Somatic and psychological factors related to the body mass index of patients with anorexia nervosa

Associations between nutritional intake, stress and hunger biomarkers, and anxiety and depression during the treatment of anorexia nervosa in adolescents and young adults

Adolescents and young adults (AYA) with anorexia nervosa (AN) frequently have co-occurring anxiety and depression, which can negatively impact prognosis. To inform treatment of co-occurring anxiety and depression, we assessed the association of nutritional intake and hunger/stress hormones on anxiety and depression using a six-month longitudinal study of 50 AYA females receiving care for AN. At baseline and six months, we measured anxiety (Spielberger State/Trait Anxiety Inventory [STAI]), depression (Beck Depression Inventory [BDI]), body mass index (BMI), 3-day dietary intake (total calories and proportion of fat, carbohydrate, protein), and serum cortisol, leptin, and adiponectin. We performed mixed effects linear regression analyses, adjusting for age, duration of AN, and percentage of median BMI (%mBMI). At baseline, median age was 16.3 (interquartile range [IQR]=2.5) years, duration of AN was 6 (IQR=8.8) months and %mBMI was 87.2 (IQR=10.5)%. Fifty-six percent had clinically significant anxiety; 30% had depression. Over 6 months, participants had significant improvements in %mBMI (+2.2[IQR=9.2]%, p<.01), STAI (-9.0[IQR=25.0], p<.01), and BDI (-5.0[IQR=13.8], p<.01) scores. Participants with larger improvements in caloric intake had greater improvements in STAI (p=.03) and BDI scores (p=.04). Larger improvement in BDI was significantly associated with increased fat intake (p<.01), but not carbohydrate or protein intake. Change in STAI was not associated with changes in fat, carbohydrate, or protein intake. Changes in STAI or BDI scores were not associated with changes in cortisol, leptin, or adiponectin. Increased caloric intake may augment treatment of co-occurring anxiety and depression, and increased fat intake may improve depression for AYA with AN.

The Association of Malnutrition, illness duration, and pre-morbid weight status with anxiety and depression symptoms in adolescents and young adults with restrictive eating disorders: a cross-sectional study

BACKGROUND

Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symptoms, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and pre-morbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs.

METHODS

145 participants with restrictive EDs (anorexia nervosa [AN], other specified feeding and eating disorders [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants' pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. We used multiple linear regression to examine the association of malnutrition, ED duration, and pre-morbid weight status with symptoms of anxiety and depression.

RESULTS

Mean (SD) age was 16.4(3.0) years; 87% were female; 89% white; 85% had AN, 6% OSFED, 10% ARFID. Of these, 2/3 had ED symptoms ≥1 year, 1/3 had previous higher level of ED care (HLOC), and half were taking psychiatric medications. Mean %eBMI was 90% (range 57-112%). Mean GAD-7 was 9.4(5.9) and CES-D was 24(13.8), indicating most participants had clinically significant anxiety and/or depression. Degree of malnutrition was not significantly associated with anxiety or depression adjusting for age, sex, sexual orientation, ED diagnosis, and use of psychiatric medication. Those with longer duration of ED symptoms had higher depression scores after adjusting for malnutrition, HLOC, length of ED symptoms, and time in our care (p = 0.038). Patients with pre-morbid BMIs ≥75th percentile had lower depression scores than those with pre-morbid BMIs <75th percentile (p = 0.014).

CONCLUSIONS

We find high degree of clinically relevant anxiety and depression symptoms in a population of AYAs with EDs. Our findings suggest that factors beyond malnutrition play a role in the co-morbid mood and anxiety disorders in this population. Overall, rapid ED diagnosis and comprehensive treatment for patients with EDs across the weight spectrum-and especially those with psychiatric co-morbidities-will likely aid in recovery.

Nutritional status and anxious and depressive symptoms in anorexia nervosa: a prospective study

The interweaving of malnutrition and symptoms of anxiety and depression in anorexia Nervosa (AN) is mentioned without any consensus regarding the course of anxious-depressive symptoms in relation to nutritional status in the course of treatment of patients with AN. The objectives of the current study in a large sample of AN inpatients were to assess the relationships between anxiety and depression symptoms and nutritional status both over the course of inpatient treatment and at discharge. 222 consecutive inpatients with AN (DSM-IV TR) were assessed (entrance and discharge) for duration of illness, psychiatric treatments, sociodemographic data and with psychometric scales for different psychopathological symptoms [depressive (BDI), anxiety and depressive (HAD scale), obsessive-compulsive (MOCI) and social phobia (LSAS fear score)]. Nutritional status was assessed with Body Mass Index (BMI) and body composition by bioelectrical impedance. The Fat free mass index [FFMI = FFM (kg)/height (m²)] was considered for the analysis. Two models were developed where the dependent variables were each psychopathological score at discharge (BDI, HAD anxiety, MOCI, and LSAS fear) in the cross-sectional model, and their variation in the longitudinal model (where a positive score reflected symptom decrease at discharge). A fixed set of predictors, defined on presumed clinical and statistical relevance (FFMI in the cross-sectional model and Variation of FFMI in the longitudinal model), were considered in each model, without any model selection procedure. This is the first study to confirm a positive relationship between the course of eating disorder symptoms and that of anxious-depressive symptoms during inpatient treatment of AN even after adjustment on a vast array of possibly confounding factors.

Adipokines in anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

The association between adipokine dysregulation and weight loss of patients with anorexia nervosa (AN) has been long investigated, in search of a causal relationship. We sought to: a) synthesize the available evidence on potential differences between AN patients and controls with regards to adipokine measurements (namely, leptin, adiponectin, resistin, soluble leptin receptor, visfatin, vaspin and omentin), b) estimate the potential differences between constitutionally thin (CT) subjects and AN patients, and c) present the available evidence with regards to biomarker efficacy of adipokines in AN.

METHODS

A structured literature search, last updated in 2/2019, was conducted in the following databases: MEDLINE, clinicaltrials.gov, PsycINFO, PSYNDEX and WHO Registry Network. The primary outcome was the standardized mean difference of each adipokine between AN patients and controls of normal BMI. Secondary outcomes included the correlation of leptin with BMI and bone mineral density among AN patients. The study protocol is published in PROSPERO (CRD42018116767).

RESULTS

In a total of 622 screened studies, after exclusion of non-relevant articles and duplicates, 84 reports on leptin, 31 reports on adiponectin, 12 on resistin, 10 on soluble leptin receptor, 5 on visfatin, 3 on vaspin and omentin were finally included in the meta-analysis. Publication bias assessment underlined the possibility of non-significant studies being underrepresented; still, significant heterogeneity renders this statement inconclusive. Leptin [ELISA: SMD (95% CI): -3.03 (-4, -2.06)], radioimmunoassay [RIA: -3.84 (-4.71, -2.98)] and resistin [-1.67 (-2.85, -0.48)] were significantly lower in patients with AN compared with controls, whereas visfatin decrease did not reach significance (-2.03 (-4.38, 0.3). Mean adiponectin, vaspin and soluble leptin receptor levels were significantly higher. In subgroup analysis, a significantly attenuated SMD was reported in ELISA studies compared with RIA studies. Leptin was significantly lower in AN patients compared to CT subjects and BMI marginally did not appear to confound the result. In all analyses, except for the correlation of leptin with BMI in AN patients, high heterogeneity was present. Meta-regression analysis indicated a potential confounding action of controls' BMI and age on leptin SMD and between-assay differences. Publication bias assessment underlined the possibility of nonsignificant studies being underrepresented; still, further investigation did not corroborate this and significant heterogeneity renders this statement inconclusive.

CONCLUSION

A distinct profile of adipokine dysregulation is apparent in AN patients, following the anticipated pattern of low BMI. A precise estimation of the magnitude is hindered by heterogeneity, partly caused by varying assays and methodologies. Interestingly, while mean leptin levels are lower in AN subjects compared with constitutionally thin women, there is an overlap in individual levels between the two groups and therefore, they cannot be used to differentiate between these states.

The Role of Ghrelin in Anorexia Nervosa

Ghrelin, a 28-amino acid peptide hormone expressed in X/A-like endocrine cells of the stomach, is the only known peripherally produced and centrally acting peptide that stimulates food intake and therefore attracted a lot of attention with one major focus on the treatment of conditions where an increased energy intake or body weight gain is desired. Anorexia nervosa is an eating disorder characterized by a pronounced reduction of body weight, a disturbed body image and hormonal alterations. Ghrelin signaling has been thoroughly investigated under conditions of anorexia nervosa. The present review will highlight these alterations of ghrelin in anorexia and discuss possible treatment strategies targeting ghrelin signaling. Lastly, gaps in knowledge will be mentioned to foster future research.

A disconnection between nutritional status (in terms of body mass index and phase angle) and psychopathology in anorexia nervosa

The aim of our study was to investigate the relationship between nutritional status (body mass index and phase angle) and psychological symptoms at admission and discharge in a residential population of anorexic patients. We also aimed to determine the evolution of the above psychological symptoms and nutrition rehabilitation from admission to discharge. Thirty-six consecutive patients were included. The evaluation was performed using the following measures at admission and discharge: body mass index, phase angle, Eating Disorders Inventory-3, Multiphasic Personality Inventory-2 and Body Uneasiness. Admission and discharge nutritional status were not correlated with psychometric scores respectively at admission and at discharge. In addition, neither the improvement in the scores on the psychometric scales between admission and discharge was correlated to body mass index, phase angle improvement. For the group as a whole there were significant improvements from admission to discharge in nutritional status, Multiphasic Personality Inventory-2-Depression, Body Uneasiness-Global Score Index and in all the composites of Eating Disorders Inventory-3. Our data showed a disconnection between nutritional status and eating disorders psychopathology and/or psychiatric comorbidities.

The outcome of treatment for anorexia nervosa inpatients who required urgent hospitalization

Background

This study was done to determine which psychosocial factors are related to the urgent hospitalization of anorexia nervosa patients (AN) due to extremely poor physical condition and to evaluate their outcome after inpatient treatment.

Methods

133 hospitalized AN patients were classified into an urgent hospitalization (n = 24) or a planned hospitalization (n = 109) group. Multiple regression analysis was done of clinical features, body mass index (BMI), psychological tests [The Minnesota Multiphasic Personality Inventory (MMPI), alexithymia, relationship with parents, and the Eating Disorder Inventory (EDI)]. The effectiveness of treatment was prospectively determined two years after discharge by the Global Clinical Score (GCS). The hospitalized weight gain and the frequency of outpatient visits were evaluated.

Results

Of the factors assessed, only BMI at admission was related to the necessity of urgent hospitalization (β = − 1.063, P = 0.00). The urgent group had significantly more weight loss after discharge and poorer social adaptation on the GCS, even when the patient had a sufficient increase in body weight during inpatient treatment and an equivalent number of outpatient consultations.

Conclusion

None of the parameters of the psychosocial tests studied were significantly different between the groups. The outcome of the urgent group was poor. Two years after discharge they had difficulty maintaining weight and continued to have poor social adaptation.

Is weight gain really a catalyst for broader recovery?: The impact of weight gain on psychological symptoms in the treatment of adolescent anorexia nervosa

The main aims of this study were to describe change in psychological outcomes for adolescents with anorexia nervosa across two treatments, and to explore predictors of change, including baseline demographic and clinical characteristics, as well as weight gain over time. Participants were 121 adolescents with anorexia nervosa from a two-site (Chicago and Stanford) randomized controlled trial who received either family-based treatment or individual adolescent supportive psychotherapy. Psychological symptoms (i.e., eating disorder psychopathology, depressive symptoms, and self-esteem) were assessed at baseline, end of treatment, 6-month, and 12-month follow-up. Conditional multilevel growth models were used to test for predictors of slope for each outcome. Most psychological symptoms improved significantly from baseline to 12 month follow-up, regardless of treatment type. Depressive symptoms and dietary restraint were most improved, weight and shape concerns were least improved, and self-esteem was not at all improved. Weight gain emerged as a significant predictor of improved eating disorder pathology, with earlier weight gain having a greater impact on symptom improvement than later weight gain. Adolescents who presented with more severe, complex, and enduring clinical presentations (i.e., longer duration of illness, greater eating disorder pathology, binge-eating/purging subtype) also appeared to benefit more psychologically from treatment.

Depression, anxiety and obsessive-compulsive symptoms in relation to nutritional status and outcome in severe anorexia nervosa

Depression, anxiety and obsessive-compulsive disorder are frequently reported to co-occur with anorexia nervosa (AN). There is clinical consensus that depressive symptoms and anxiety may in part be sequelae of malnutrition in AN. However, evidence-based data are still very rare. The present study among severe AN patients investigates links between these psychological variants and nutritional status at admission and subsequent to nutritional rehabilitation. Twenty-four women with AN diagnosed according to the Diagnostic and Statistical Manual IV (DSM-IV) were included prospectively and consecutively at hospitalisation. Nutritional status was assessed by body mass index (BMI). Several psychological aspects were assessed using various scales for depression, anxiety, social phobia, obsessive and eating behaviour symptoms. Follow-up weights and heights at 4-12 years after hospital discharge were measured in 18 patients. BMI and all the scores except the Yale-Brown obsessive-compulsive scale (Y-BOCS) showed significant improvement between admission and discharge. This study highlights the fact that some of the depressive and anxiety symptoms at least partially decrease with nutrition rehabilitation. The improvement in the scores on the psychometric scales between admission and discharge was not correlated with BMI improvement. Psychometric scores at admission and at discharge were not correlated with BMI at follow-up. BMI at follow-up was correlated with minimum lifetime BMI (r=0.486, P=0.04). Future studies should use a better indicator for nutritional status than BMI alone, and should also consider the initial degree of weight loss and the rate at which weight was lost.

Relationship between malnutrition and depression or anxiety in Anorexia Nervosa: a critical review of the literature

BACKGROUND

Depression, anxiety and obsessive-compulsive disorder (OCD) frequently co-occur with Anorexia Nervosa (AN). Clinical consensus admits that depressive symptoms and anxiety are the sequelae of malnutrition in AN. This review presents a critical assessment of the literature that looked into the link between depression/anxiety symptoms in relation to malnutrition and their improvement throughout the treatment.

METHODS

We performed a systematic search of literature in Medline and PsychInfo for all the studies done to investigate psychological factors in relation to malnutrition in AN using the keywords "Anorexia Nervosa", "depression", "anxiety", "obsessive-compulsive disorder" and "malnutrition". Only articles published between 1980 and 2010 in English or French were reviewed. From the articles on AN and depression, anxiety, and/or OCD, only the ones which investigated on the relation with malnutrition were kept. This search was complemented by a manual search. We also checked the reference lists of the articles we found.

RESULTS

Seven papers were analyzed and critically reviewed for their methods and results. Results are contradictory and inconsistent at all levels of assessment.

CONCLUSIONS

Evidence based data is very rare. From the 7 reviewed studies, none of them draw the same conclusion. This is mainly due to the large differences in the samples' populations and the studies' protocols. Future studies are needed to focus on the relationship between depression/anxiety symptoms and malnutrition. A more critical nutritional assessment should be undertaken with multiple psychological assessment scales.