, personality, and childhood maltreatment.

METHOD

Participants were women (aged 18-55) recruited from the community and eating disorder clinics who met DSM-IV criteria for BN; 37 had a history of AN and 101 did not. Participants completed questionnaires related to eating disorder pathology, multidimensional perfectionism, multidimensional impulsivity, and childhood maltreatment.

RESULTS

Women with BN and a history of AN had higher levels of dietary restraint and purging and lower body mass indices as well as higher levels of all forms of childhood neglect and abuse. In contrast, no group differences were found for perfectionism or impulsivity dimensions.

CONCLUSION

The group differences in terms of eating pathology and maltreatment have clinical implications. Further research is needed regarding if and how a history of AN among those with BN may reflect different etiological pathways and predict different outcomes.

Should bulimia nervosa be subtyped by history of anorexia nervosa? A longitudinal validation

OBJECTIVE

To determine whether a past diagnosis of anorexia nervosa (AN) predicts longitudinal course and outcome among women with bulimia nervosa (BN).

METHOD

A subset (n = 176) of participants in the Longitudinal Study of Anorexia and Bulimia Nervosa who met DSM-IV criteria for BN either at study intake (n = 144) or during follow-up (n = 32; 4 had restricting AN at intake, 28 had binge/purge AN at intake) were included in this report. Over a median of 9 years, weekly eating disorder symptom data were collected from participants using the Longitudinal Interview Follow-up Examination, Eating Disorders Version.

RESULTS

While there were no between-group differences in likelihood of partial recovery, women with BN who had a history of AN were more likely to have a protracted illness, relapsing into AN during follow-up, compared to those with no AN history who were more likely to move from partial to full recovery.

CONCLUSION

Lifetime AN is an important prognostic indicator among women with BN and these longitudinal data would support the subtyping of BN on the basis of AN history.

Body composition and endocrine status of long-term stress-induced binge-eating rats

Clinical binge eating runs a protracted course. The etiology of binge eating remains perplexing in part because, in humans, it is difficult to isolate and assess the independent and aggregate impact of various contributing variables. Using rats, we found that footshock stress and a history of caloric restriction (S+R), combine synergistically to induce binge eating. Stress and dieting are also strong antecedents and relapse factors in human eating disorders. Here we report further behavioral and physiological parallels to human binge eating. Like the protracted course of human binge eating, young female Sprague-Dawley rats continued to binge eat after 23 restriction/stress cycles (7 months) and this despite experiencing no significant weight loss during the restriction phases. Stress alone reduced adiposity by 35% (p<0.001) but S+R rats had no significant fat loss. An endocrine profile of normal plasma leptin and insulin levels but marked elevation of plasma corticosterone levels was found only in the binge-eating (S+R) rats (p<0.01), also paralleling endocrine profiles reported in clinical binge-eating studies. These behavioral and physiological similarities between this animal model and clinical binge eating increase its utility in understanding binge eating. Importantly, our findings also highlight the stubborn nature of binge eating: once a critical experience with dieting and stress is experienced, little if any further weight loss or food restriction is necessary to sustain it.

Anorexia nervosa patients with a prior history of bulimia nervosa

OBJECTIVES

To investigate clinical and psychological features of patients with anorexia nervosa (AN) with a previous history of bulimia nervosa.

METHOD

Three hundred thirty-three patients with a full diagnosis of AN were assessed by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Eating Disorders Inventory, and the Hopkins Symptom Checklist.

RESULTS

Twenty-four patients (7%) reported a previous diagnosis of bulimia nervosa and were compared with a control group of 48 patients without a history of bulimia, matched for diagnostic subtype. Among the patients with a history of bulimia nervosa, 11 were of the restricting type and 13 of the binge eating/purging type. Among restricting anorexic patients, those with a history of bulimia reported greater age of onset, more psychiatric symptoms, more family psychiatric morbidity, and a higher rate of sexual abuse. On the contrary, among patients with the AN bingeing-purging subtype, the presence of a previous bulimia nervosa was not associated with any of the investigated variables.

CONCLUSIONS

Patients with restricting AN who report a history of previous bulimia nervosa are not frequent among those referring to an outpatient eating disorders unit. However, our findings in this small group of subjects confirm that a lifetime history of bingeing and purging in patients with eating disorder, irrespective of when it occurs, is always associated with more psychopathology compared with those restricting patients with AN who have never had a period of bingeing and purging.

Plasma ghrelin in anorexia, bulimia, and binge-eating disorder: relations with eating patterns and circulating concentrations of cortisol and thyroid hormones

The present study was designed to investigate the relations between plasma ghrelin concentrations, eating patterns, and circulating concentrations of cortisol and thyroid hormones in women with anorexia nervosa, bulimia nervosa, and binge-eating disorder. The patterns of disordered eating behavior were assessed using the Eating Attitudes Test (EAT-26) and the Bulimia Test-Revised (BULIT-R). In women with eating disorders, but not in healthy control women, plasma ghrelin concentrations were negatively correlated with body mass index (BMI) and plasma concentrations of thyreotropin (TSH), free T3 and free T4, and positively correlated with plasma concentrations of cortisol. The ghrelin concentrations of women with binge-eating and purging behavior were significantly lower than those of women with anorexia nervosa, restricting type, and there was a negative relation between the frequency and severity of binge-eating and purging behavior, as measured by the BULIT-R total score, and ghrelin concentrations. In a multivariate regression model controlling for the confounding effects of body mass index (BMI) and age, higher ghrelin concentrations were correlated with lower BULIT-R total scores. The results of this study did not confirm the hypothesis advanced in previous studies that ghrelin concentrations are higher in patients with binge-eating/purging forms of eating disorders. Based on these data, we suggest that, in women with eating disorders, ghrelin concentrations best reflect nutritional status rather than specific patterns of disordered eating behavior.

Bulimia Nervosa: A Primary Care Review

Bulimia nervosa is a psychiatric condition that affects many adolescent and young adult women. The disorder is characterized by bingeing and purging behavior and can lead to medical complications. Thus, patients with bulimia nervosa commonly present in the primary care setting. Physical and laboratory examinations reveal markers of bulimia nervosa that are useful in making the diagnosis. Treatment is beneficial, and outcomes of early intervention are good. This article discusses the history, presentation, and tools needed for recognizing and treating bulimia nervosa in primary care.