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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. J Nutr 2023; 153:1309-1322. [PMID: 36934952 DOI: 10.1016/j.tjnut.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
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.
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Quesnel DA, Cooper M, Fernandez-Del-Valle M, Reilly A, Calogero RM. Medical and physiological complications of exercise for individuals with an eating disorder: A narrative review. J Eat Disord 2023; 11:3. [PMID: 36627654 PMCID: PMC9832767 DOI: 10.1186/s40337-022-00685-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 11/01/2022] [Indexed: 01/12/2023] Open
Abstract
Individuals with eating disorders (ED) experience prolonged malnutrition, binge episodes, and compensatory behaviours that affect every organ system. Psychological and physiological symptoms are worsened with comorbid dysfunctional exercise, seen in up to 80% of those with an ED. Although return to exercise is an important component of treatment and recovery, little is known about the contraindications and risks of exercise engagement specific to those with an ED. This paper provides a comprehensive narrative review of the medical and physiological complications of engaging in exercise during ED treatment and outlines when exercise may be contraindicated or used in modified or cautionary ways. We conducted a literature search on MEDLINE, PubMed, and PsychArticles to identify relevant articles, which yielded six categories of medical and physiological complications of ED that may be exacerbated by exercise: energy availability, cardiovascular health, electrolyte abnormalities, biomedical function markers, sex hormones, and body composition. We summarize the evidence for these complications for readers and offer an initial set of recommendations for incorporating exercise during ED treatment based on our findings. This review may serve as a resource for members of ED treatment teams to help evaluate more readily and confidently whether exercise is safe for individual patients and when modifications and caution may be warranted.
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Affiliation(s)
- Danika A Quesnel
- Department of Psychological Clinical Science, University of Toronto, 320 Huron Street, Toronto, ON, M5S 3J7, Canada.
| | - Marita Cooper
- Department of Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maria Fernandez-Del-Valle
- Department of Functional Biology, University of Oviedo, Oviedo, Spain.,Health Research Institute of the Principality of Asturias (ISPA), Oviedo, Spain
| | - Alanah Reilly
- Alanah Reilly Exercise Physiologist, Brisbane, Australia
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3
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Lopes MP, Robinson L, Stubbs B, Dos Santos Alvarenga M, Araújo Martini L, Campbell IC, Schmidt U. Associations between bone mineral density, body composition and amenorrhoea in females with eating disorders: a systematic review and meta-analysis. J Eat Disord 2022; 10:173. [PMID: 36401318 PMCID: PMC9675098 DOI: 10.1186/s40337-022-00694-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 10/23/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lower bone mineral density (BMD) increases the risk of osteoporosis in individuals with eating disorders (EDs), particularly women with anorexia nervosa (AN), making them susceptible to pain and fractures throughout adulthood. In AN, low weight, hypothalamic amenorrhoea, and longer illness duration are established risk factors for low BMD, and in people with other EDs a history of AN seems to be an important risk factor for low BMD. PURPOSE To conduct a systematic review and meta-analysis of BMD in individuals with EDs, including AN, bulimia nervosa (BN), binge-eating disorder (BED) and other specified feeding or eating disorders (OSFED) compared to healthy controls (HC). METHODS Following PRISMA guidelines, electronic databases were reviewed and supplemented with a literature search until 2/2022 of publications measuring BMD (dual-energy X-ray absorptiometry or dual photon absorptiometry) in females with any current ED diagnosis and a HC group. Primary outcomes were spine, hip, femur and total body BMD. Explanatory variables were fat mass, lean mass and ED clinical characteristics (age, illness duration, body mass index (BMI), amenorrhoea occurrence and duration, and oral contraceptives use). RESULTS Forty-three studies were identified (N = 4163 women, mean age 23.4 years, min: 14.0, max: 37.4). No study with individuals with BED met the inclusion criteria. BMD in individuals with AN (total body, spine, hip, and femur), with BN (total body and spine) and with OSFED (spine) was lower than in HC. Meta-regression analyses of women with any ED (AN, BN or OSFED) (N = 2058) showed low BMI, low fat mass, low lean mass and being amenorrhoeic significantly associated with lower total body and spine BMD. In AN, only low fat mass was significantly associated with low total body BMD. CONCLUSION Predictors of low BMD were low BMI, low fat mass, low lean mass and amenorrhoea, but not age or illness duration. In people with EDs, body composition measurement and menstrual status, in addition to BMI, are likely to provide a more accurate assessment of individual risk to low BMD and osteoporosis.
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Affiliation(s)
- Mariana P Lopes
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil. .,Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.
| | - Lauren Robinson
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK
| | - Brendon Stubbs
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.,Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
| | - Marle Dos Santos Alvarenga
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil
| | - Ligia Araújo Martini
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil
| | - Iain C Campbell
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.,Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
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4
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Hung C, Muñoz M, Shibli-Rahhal A. Anorexia Nervosa and Osteoporosis. Calcif Tissue Int 2022; 110:562-575. [PMID: 33666707 DOI: 10.1007/s00223-021-00826-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/14/2021] [Indexed: 12/12/2022]
Abstract
Patients with anorexia nervosa (AN) often experience low bone mineral density (BMD) and increased fracture risk, with low body weight and decreased gonadal function being the strongest predictors of the observed bone mineral deficit and fractures. Other metabolic disturbances have also been linked to bone loss in this group of patients, including growth hormone resistance, low insulin-like growth factor-1 (IGF-1) concentrations, low leptin concentrations, and hypercortisolemia. However, these correlations lack definitive evidence of causality. Weight restoration and resumption of menstrual function have the strongest impact on increasing BMD. Other potential treatment options include bisphosphonates and teriparatide, supported by data from small clinical trials, but these agents are not approved for the treatment of low BMD in adolescents or premenopausal women with AN.
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Affiliation(s)
- Chermaine Hung
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Marcus Muñoz
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Amal Shibli-Rahhal
- Division of Endocrinology, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
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Legroux I, Cortet B. Factors influencing bone loss in anorexia nervosa: assessment and therapeutic options. RMD Open 2019; 5:e001009. [PMID: 31798952 PMCID: PMC6861073 DOI: 10.1136/rmdopen-2019-001009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
Decreased mineral density is one of the major complications of anorexia nervosa. The phenomenon is even more pronounced when the disease occurs during adolescence and when the duration of amenorrhoea is long. The mechanisms underlying bone loss in anorexia are complex. Oestrogen deficiency has long been considered as the main factor, but cannot explain the phenomenon on its own. The essential role of nutrition-related factors—especially leptin and adiponectin—has been reported in recent studies. Therapeutic strategies to mitigate bone involvement in anorexia are still a matter for debate. Although resumption of menses and weight recovery appear to be essential, they are not always accompanied by a total reversal of bone loss. There are no studies in the literature demonstrating that oestrogen treatment is effective, and the best results seem to have been obtained with agents that induce bone formation—such as IGF-1—especially when associated with oestrogen. As such, bone management in anorexia remains difficult, hence, the importance of early detection and multidisciplinary follow-up.
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Affiliation(s)
- Isabelle Legroux
- Department of Rheumatology and EA 4490, Lille University Hospital and University of Lille, Lille, France
| | - Bernard Cortet
- Department of Rheumatology and EA 4490, Lille University Hospital and University of Lille, Lille, France
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Steinman J, Shibli-Rahhal A. Anorexia Nervosa and Osteoporosis: Pathophysiology and Treatment. J Bone Metab 2019; 26:133-143. [PMID: 31555610 PMCID: PMC6746661 DOI: 10.11005/jbm.2019.26.3.133] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/06/2019] [Accepted: 07/21/2019] [Indexed: 01/18/2023] Open
Abstract
Anorexia nervosa (AN) affects 2.9 million people, many of whom experience bone loss and increased fracture risk. In this article, we review data on the underlying pathophysiology of AN-related osteoporosis and possible approaches to disease management. Available research suggests that low body weight and decreased gonadal function are the strongest predictors of bone loss and fractures in patients with AN. Additionally, other metabolic disturbances have been linked to bone loss, including growth hormone resistance, low leptin concentrations, and hypercortisolemia, but those correlations are less consistent and lack evidence of causality. In terms of treatment of AN-related bone disease, weight gain has the most robust impact on bone mineral density (BMD). Restoration of gonadal function seems to augment this effect and may independently improve BMD. Bisphosphonates, insulin-like growth factor 1 supplementation, and teriparatide may also be reasonable considerations, however need long-term efficacy and safety data.
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Affiliation(s)
- Jeremy Steinman
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Amal Shibli-Rahhal
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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7
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Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews. J Clin Med 2019; 8:jcm8020278. [PMID: 30823566 PMCID: PMC6406645 DOI: 10.3390/jcm8020278] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 12/12/2022] Open
Abstract
Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa.
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Singhal V, Tulsiani S, Campoverde KJ, Mitchell DM, Slattery M, Schorr M, Miller KK, Bredella MA, Misra M, Klibanski A. Impaired bone strength estimates at the distal tibia and its determinants in adolescents with anorexia nervosa. Bone 2018; 106:61-68. [PMID: 28694162 PMCID: PMC5694353 DOI: 10.1016/j.bone.2017.07.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/29/2017] [Accepted: 07/06/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Altered bone microarchitecture and higher marrow adipose tissue (MAT) may reduce bone strength. High resolution pQCT (HRpQCT) allows assessment of volumetric BMD (vBMD), and size and microarchitecture parameters of bone, while 1H-magnetic resonance spectroscopy (1H-MRS) allows MAT evaluation. We have reported impaired microarchitecture at the non-weight bearing radius in adolescents with anorexia nervosa (AN) and that these changes may precede aBMD deficits. Data are lacking regarding effects of AN on microarchitecture and strength at the weight-bearing tibia in adolescents and young adults, and the impact of changes in microarchitecture and MAT on strength estimates. OBJECTIVE To compare strength estimates at the distal tibia in adolescents/young adults with AN and controls in relation to vBMD, bone size and microarchitecture, and spine MAT. DESIGN AND METHODS This was a cross-sectional study of 47 adolescents/young adults with AN and 55 controls 14-24years old that assessed aBMD and body composition using DXA, and distal tibia vBMD, size, microarchitecture and strength estimates using HRpQCT, extended cortical analysis, individual trabecular segmentation, and finite element analysis. Lumbar spine MAT (1H-MRS) was assessed in a subset of 19 AN and 22 controls. RESULTS Areal BMD Z-scores were lower in AN than controls. At the tibia, AN had greater cortical porosity, lower total and cortical vBMD, cortical area and thickness, trabecular number, and strength estimates than controls. Within AN, strength estimates were positively associated with lean mass, aBMD, vBMD, bone size and microarchitectural parameters. MAT was higher in AN, and associated inversely with strength estimates. CONCLUSIONS Adolescents/young adults with AN have impaired microarchitecture at the weight-bearing tibia and higher spine MAT, associated with reduced bone strength.
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Affiliation(s)
- Vibha Singhal
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States; Pediatric Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States.
| | - Shreya Tulsiani
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Karen Joanie Campoverde
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Deborah M Mitchell
- Pediatric Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Meghan Slattery
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Melanie Schorr
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States; Pediatric Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States
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Giollo A, Idolazzi L, Caimmi C, Fassio A, Bertoldo F, Dalle Grave R, El Ghoch M, Calugi S, Bazzani PV, Viapiana O, Rossini M, Gatti D. Vitamin D levels strongly influence bone mineral density and bone turnover markers during weight gain in female patients with anorexia nervosa. Int J Eat Disord 2017; 50:1041-1049. [PMID: 28593655 DOI: 10.1002/eat.22731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/09/2017] [Accepted: 05/17/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of the study was to investigate a potential role for vitamin D status on bone mineral density (BMD) during weight gain in patients with anorexia nervosa (AN). METHOD Spine and hip BMD assessed by dual-energy X-ray absorptiometry (DXA), serum vitamin D (25-OH-D), N-propeptide of type I collagen (P1NP), C-terminal telopeptide of type I collagen (CTX), and intact parathyroid hormone (PTH) were measured before and after a 20-week intensive weight-restoration program in ninety-one female patients with AN and secondary amenorrhoea. RESULTS Ninety-one consecutive female patients (age 13-45 years; weight 39.4 ± 5.6 kg, body mass index [BMI] 15.1 ± 1.6 kg m-2 ) were included in the study. Although weight and BMI significantly increased in all patients during treatment, mean BMD only significantly increased at the spine (1.0% ± 3.6%, p = .009). The increase in spine BMD was significantly higher only above post-treatment 25-OH-D levels of 30 ng mL-1 (2.5% vs. 0.5%, respectively, for 25-OH-D ≥ and < 30 ng mL-1 , p = .026). There was a significant decrease in bone resorption (CTX; p = .043) and increased bone formation (P1NP; p < .001) after weight restoration. Nevertheless, a significant increase in PTH was also found, which was inversely correlated with decreased post-treatment 25-OH-D levels (R2 = .153, p < .001). DISCUSSION Hypovitaminosis D may counteract the efficacy of refeeding in AN through increased bone resorption mediated by secondary hyperparathyroidism, which strongly supports the use of vitamin D supplements for bone health in AN.
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Affiliation(s)
- Alessandro Giollo
- Department of Medicine, Rheumatology Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
| | - Luca Idolazzi
- Department of Medicine, Rheumatology Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
| | - Cristian Caimmi
- Department of Medicine, Rheumatology Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
| | - Angelo Fassio
- Department of Medicine, Rheumatology Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
| | - Francesco Bertoldo
- Department of Medicine, Internal Medicine Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
| | - Riccardo Dalle Grave
- Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo 89, Garda, 37016, Italy
| | - Marwan El Ghoch
- Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo 89, Garda, 37016, Italy
| | - Simona Calugi
- Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo 89, Garda, 37016, Italy
| | | | - Ombretta Viapiana
- Department of Medicine, Rheumatology Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
| | - Maurizio Rossini
- Department of Medicine, Rheumatology Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
| | - Davide Gatti
- Department of Medicine, Rheumatology Unit, University of Verona, Piazzale L.A. Scuro 10, Verona, 37026, Italy
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Solmi M, Veronese N, Correll CU, Favaro A, Santonastaso P, Caregaro L, Vancampfort D, Luchini C, De Hert M, Stubbs B. Bone mineral density, osteoporosis, and fractures among people with eating disorders: a systematic review and meta-analysis. Acta Psychiatr Scand 2016; 133:341-51. [PMID: 26763350 DOI: 10.1111/acps.12556] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To provide meta-analytical evidence of bone mineral density (BMD), fractures, and osteoporosis rates in eating disorders (ED) vs. healthy controls (HCs). METHOD Three independent authors searched major electronic databases from inception till August 2015 for cross-sectional studies reporting BMD in people with ED (anorexia nervosa, (AN); bulimia nervosa, (BN); eating disorders not otherwise specified, (EDNOS)) vs. HCs. Standardized mean differences (SMDs) ±95% and confidence intervals (CIs) were calculated for BMD, and odds ratios (ORs) for osteopenia, osteoporosis, and fractures. RESULTS Overall, 57 studies were eligible, including 21 607 participants (ED = 6485, HCs = 15 122). Compared to HC, AN subjects had significantly lower BMD values at lumbar spine (SMD = -1.51, 95% CI = -1.75, -1.27, studies = 42), total hip (SMD = -1.56, 95%CI = -1.84, -1.28, studies = 23), intertrochanteric region (SMD = -1.80, 95%CI = -2.46, -1.14, studies = 7), trochanteric region (SMD = -1.05, 95%CI = -1.44, -0.66, studies = 7), and femoral neck (SMD = -0.98, 95%CI = -1.12, -0.77, studies = 20). Reduced BMD was moderated by ED illness duration and amenorrhea (P < 0.05). AN was associated with an increased likelihood of osteoporosis (OR = 12.59, 95%CI = 3.30-47.9, P < 0.001, studies = 4) and fractures (OR = 1.84, 95% CI = 1.17-2.89, I(2) = 56, studies = 6). No difference in BMD was found between BN and EDNOS vs. HC. CONCLUSION People with AN have reduced BMD, increased odds of osteoporosis and risk of fractures. Proactive monitoring and interventions are required to ameliorate bone loss in AN.
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Affiliation(s)
- M Solmi
- Department of Neurosciences, University of Padova, Padova, Italy
| | - N Veronese
- Department of Medicine, Geriatrics Section, University of Padova, Italy
| | - C U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, North Shore-Long Island Jewish Health System, Glen Oaks, NY, USA.,Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - A Favaro
- Department of Neurosciences, University of Padova, Padova, Italy
| | - P Santonastaso
- Department of Neurosciences, University of Padova, Padova, Italy
| | - L Caregaro
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - D Vancampfort
- Department of Rehabilitation Sciences, Leuven - University of Leuven, Leuven, Belgium.,Z.org Leuven, KU Leuven - University of Leuven, Kortenberg, Belgium
| | - C Luchini
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, Verona, Italy
| | - M De Hert
- Department of Rehabilitation Sciences, Leuven - University of Leuven, Leuven, Belgium
| | - B Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Health Service and Population Research Department, Institute of Psychiatry King's College London, London, UK
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12
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Treasure J, Zipfel S, Micali N, Wade T, Stice E, Claudino A, Schmidt U, Frank GK, Bulik CM, Wentz E. Anorexia nervosa. Nat Rev Dis Primers 2015; 1:15074. [PMID: 27189821 DOI: 10.1038/nrdp.2015.74] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anorexia nervosa (AN) is a psychiatric condition characterized by severe weight loss and secondary problems associated with malnutrition. AN predominantly develops in adolescence in the peripubertal period. Without early effective treatment, the course is protracted with physical, psychological and social morbidity and high mortality. Despite these effects, patients are noted to value the beliefs and behaviours that contribute to their illness rather than regarding them as problematic, which interferes with screening, prevention and early intervention. Involving the family to support interventions early in the course of the illness can produce sustained changes; however, those with a severe and/or protracted illness might require inpatient nursing support and/or outpatient psychotherapy. Prevention programmes aim to moderate the overvaluation of 'thinness' and body dissatisfaction as one of the proximal risk factors. The low prevalence of AN limits the ability to identify risk factors and to study the timing and sex distribution of the condition. However, genetic profiles, premorbid features, and brain structures and functions of patients with AN show similarities with other psychiatric disorders and contrast with obesity and metabolic disorders. Such studies are informing approaches to address the neuroadaptation to starvation and the other various physical and psychosocial deficits associated with AN. This Primer describes the epidemiology, diagnosis, screening and prevention, aetiology, treatment and quality of life of patients with AN.
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Affiliation(s)
- Janet Treasure
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London SE5 8AF, UK
| | - Stephan Zipfel
- Department of Psychosomatic Medicine, University of Tuebingen, Tuebingen, Germany
| | - Nadia Micali
- University College London, Institute of Child Health, Behavioural and Brain Sciences Unit, London, UK.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tracey Wade
- School of Psychology, Flinders University, Adelaide, Australia
| | - Eric Stice
- Oregon Research Institute, Eugene, Oregon, USA
| | - Angélica Claudino
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Ulrike Schmidt
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London SE5 8AF, UK
| | - Guido K Frank
- Eating Disorder Centre of Denver, University of Colorado, Denver, Colorado, USA
| | - Cynthia M Bulik
- University of North Carolina at Chapel Hill, North Carolina, USA.,Karolinska Institutet, Stockholm, Sweden
| | - Elisabet Wentz
- Gillberg Neuropsychiatry Centre, University of Gothenburg, Gothenburg Sweden
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13
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Veronese N, Solmi M, Rizza W, Manzato E, Sergi G, Santonastaso P, Caregaro L, Favaro A, Correll CU. Vitamin D status in anorexia nervosa: A meta-analysis. Int J Eat Disord 2015; 48:803-13. [PMID: 25445242 DOI: 10.1002/eat.22370] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVE In anorexia nervosa (AN), osteoporosis and osteopenia are common, which have been associated with low circulating levels of vitamin D (VitD) in other settings. We aimed to meta-analyze cross-sectional studies reporting on VitD parameters in patients with AN and healthy controls (HCs). METHOD Electronic PubMed search from database inception until December 31, 2013 and meta-analysis of cross-sectional studies comparing serum levels of 25-hydroxyvitamin D (25OH-D), 1,25-dihydroxyvitamin D (1,25OH-D) and dietary VitD between patients with AN and HCs, before or after VitD supplementation. We calculated random effects standardized mean differences (SMDs) ±95% confidence intervals (CIs) as effect size measures. RESULTS Out of 1,739 initial hits, 15 studies with a total of 927 participants (AN = 408 and HCs = 519) were meta-analyzed. In the unsupplemented state, both serum 25OH-D (studies = 4; n = 168; SMD = -0.43; 95%CI: -0.83 to -0.03; p = .03) and 1,25OH-D levels (studies = 4; n = 113; SMD = -1.06; 95%CI: -1.47 to -0.66; p < .00001) were significantly lower in AN than HCs. In AN patients treated with cholecalciferol supplementation, serum 25OH-D levels were significantly higher than in HCs (studies = 5; n = 449; SMD = 0.66; 95%CI: 0.01-1.31; p = .05). Paradoxically, despite lower 25OH-D and 1,25OH-D levels, AN patients reported similar intake of VitD compared to HCs (studies = 6; n = 314; SMD = 0.33; 95%CI: -0.16, 0.81; p = .19). DISCUSSION Although AN patients reported similar dietary VitD intake compared to HCs, AN patients had significantly lower 25OH-D and 1,25OH-D levels without supplementation. Conversely, supplementation with cholecalciferol fully normalized VitD serum levels. Future studies are needed to clarify the role of VitD supplementation in AN for improving bone health.
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Affiliation(s)
- Nicola Veronese
- Department of Medicine, DIMED, Geriatrics Section, University of Padova, Padova, Italy
| | - Marco Solmi
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Wanda Rizza
- Department of Food and Human Nutrition Science, University Campus Bio-Medico, Rome, Italy
| | - Enzo Manzato
- Department of Medicine, DIMED, Geriatrics Section, University of Padova, Padova, Italy
| | - Giuseppe Sergi
- Department of Medicine, DIMED, Geriatrics Section, University of Padova, Padova, Italy
| | | | - Lorenza Caregaro
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Angela Favaro
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA.,Hofstra North Shore LIJ School of Medicine, Department of Psychiatry and Molecular Medicine, Hempstead, New York, USA.,The Feinstein Institute for Medical Research, Psychiatric Neuroscience Center of Excellence, Manhasset, New York, USA.,Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences, Bronx, New York, USA
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14
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Abstract
Bone metabolism is regulated by the action of two skeletal cells: osteoblasts and osteoclasts. This process is controlled by many genetic, hormonal and lifestyle factors, but today more and more studies have allowed us to identify a neuronal regulation system termed 'bone-brain crosstalk', which highlights a direct relationship between bone tissue and the nervous system. The first documentation of an anatomic relationship between nerves and bone was made via a wood cut by Charles Estienne in Paris in 1545. His diagram demonstrated nerves entering and leaving the bones of a skeleton. Later, several studies were conducted on bone innervation and, as of today, many observations on the regulation of bone remodeling by neurons and neuropeptides that reside in the CNS have created a new research field, that is, neuroskeletal research.
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Affiliation(s)
- Alessia Metozzi
- a 1 Department of Surgery and Translational Medicine, Metabolic Bone Diseases Unit, University of Florence, Largo Palagi 1, 50138 Florence, Italy
| | - Lorenzo Bonamassa
- a 1 Department of Surgery and Translational Medicine, Metabolic Bone Diseases Unit, University of Florence, Largo Palagi 1, 50138 Florence, Italy
| | - Gemma Brandi
- b 2 Public Mental Health system 1-4 of Florence, Florence, Italy
| | - Maria Luisa Brandi
- c 3 Department of Surgery and Translational Medicine, Metabolic Bone Diseases Unit, AOUC Careggi, University of Florence, Largo Palagi 1, 50138 Florence, Italy
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15
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Krause M, Keller J, Beil B, van Driel I, Zustin J, Barvencik F, Schinke T, Amling M. Calcium gluconate supplementation is effective to balance calcium homeostasis in patients with gastrectomy. Osteoporos Int 2015; 26:987-95. [PMID: 25391248 DOI: 10.1007/s00198-014-2965-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 11/03/2014] [Indexed: 02/07/2023]
Abstract
UNLABELLED We demonstrate histological evidence for hyperparathyroidism in patients with gastrectomy. This is, at least in part, explained by impaired calcium absorption, resulting in mineralization defects and secondary hyperparathyroidism. Additionally, we demonstrate improved bone mineralization in patients with gastrectomy after gluconate therapy and showed the effectiveness of calcium gluconate over carbonate to balance impaired calcium hemostasis in mice. INTRODUCTION Gastrectomy and hypochlorhydria due to long-term proton pump inhibitor therapy are associated with increased fracture risk because of intestinal calcium malabsorption. Hence, our objectives were to histologically investigate bone metabolism in patients with gastrectomy and to analyze the impact of calcium gluconate supplementation on skeletal integrity in the setting of impaired gastric acidification. METHODS Undecalcified bone biopsies of 26 gastrectomized individuals were histologically analyzed. In the clinical setting, we retrospectively identified 5 gastrectomized patients with sufficient vitamin D level, who were additionally supplemented with calcium gluconate and had a real bone mineral density (aBMD) follow-up assessments. A mouse model of achlorhydria (ATP4b-/-) was used to compare the effect of calcium gluconate and calcium carbonate supplementation on bone metabolism. RESULTS Biopsies from gastrectomized individuals showed significantly increased osteoid, osteoclast, and osteoblast indices and fibroosteoclasia (p < 0.05) as well as impaired calcium distribution in mineralized bone matrix compared to healthy controls. Five gastrectomized patients with sufficient vitamin D level demonstrated a significant increase in aBMD after a treatment with calcium gluconate alone for at least 6 months (p < 0.05). Calcium gluconate was superior to calcium carbonate in maintaining calcium metabolism in a mouse model of achlorhydria. CONCLUSION Gastrectomy is associated with severe osteomalacia, marrow fibrosis, and impaired calcium distribution within the mineralized matrix. We show that calcium gluconate supplementation can increase bone mineral density in gastrectomized individuals and performs superior to calcium carbonate in restoring calcium/skeletal homoeostasis in a mouse model of achlorhydria.
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Affiliation(s)
- M Krause
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
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16
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Abstract
PURPOSE OF REVIEW Despite evidence that energy deficit produces multiple physiological and metabolic benefits, clinicians are often reluctant to prescribe weight loss in older individuals or those with low bone mineral density (BMD), fearing BMD will be decreased. Confusion exists concerning the effects that weight loss has on bone health. RECENT FINDINGS Bone density is more closely associated with lean mass than total body mass and fat mass. Although rapid or large weight loss is often associated with loss of bone density, slower or smaller weight loss is much less apt to adversely affect BMD, especially when it is accompanied with high intensity resistance and/or impact loading training. Maintenance of calcium and vitamin D intake seems to positively affect BMD during weight loss. Although dual energy X-ray absorptiometry is normally used to evaluate bone density, it may overestimate BMD loss following massive weight loss. Volumetric quantitative computed tomography may be more accurate for tracking bone density changes following large weight loss. SUMMARY Moderate weight loss does not necessarily compromise bone health, especially when exercise training is involved. Training strategies that include heavy resistance training and high impact loading that occur with jump training may be especially productive in maintaining, or even increasing bone density with weight loss.
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Affiliation(s)
- Gary R Hunter
- Division of Kinesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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17
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Zuckerman-Levin N, Hochberg Z, Latzer Y. Bone health in eating disorders. Obes Rev 2014; 15:215-23. [PMID: 24165231 DOI: 10.1111/obr.12117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 09/11/2013] [Accepted: 09/13/2013] [Indexed: 12/30/2022]
Abstract
Eating disorders (EDs) put adolescents and young adults at risk for impaired bone health. Low bone mineral density (BMD) with ED is caused by failure to accrue peak bone mass in adolescence and bone loss in young adulthood. Although ED patients diagnosed with bone loss may be asymptomatic, some suffer bone pains and have increased incidence of fractures. Adolescents with ED are prone to increased prevalence of stress fractures, kyphoscoliosis and height loss. The clinical picture of the various EDs involves endocrinopathies that contribute to impaired bone health. Anorexia nervosa (AN) is characterized by low bone turnover, with relatively higher osteoclastic (bone resorptive) than osteoblastic (bone formation) activity. Bone loss in AN occurs in both the trabecular and cortical bones, although the former is more vulnerable. Bone loss in AN has been shown to be influenced by malnutrition and low weight, reduced fat mass, oestrogen and androgen deficiency, glucocorticoid excess, impaired growth hormone-insulin-like growth factor 1 axis, and more. Bone loss in AN may not be completely reversible despite recovery from the illness. Treatment modalities involving hormonal therapies have limited effectiveness, whereas increased caloric intake, weight gain and resumption of menses are essential to improved BMD.
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Affiliation(s)
- N Zuckerman-Levin
- Eating Disorders Clinic, Psychiatric Division, Rambam Medical Center, Haifa, Israel
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18
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Keller J, Schinke T. The role of the gastrointestinal tract in calcium homeostasis and bone remodeling. Osteoporos Int 2013; 24:2737-48. [PMID: 23536255 DOI: 10.1007/s00198-013-2335-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/25/2013] [Indexed: 12/11/2022]
Abstract
While skeletal biology was approached in a rather isolated fashion in the past, an increasing understanding of the interplay between extraskeletal organs and bone remodeling has been obtained in recent years. This review will discuss recent advances in the field that have shed light on how the gastrointestinal tract and bone relate to each other. In particular, the importance of the GI tract in maintaining calcium homeostasis and skeletal integrity will be reviewed as impaired gastric acid production represents a major public health problem with possible implications for sufficient calcium absorption. Osteoporosis, the most prevalent bone disease worldwide, is caused not only by intrinsic defects affecting bone cell differentiation and function but also by a large set of extrinsic factors including hormonal disturbances, malnutrition, and iatrogenic drug application. Given the skeletal requirements of calcium, amino acids, and energy for bone turnover and renewal, it is not surprising that the gastrointestinal (GI) tract is of major importance for skeletal integrity.
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Affiliation(s)
- J Keller
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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19
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Abstract
Nutritional status is an essential component in determining whole body energy homeostasis. The balance between energy/food intake and metabolism is governed by a range of hormones secreted from various parts of the body. Their subsequent dissemination via the blood results in a wide range of biological responses including satiety, hunger, and glucose uptake. The roles of these systemic hormones also extend to bone regulation with animal and clinical studies establishing a relationship between these regulatory pathways. This review covers the gastrointestinal hormones, ghrelin, PYY, GIP, GLP-1, and GLP-2, and the adipokines, leptin, and adiponectin and their roles in regulating bone homeostasis. Their known actions are reviewed, with an emphasis upon recent advances in understanding. Taken together, this review outlines an expanding appreciation of the interactions between bone mass and the nutritional control of whole body energy balance by gut and adipose tissue.
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Affiliation(s)
- Ee Cheng Khor
- Bone Regulation, Neuroscience Research Division, Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, Sydney, New South Wales, 2010, Australia
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20
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Méquinion M, Langlet F, Zgheib S, Dickson S, Dehouck B, Chauveau C, Viltart O. Ghrelin: central and peripheral implications in anorexia nervosa. Front Endocrinol (Lausanne) 2013; 4:15. [PMID: 23549309 PMCID: PMC3581855 DOI: 10.3389/fendo.2013.00015] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 02/01/2013] [Indexed: 11/15/2022] Open
Abstract
Increasing clinical and therapeutic interest in the neurobiology of eating disorders reflects their dramatic impact on health. Chronic food restriction resulting in severe weight loss is a major symptom described in restrictive anorexia nervosa (AN) patients, and they also suffer from metabolic disturbances, infertility, osteopenia, and osteoporosis. Restrictive AN, mostly observed in young women, is the third largest cause of chronic illness in teenagers of industrialized countries. From a neurobiological perspective, AN-linked behaviors can be considered an adaptation that permits the endurance of reduced energy supply, involving central and/or peripheral reprograming. The severe weight loss observed in AN patients is accompanied by significant changes in hormones involved in energy balance, feeding behavior, and bone formation, all of which can be replicated in animals models. Increasing evidence suggests that AN could be an addictive behavior disorder, potentially linking defects in the reward mechanism with suppressed food intake, heightened physical activity, and mood disorder. Surprisingly, the plasma levels of ghrelin, an orexigenic hormone that drives food-motivated behavior, are increased. This increase in plasma ghrelin levels seems paradoxical in light of the restrained eating adopted by AN patients, and may rather result from an adaptation to the disease. The aim of this review is to describe the role played by ghrelin in AN focusing on its central vs. peripheral actions. In AN patients and in rodent AN models, chronic food restriction induces profound alterations in the « ghrelin » signaling that leads to the development of inappropriate behaviors like hyperactivity or addiction to food starvation and therefore a greater depletion in energy reserves. The question of a transient insensitivity to ghrelin and/or a potential metabolic reprograming is discussed in regard of new clinical treatments currently investigated.
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Affiliation(s)
- Mathieu Méquinion
- UMR INSERM 837, Development and Plasticity of Postnatal BrainLille, France
| | - Fanny Langlet
- UMR INSERM 837, Development and Plasticity of Postnatal BrainLille, France
| | - Sara Zgheib
- Pathophysiology of inflammatory of bone diseases, Université Lille Nord de France-ULCO – Lille 2Boulogne sur Mer, France
| | - Suzanne Dickson
- Department of Physiology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of GothenburgGothenburg, Sweden
- Department of Endocrinology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of GothenburgGothenburg, Sweden
| | - Bénédicte Dehouck
- UMR INSERM 837, Development and Plasticity of Postnatal BrainLille, France
- Université Lille Nord de France – Université d’ArtoisLiévin, France
| | - Christophe Chauveau
- Pathophysiology of inflammatory of bone diseases, Université Lille Nord de France-ULCO – Lille 2Boulogne sur Mer, France
| | - Odile Viltart
- UMR INSERM 837, Development and Plasticity of Postnatal BrainLille, France
- Université Lille Nord de France-USTL (Lille 1)Villeneuve d’Ascq, France
- *Correspondence: Odile Viltart, Development and Plasticity of the Postnatal Brain, Team 2, Jean-Pierre Aubert Research Center, UMR INSERM 837, Bât Biserte, 1 place de Verdun, 59,045 Lille cedex, France. e-mail:
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