Medical complications of anorexia nervosa and their treatments: an update on some critical aspects

Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

Can we predict the development of acute gastric dilatation in patients with anorexia nervosa?

BACKGROUND

Acute gastric dilatation can develop in patients with anorexia nervosa who are being refed to achieve weight restoration. If unrecognized, this condition is associated with significant morbidity and mortality. Patients with acute gastric dilatation usually have abdominal pain, nausea, and vomiting. Abdominal imaging confirms the diagnosis. This study aims to identify risk factors associated with the development of acute gastric dilatation in patients with severe restrictive eating disorders in order to hasten diagnosis and guide treatment. This study also aims to define the clinical outcomes of patients with acute gastric dilatation.

METHODS

In this retrospective case series, 15 patients with a restrictive eating disorder were studied. Multiple variables were assessed for significant correlation with stomach size.

RESULTS

15 patients with a restrictive eating disorder were identified as being diagnosed with acute gastric dilatation through chart review during the study period. The average dilated stomach size was 20.5 cm. There was no significant correlation of stomach size with any of the following: % ideal body weight on day of admission, % ideal body weight on day of imaging study, rate of weight gain (kg per week), or duration of illness. Serum levels of sodium, potassium, phosphorus, magnesium, calcium, bicarbonate, blood urea nitrogen, glucose, albumin, and hematocrit on the day of imaging, did not correlate with stomach size. All patients were treated with conservative management. None of the patients required surgical intervention or progressed to gastric necrosis or perforation, and there were no recurrences of the acute gastric dilatation.

CONCLUSIONS

There are no specific risk factors significantly associated with the development of acute gastric dilatation in patients with severe restrictive eating disorders. Clinicians should maintain a high index of suspicion for this condition when patients are experiencing abdominal pain, nausea, or vomiting. When promptly diagnosed and treated, outcomes are good. If diagnosis is delayed, the outcome can be dire.

The multisensory mind: a systematic review of multisensory integration processing in Anorexia and Bulimia Nervosa

Individuals with Anorexia Nervosa and Bulimia Nervosa present alterations in the way they experience their bodies. Body experience results from a multisensory integration process in which information from different sensory domains and spatial reference frames is combined into a coherent percept. Given the critical role of the body in the onset and maintenance of both Anorexia Nervosa and Bulimia Nervosa, we conducted a systematic review to examine multisensory integration abilities of individuals affected by these two conditions and investigate whether they exhibit impairments in crossmodal integration. We searched for studies evaluating crossmodal integration in individuals with a current diagnosis of Anorexia Nervosa and Bulimia Nervosa as compared to healthy individuals from both behavioral and neurobiological perspectives. A search of PubMed, PsycINFO, and Web of Sciences databases was performed to extract relevant articles. Of the 2348 studies retrieved, 911 were unique articles. After the screening, 13 articles were included. Studies revealed multisensory integration abnormalities in patients affected by Anorexia Nervosa; only one included individuals with Bulimia Nervosa and observed less severe impairments compared to healthy controls. Overall, results seemed to support the presence of multisensory deficits in Anorexia Nervosa, especially when integrating interoceptive and exteroceptive information. We proposed the Predictive Coding framework for understanding our findings and suggested future lines of investigation.

COVID-19 induced anorexia nervosa: A case series and brief review of literature

Key Clinical Message

This article emphasizes that patients presenting with COVID-19 infection especially presenting with predominantly gastrointestinal symptoms and a history of eating disorder or even other mental disorders should be evaluated thoroughly and differential diagnoses should be considered. Clinicians should keep in mind that eating disorders may happen after COVID infection or vaccination.

Abstract

The emergence and global spread of the 2019 novel coronavirus (COVID-19) have caused a significant mental health burden on communities around the world. Factors related to COVID-19 affect mental health in the general community, but may have more adverse effects on individuals with pre-existing mental illnesses. Additionally with the new living conditions and increased focus on hand hygiene and fear of contracting COVID-19, depression, anxiety, and obsessive-compulsive disorder (OCD) are more likely to be exacerbated. Eating disorders such as anorexia nervosa (AN) have exhibited an alarming increase due to social pressure especially through social media. Also, many patients reported relapses since the commencement of the COVID-19 pandemic. We report five cases of AN that developed or exacerbated after COVID-19 infection. Four patients have newly developed (AN) and one case relapsed after COVID-19 infection. Also, one of the patient's symptoms exacerbated after remission following a COVID-19 vaccine shot. The patients were managed medical and non-medically. Three of cases have reported improvements while two other cases were lost because of poor compliance. It might be possible that people with history of eating disorder, or other mental disorders may be more susceptible to newly develop or exacerbate eating disorders after COVID-19 infection especially when symptoms are gastrointestinal dominant. There is currently minimal evidence on the specific risk of COVID-19 infection in patients with AN and reporting cases of AN after COVID-19 infection could help learn the risk, prevent and manage patients. Clinicians should keep in mind that eating disorders may happen after COVID infection or vaccination.

Physical Therapy Interventions in Patients with Anorexia Nervosa: A Systematic Review

OBJECTIVE

Assess the effectiveness of physical therapy, including supervised physical exercise for body mass index (BMI) restoration; improving muscle strength and the psychological, behavioural, cognitive symptoms and quality of life in patients with anorexia nervosa (AN).

METHODS

A Systematic Review (SR) was conducted in the following scientific databases: Medline, PubMed, PEDro, PsychInfo, Cochrane Library plus, Nursing and Allied Health database, Scopus and Web of Science databases, from inception until November 2021. An assessment of the risk of bias and the certainty of evidence across studies was conducted. Articles were eligible if they followed randomized and non-randomized control trial designs with treatments based on physical therapy or exercise or physical activity in AN patients.

RESULTS

496 records were screened, and after eligibility assessment, 6 studies from 8 articles were finally analysed. The studies, involving 176 AN patient (85.02% of patients), reported improvements in muscle strength, eating behaviour, eating attitude, mood and quality of life. Three studies included nutritional co-interventions and four studies included psychological therapy. None of the studies reported adverse effects.

CONCLUSIONS

In two of the RCTs included in this SR, strength training and high intensity resistance improved the muscle strength of patients with AN. In addition, in two RCTs, improvements were observed in patients' attitudes towards their bodies after basic body awareness therapy or after full body massage and instruction to relax. In addition, quality of life improved in two studies, with stretching, isometrics, endurance cardiovascular and muscular exercising.

Parent and clinician perspectives on virtual guided self-help family-based treatment (GSH-FBT) for adolescents with anorexia nervosa

PURPOSE

Guided self-help (GSH) treatments have the capacity to expand access to care, decrease costs, and increase dissemination compared to traditional therapist-directed treatment approaches. However, little is known about parent and clinician perspectives about the acceptability of GSH for adolescents with eating disorders.

METHODS

This study utilized a mixed methods approach to obtain qualitative and quantitative data regarding clinician and participants' experiences with GSH. Parent participants were enrolled in a randomized trial comparing GSH family-based treatment (GSH-FBT) to family-based treatment delivered via videoconferencing (FBT-V) for adolescents (12-18 years old) with a DSM-5 diagnosis of anorexia nervosa (AN). Parent participants provided qualitative feedback using the Helping Alliances Questionnaire about their experience of treatment. Clinician participants were six master's or PhD-level therapists. These clinicians were trained in and provided both treatments (GSH-FBT and FBT-V). They provided responses to questionnaires and participated in a 1-h focus group about their experience as treatment providers.

RESULTS

Regardless of treatment condition, parents listed more improvement than worsening of symptoms in their child with AN. Clinicians reported lower scores on competency and comfort metrics with GSH-FBT compared to FBT-V. Qualitatively, clinicians reported both advantages and disadvantages of delivering GSH-FBT.

CONCLUSION

Further studies are needed to better understand how GSH interventions can be disseminated to patients and families, particularly those with limited access to specialized eating disorder treatment centers. Level of evidence Level I, data collected as part of a randomized controlled trial.

Broad and Narrow Transdiagnostic Risk Factors in Eating Disorders: A Preliminary Study on an Italian Clinical Sample

Eating disorders are multifaceted psychopathologies and the transdiagnostic approach is currently considered a useful framework to understand their complexity. This preliminary study aimed to investigate both broad (i.e., intolerance of uncertainty and emotion dysregulation) and narrow (i.e., extreme body dissatisfaction) transdiagnostic risk factors underlying eating disorders. 50 Italian female patients seeking treatment for an eating disorder were involved (M_age = 31.6 years ± 12.8, 18–65). They completed self-report measures assessing emotion regulation difficulties, intolerance of uncertainty, extreme body dissatisfaction, general psychological distress, and eating disorder symptomatology. To explore whether the abovementioned transdiagnostic factors predicted patients’ psychological distress and eating disorder symptoms, two linear regressions were performed. Emotion dysregulation emerged as the only significant predictor of distress, while extreme body dissatisfaction was the only significant predictor of overall eating disorder symptomatology. Then, to analyze the differences between patients with anorexia nervosa and bulimia nervosa in intolerance of uncertainty and emotion regulation problems, t-tests were conducted. The two groups differed significantly in intolerance of uncertainty levels only, with higher scores obtained by patients with anorexia nervosa. Overall, our findings suggest that emotion dysregulation and extreme body dissatisfaction may be relevant constructs in eating disorders in general, while intolerance of uncertainty may be more involved in restrictive eating disorders. The clinical implications of such results are discussed.

A standard enteral formula versus an iso-caloric lower carbohydrate/high fat enteral formula in the hospital management of adolescent and young adults admitted with anorexia nervosa: a randomised controlled trial

BACKGROUND

The nutritional rehabilitation of malnourished patients hospitalised with anorexia nervosa is essential. The provision of adequate nutrition must occur, while simultaneously, minimising the risk of refeeding complications, such as electrolyte, metabolic, and organ dysfunction. The aim of this study was to compare the efficacy and safety of an iso-caloric lower carbohydrate/high fat enteral formula (28% carbohydrate, 56% fat) against a standard enteral formula (54% carbohydrate, 29% fat).

METHODS

Patients (aged 15-25 years) hospitalised with anorexia nervosa were recruited into this double blinded randomised controlled trial. An interim analysis was completed at midpoint, when 24 participants, mean age 17.5 years (± 1.1), had been randomly allocated to lower carbohydrate/high fat (n = 14) or standard (n = 10) feeds.

RESULTS

At baseline, there was no significant difference in degree of malnutrition, medical instability, history of purging or serum phosphate levels between the two treatment arms. A significantly lower rate of hypophosphatemia developed in patients who received the lower carbohydrate/high fat formula compared to standard formula (5/14 vs 9/10, p = 0.013). The serum phosphate level decreased in both feeds, however it decreased to a larger extent in the standard feed compared to the lower carbohydrate/high fat feed (standard feed 1.11 ± 0.13 mmol/L at baseline vs 0.88 ± 0.12 mmol/L at week 1; lower carbohydrate/high fat feed 1.18 ± 0.19 mmol/L at baseline vs 1.06 ± 0.15 mmol/L at week 1). Overall, serum phosphate levels were significantly higher in the lower carbohydrate/high fat feed compared with standard feed treatment arm at Week 1 (1.06 ± 0.15 mmol/L vs 0.88 ± 0.12 mmol/L, p < 0.001). There was no significant difference in weight gain, number of days to reach medical stability, incidence of hypoglycaemia, or hospital length of stay.

CONCLUSIONS

The results of this study indicate that enteral nutrition provided to hospitalised malnourished young people with anorexia nervosa using a lower carbohydrate/high fat formula (28% carbohydrate, 56% fat) seems to provide protection from hypophosphatemia in the first week compared to when using a standard enteral formula. Further research may be required to confirm this finding in other malnourished populations.

TRIAL REGISTRATION

ANZCTR, ACTRN12617000342314. Registered 3 March 2017, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000342314.

Prophylactic supplementation of phosphate, magnesium, and potassium for the prevention of refeeding syndrome in hospitalized individuals with anorexia nervosa

Medical stabilization, nutrition rehabilitation, and weight restoration, while minimizing risk for the potentially fatal complication of refeeding syndrome, are the primary goals for the treatment of hospitalized individuals with anorexia nervosa and other restrictive-type eating disorders. The purpose of this review was to examine the literature exploring the prophylactic supplementation of phosphate, magnesium, and potassium, in addition to routine thiamin and multivitamin supplementation, for the prevention of refeeding syndrome in adolescents and adults with anorexia nervosa. Through evaluation of outcomes (including serum electrolyte levels and clinical signs and symptoms such as respiratory failure, cardiac failure, peripheral edema, rhabdomyolysis, and encephalopathy), three studies found that prophylactic supplementation of potassium, magnesium, and/or phosphate were effective in preventing refeeding syndrome or refeeding hypophosphatemia (a characteristic of refeeding syndrome). Although all studies found that prophylactic supplementation was effective in preventing refeeding syndrome, refeeding approaches (including the method, amount, and duration of nutrient delivery) as well as the populations studied varied considerably, making it difficult to arrive at specific recommendations for practice. Randomized controlled trials are needed to further examine the safety and effectiveness of prophylactic supplementation of phosphate, magnesium, and potassium on the prevention of refeeding syndrome, utilizing similar feeding and supplementation protocols.

Serum profiling of anorexia nervosa: A 1H NMR-based metabolomics study

Our understanding of pathophysiological mechanisms underlying anorexia nervosa (AN) is incomplete. The aim was to conduct a metabolomics profiling of serum samples from women with AN (n = 65), women who have recovered from AN (AN-REC, n = 65), and age-matched healthy female controls (HC, n = 65). Serum concentrations of 21 metabolites were measured using proton nuclear magnetic resonance (¹H NMR). We used orthogonal partial least-squares discriminant analysis (OPLS-DA) modeling to assign group classification based on the metabolites. Analysis of variance (ANOVA) was used to test for metabolite concentration differences across groups. The OPLS-DA model could distinguish between the AN and HC groups (p = 9.05 × 10-11 R2Y = 0.36, Q2 = 0.37) and between the AN-REC and HC groups (p = 8.47 × 10-6, R2Y = 0.36, Q2 = 0.24,), but not between the AN and AN-REC groups (p = 0.63). Lower methanol concentration in the AN and AN-REC group explained most of the variance. Likewise, the strongest finding in the univariate analyses was lower serum methanol concentration in both AN and AN-REC compared with HC, which withstood adjustment for body mass index (BMI). We report for the first time lower serum concentrations of methanol in AN. The fact that low methanol was also found in recovered AN suggests that low serum concentration of methanol could either be trait marker or a scar effect of AN.

Anorexia nervosa: COVID-19 pandemic period (Review)

Anorexia nervosa is an eating disorder characterized by restrictive eating and an intense fear of gaining weight. It is a disease with an increasing incidence during the last few decades, and represents a complex psychiatric condition which includes secondary amenorrhea, nutritional and metabolic damage, and impaired endocrine panel up to bone loss as well as cardiac, gastrointestinal and hematological complications. This is a narrative review which includes an update on this eating disorder from the perspective of an endocrine panel of anomalies, especially of the skeleton, considering the pressure of the recent global COVID-19 pandemic changes. Practically affecting every organ, anorexia nervosa needs to be taken into consideration during the pandemic period because of the higher risk of relapse due to new living conditions, social distancing, self-isolation, changes in food access, more intense use of social media platforms, disruption of daily habits, and more difficult access to healthcare practitioners. The lack of physical activity in addition to vitamin D deficiency related to low sun exposure or to the use of facial masks may also be connected to further bone damage related to this disease.

A Systematic Review and Meta-Analysis Finds Increased Blood Levels of All Forms of Ghrelin in Both Restricting and Binge-Eating/Purging Subtypes of Anorexia Nervosa

Anorexia nervosa (AN) is a severe psychiatric condition associated with high mortality and chronicity. The hunt for state, trait, subtyping, and prognostic biomarkers is ongoing and the orexigenic hormone ghrelin and its different forms, acyl ghrelin and desacyl ghrelin, have been proposed to be increased in AN, especially in the restrictive subtype. A systematic literature search was performed using established databases up to 30 November 2020. Forty-nine studies met inclusion criteria for cross-sectional and longitudinal meta-analyses on total ghrelin, acyl ghrelin, and desacyl ghrelin. All forms of ghrelin were increased in the acute stage of anorexia nervosa during fasting compared to healthy controls. Previous notions on differences in ghrelin levels between AN subtypes were not supported by current data. In addition, a significant decrease in total ghrelin was observed pre-treatment to follow-up. However, total ghrelin levels at follow-up were still marginally elevated compared to healthy controls, whereas for acyl ghrelin, no overall effect of treatment was observed. Due to heterogeneity in follow-up designs and only few data on long-term recovered patients, longitudinal results should be interpreted with caution. While the first steps towards a biomarker in acute AN have been completed, the value of ghrelin as a potential indicator of treatment success or recovery status or its use in subtype differentiation are yet to be established.

Acute and life-threatening complications in patients with anorexia nervosa: A case report and literature study

Anorexia nervosa (AN) is characterized by a strong fear of weight gain and body image disorders and is classified as a mental illness that can cause direct damage to one's mental health and body. Many individuals with AN tend to commit suicide. Additionally, the disease can lead to chronic undernutrition and low body weight, adversely affecting each body system, exacerbating systemic medical complications, especially acute life-threatening complications. Therefore, AN has the highest mortality and disability rates among all mental diseases. There is a basic clinical need to identify and address the acute and critical complications of this disease as soon as possible. However, the current literature has a poor description of the acute and critical complications of AN and lacks a systematic review. We report a case of a patient with AN and severe hypokalemia, significant Q-T interval prolongation, stomach dilation, and intestinal obstruction who recovered after conservative treatment. The defecation method we used, to our knowledge, has not been previously reported in the literature. We also briefly review the various acute and life-threatening complications of AN.

Acute gastric dilatation in a patient with severe anorexia nervosa: a case report

Background

Acute gastric dilatation (AGD) leading to gastric necrosis and perforation has been reported to be a rare but fatal complication in young patients with eating disorders, particularly anorexia nervosa.

Case presentation

We report a case of a Canadian female patient presenting with mild abdominal pain, with a history of anorexia nervosa, the binge/purge subtype, who was found to have severe acute gastric dilatation on subsequent computed tomography imaging. Her clinical course was uncomplicated after gastric decompression. The cause of her AGD was thought to be secondary to dysmotility disorder caused by her anorexia nervosa.

Conclusion

Our case report demonstrates the importance of clinical identification of AGD and subsequent diagnosis and management. Because of the urgency to rule out obstruction or perforation through consultation or additional imaging modalities, recognition and correct diagnosis of this condition is necessary for appropriate patient management. In addition, our case report adds to an underreported but important complication of anorexia nervosa.

Evaluation of muscle-skeletal strength and peak expiratory flow in severely malnourished inpatients with anorexia nervosa: A pilot study

OBJECTIVES

Anorexia nervosa is a complex psychiatric disorder that can lead to specific somatic complications. Malnutrition is frequent and can involve a decrease of mobility, up to functional impotence, in individuals with extremely severe cases. The aim of this pilot study was to examine muscle strength and peak expiratory flow (PEF) in severely undernourished patients with anorexia nervosa at admission and after 5 wk of renutrition by tube feeding, and to find the clinical and biological correlates of muscle-strength impairment.

METHODS

A prospective observational study was conducted over 6 mo. Manual muscle testing, measures of PEF, and clinical and biologic assessments were performed at baseline and after 5 wk of renutrition.

RESULTS

Twenty-three extremely malnourished female participants (mean body mass index: 11.4 ± 1.3 kg/m²) were included. All participants had global impairment in muscle strength (manual muscle testing: 37.7 ± 7.7) and PEF (253.3 ± 60 mL/min) at admission. Muscle weakness was higher in axial than peripheral muscle groups (P < 0.01), with no significant difference between proximal and distal muscles (P > 0.05). Muscle strength at admission was significantly associated with severity of undernourishment (body mass index and albumin) and transaminitis (P < 0.05). At follow-up, musculoskeletal strength and PEF were significantly improved after partial weight recovery (P < 0.01).

CONCLUSIONS

Extremely undernourished people with anorexia nervosa present a decrease of PEF and musculoskeletal strength predominant on axial muscles. Both are associated with severity of malnutrition and liver damage. Partial recovery was observed after 5 wk of enteral nutrition.

Skeletal effects and refeeding syndrome in anorexia nervosa

Purpose Anorexia nervosa (AN) is a psychiatric disorder which can lead to numerous medical complications. In the clinical practice, during weight restoration, it is relatively common to observe potentially fatal complications, such as refeeding syndrome (RS). The objective of this case report is to highlight some key factors regarding nutritional support and the therapeutic approach in AN to avoid life-threatening complications, for example severe hypophosphatemia. Methods We present the case of a 14-year-old girl suffering from AN, who was admitted to our hospital with lethargy, emaciation with bitemporal wasting, hirsutism and pitting lower extremity edema. Results Based on the laboratory findings, the concerning condition of the patient was attributed to hypophosphatemia (1,64 mg/dl) caused by RS. Conclusions Refeeding syndrome is a potentially lethal condition in the case of AN patients. Hypophosphatemia, which is a result of the refeeding syndrome, is a relatively common complication of overly aggressive nutritional rehabilitation. Physicians who are involved in treating this condition, should be aware of this potentially life-threatening syndrome, and assess their therapeutic approach accordingly Keywords: anorexia nervosa, hypophosphatemia, refeeding syndrome, nutritional support,

Bladder and voiding dysfunction in adolescents with anorexia nervosa: a novel finding and potential causes

PURPOSE

This study aimed to investigate the bladder capacity (BC) and bladder dynamics of adolescents with anorexia nervosa (AN).

METHODS

The participants consisted of 15 adolescents newly diagnosed with AN according to the DSM 5 criteria and in the acute weight loss period who were questioned about the symptoms of lower urinary tract (LUT) dysfunction. Functional bladder capacity (FBC) and voided volume with uroflowmetry were measured for each subject; the larger volume of the two was chosen for the bladder capacity. Uroflowmetry was used to obtain uroflow curves for the participants whose patterns were labeled as pathologic if they were outside the bell-shape.

RESULTS

Fourteen (93.3%) of the patients exhibited at least one of the LUT dysfunction symptoms (pathologic voiding symptom/urinary incontinence/pathologic uroflow pattern). BC was observed to increase in 86.6% (n = 13) of the patients. Eighty% of the patients (n = 12) showed pathological uroflow patterns. In patients with pathological uroflow patterns, which showed insufficiency of bladder contraction, assistance of abdominal muscles was needed during voiding.

CONCLUSION

The novel findings presented in this study are the increase of BC in adolescents with AN, the presence of at least one type of voiding or bladder dysfunction, and the pathology of uroflow patterns of most patients show that the bladder dynamics is affected in AN. The most important contribution of this study to the literature is that impaired bladder dynamics was determined to be a medical complication of AN.

LEVEL OF EVIDENCE

Case-control analytic study, Level III.

Echocardiographic abnormalities in 124 severely malnourished adult anorexia nervosa patients: frequency and relationship with body composition and biological features

BACKGROUND

Anorexia Nervosa (AN) is a complex psychiatric disorder that can lead to specific somatic complications. Heart abnormalities are frequently reported, while their frequency and associated factors in severely malnourished AN patients remain poorly defined.

OBJECTIVES

This study aimed to characterize echocardiographic abnormalities in severely malnourished AN patients and to assess associated clinical, biological and related body composition features.

METHODS

Between January 2013 and January 2015, all severely malnourished adult patients with AN (Mental Disorders, 4th Edn.-DSM IVr) were included in a monocentric study performed in in a highly specialized AN inpatient unit. Electrocardiogram (ECG) and echocardiography were used to assess both heart rhythm and function. All inpatients underwent a Doppler echocardiography procedure after undergoing combined blood volume adjustment, micronutrients deficiencies supplementation and electrolyte disorders correction. Right Ventricular (RV) and Left Ventricular (LV) systolic and diastolic functions were collected and compared to 29 healthy normal subjects in a control group.

RESULTS

One hundred and 24 patients (119 (96%) women, 5 (4%) men) with a mean age of 30.1 ± 11 years old and an average Body Mass Index (BMI) of 12 kg/m² were included. Ninety patients (73%) had been diagnosed with AN Restrictive type (AN-R), 34 (27%) an AN Binge eating/Purging type (AN-BP). Eighteen patients (15%) disclosed an abnormal Left Ventricular Ejection Fraction (LVEF) (< 52% for male and < 54% for female). LVEF impairment was associated with AN-BP patients (p < 0.017) and hypertransaminasemia (AST and/or ALT ≥2 N) (p < 0.05). Left Ventricular mass (LV mass) and Left Ventricular End Diastolic Diameter (LVEDD) were significantly reduced in patients (p < 0.001, p < 0.001). Left and right ventricular tissue Doppler Imaging Velocities (TDI) peak were reduced in patients: Septal and Lateral LV Sm velocities peaks respectively 10 ± 2 cm/s (vs 14 ± 2 cm/s in controls, p < 0.001), 12 ± 3 cm/s (vs 16 ± 3 cm/s in controls, p < 0.001), basal RV Sm velocity peaks at 14 ± 3 cm/s (vs 19 ± 3 cm/s in controls, p < 0.001). Additionally, LV and RV diastolic velocity peaks were reduced: LV septal and lateral velocity peaks were respectively 13 ± 3 cm/s (vs 18 ± 2 cm/s p < 0.001), 12 ± 3 cm/s (vs 22 ± 4 cm/s, p < 0.001) and RV diastolic velocity peaks at 14 ± 3 cm/s (vs 21 ± 4 cm/s p < 0.001). LV diastolic velocity TDI peaks were significantly associated with hypertransaminasemia (p < 0.05) and tended to be associated with a low all body Fat-Free Mass Index (FFMI) (using Dual-energy X- ray Absorptiometry (DXA) (HOLOGICQDR 4500) (p = 0.056). Thirty-four patients (27%) had a pericardial effusion and were significantly associated with a decreased all body FFMI (p < 0.036).

CONCLUSION

Heart abnormalities are frequent in malnourished patients with AN, particularly in AN-BP type. Both liver enzymes and body composition abnormalities tended to be associated with heart dysfunction (non-significant association). Prospective studies are needed to better characterize and describe the evolution of cardiac abnormalities during the refeeding period and subsequent weight restoration.

Study protocol for a randomised controlled trial investigating two different refeeding formulations to improve safety and efficacy of hospital management of adolescent and young adults admitted with anorexia nervosa

INTRODUCTION

Providing effective nutritional rehabilitation to patients hospitalised with anorexia nervosa (AN) is challenging, partly due to conservative recommendations that advocate feeding patients at low energy intakes. An 'underfeeding syndrome' can develop when patients are not provided with adequate nutrition during treatment, whereby malnourished patients fail to restore weight in a timely matter, and even lose weight. Of particular concern, the reintroduction of carbohydrate in a starved patient can increase the risk of developing electrolyte, metabolic and organ dysfunction. The proposed trial assesses the efficacy and safety of a lower carbohydrate enteral formula (28% carbohydrate) against a standard enteral formula (54% carbohydrate), in adolescent and young adult patients (aged 15-25 years), hospitalised with AN.

METHODS AND ANALYSIS

The study employs a double-blind randomised controlled trial design. At admission to hospital, malnourished adolescent and young adults with AN will be randomly allocated to commence feeding on a standard enteral feeding formula (1.5 kcal/mL, 54% carbohydrate) or a lower carbohydrate isocaloric enteral feeding formula (1.5 kcal/mL, 28% carbohydrate). Assessments of nutritional intake, weight and biochemistry (phosphate, magnesium, potassium) will be conducted at baseline and during the first 3 weeks of hospital admission. The primary outcome measure will be incidence of hypophosphatemia. Secondary outcomes include weight gain, oedema, other electrolyte distortion, length of hospital admission, admission to the Intensive Care Unit (ICU) and number of days to reach medical stability, using defined parameters.

ETHICS AND DISSEMINATION

The protocol was approved by the Western Sydney Local Health District Human Research Ethics Committee and institutional research governance approvals were granted. Written informed consent will be sought prior to study enrolment. Study findings will be widely disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12617000342314); Pre-results.

Long-Term Outcomes from a 10-Year Follow-Up of Women Living with a Restrictive Eating Disorder: A Brief Report

BACKGROUND

This study aimed to evaluate several socio-demographic and long-term clinical outcomes in a cohort of women living with a restrictive eating disorder.

METHODS

Patients were asked to fill in a general data collection form aiming to investigate their current conditions and to attend the outpatient unit for a 10-year follow-up clinical and laboratory evaluation.

RESULTS

Forty-four patients completed the follow-up general data collection form and 20 agreed to attend the outpatient unit for the 10 year-follow-up evaluation. In total, 52% of patients were single, 55% had achieved a university degree, and 55% had steady employment. After 10 years, there was a clear improvement in biochemical markers, but cholesterol levels were still slightly high. The prevalence of osteopenia in the whole sample was 70% when measured on the lumbar column and 20% on the total body, while osteoporosis was found in 10% of patients and only on the lumbar column.

CONCLUSION

According to the collected data, women with a history of restrictive eating disorders appear to re-adapt well to social life by obtaining the level of their unaffected peers in terms of education and employment.

Excessive laboratory monitoring to prevent adolescent's refeeding syndrome: opportunities for enhancement

PURPOSE

Anorexia nervosa (AN) is a complex medical condition affecting mainly adolescents and young adults. To monitor and prevent refeeding syndrome, current guidelines recommend daily laboratory testing in the first week of hospitalization and 2-3 times/week for the following 3 weeks. The aims of this study were to determine the proportion of abnormal results of the blood tests done during the first week of nutritional rehabilitation in adolescents with AN, the proportion of test having led to supplementation and the cost of all these tests.

METHOD

A retrospective chart review of admissions for eating disorders between May 2014 and May 2015 in a tertiary Pediatric University Hospital center was performed. Patients were included if they were younger than 18 years, admitted for protocol-based refeeding and met criteria for AN (DSM 5).

RESULTS

Among the 99 hospitalizations included in the study, the mean age was 14.6 years (± 1.7), with a female predominance (97%). The mean admission BMI was 15.3 ± 2 kg/m² (Z-score - 2.6 ± 1.4). The mean length of hospitalization was 40.3 days ± 21.8. Of the 1289 laboratory tests performed, only 1.5% revealed abnormal values and 0.85% led to supplementation. No critical value was identified. The total cost for the tests performed was 148,926.80 CAD$, 1504$/admitted patient, instead of 3890$/admitted patient had we followed the recommendations.

CONCLUSION

More precise criteria should be developed regarding the frequency of laboratory tests needed to monitor and prevent refeeding syndrome. At present, the recommendations could lead to unnecessary testing and expenses.

LEVEL OF EVIDENCE

Level IV: Dramatic results in uncontrolled trials.

Assessment and management of anorexia nervosa during COVID-19

Management of the high rates of medical and psychiatric complications, including self-harm and suicide, associated with anorexia nervosa requires regular clinical review. However, during the current pandemic, face-to-face clinical assessments carry the risk of infection and transmission in this vulnerable cohort already compromised by low weight and lowered immunity. This paper describes how one service has had to adapt usual care during the COVID-19 pandemic without contributing excessively to carer burden or compromising patient safety.

A loss of consciousness in a teenage girl with anorexia nervosa, due to polydipsia: case report and a minireview

PURPOSE

Anorexia nervosa is a chronic disease which may result in various complications. In pediatric clinical practice, it is common to observe complications related to progressive cachexia caused by malnutrition; however, cases of severe complications, like electrolyte disorders, which represent a direct threat to life, due to polydipsia, are rarely observed. The purpose of this study is to highlight that excessive drinking is of primary importance in anorexia nervosa patients, as it can result in severe medical complications, including increased risk of death.

METHODS

We report the case of a 13-year-old girl with anorexia nervosa, who was referred to hospital with seizures, disorders of consciousness, and cardiorespiratory failure.

RESULTS

The unstable condition of the patient was attributed to hyponatremia (119 mmol/l), decreased serum osmolality (248 mmol/kg), and decreased urine osmolality (95 mmol/kg) caused by polydipsia (water intoxication) and persistent vomiting. The presented girl was drinking large amounts of water prior to a weigh-in to falsify her low body weight.

CONCLUSIONS

Polydipsia is a common problem reported by patients with eating disorders, but one which rarely leads to serious clinical complications, due to severe hyponatremia. This case underscores the importance of careful evaluation of fluid intake and the need for regular monitoring of serum electrolytes in patients with anorexia nervosa. All clinicians treating patients with such disease, as well as the parents of sick children, should be familiar with this life-threatening condition.

LEVEL IV

Evidence obtained from multiple time series with or without the intervention, such as case studies.

IS BODY FAT PERCENTAGE A GOOD PREDICTOR OF MENSTRUAL RECOVERY IN FEMALES WITH ANOREXIA NERVOSA AFTER WEIGHT RESTORATION? A SYSTEMATIC REVIEW AND EXPLORATORY AND SELECTIVE META-ANALYSIS

The resumption of menses (ROM) is an important outcome in anorexia nervosa treatment and is considered as a sign of recovery. Identification of relevant factors in its prediction is important in clinical practice. Therefore we aimed to conduct a systematic review and exploratory meta-analysis of the association between total body fat percentage (%BF) and ROM after weight restoration in adolescents and young adults with anorexia nervosa. The study was conducted by adhering to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data were collated using meta-analysis and a narrative approach. Of the 604 articles retrieved, only seven studies comprising a total of 366 adolescent and young adult females with anorexia nervosa met the inclusion criteria and were reviewed, and preliminary results revealed three main findings. Firstly, patients who resumed their menstrual cycle had a significantly higher mean %BF when compared to those who did not, an overall effect confirmed by the meta-analysis (SMD: 3.74, 95% CI: 2.26-5.22). Secondly, %BF was found to be an independent predictor of the ROM in this population and an increase of only one unit of %BF can increase the odds of menstruation by ≈15-20%. Thirdly, despite the paucity of data, a cut-off point of %BF≈21was suggested as the minimum needed for ROM. In conclusion, a higher %BF seems to be associated with the ROM in weight-restored adolescent and young adult females with anorexia nervosa. Its assessment is important in a clinical setting, especially after complete weight restoration. The PROSPERO Registry - A systematic review and meta-analysis of the factors associated with the resumption of the menstrual cycle in females with anorexia nervosa after weight restoration (CRD42019111841).

Micronutrients Deficiencies in 374 Severely Malnourished Anorexia Nervosa Inpatients

Introduction: Anorexia nervosa (AN) is a complex psychiatric disorder, which can lead to specific somatic complications. Undernutrition is a major diagnostic criteria of AN which can be associated with several micronutrients deficiencies. Objectives: This study aimed to determinate the prevalence of micronutrients deficiencies and to compare the differences between the two subtypes of AN (restricting type (AN-R) and binge-eating/purging type (AN-BP)). Methods: We report a large retrospective, monocentric study of patients hospitalized in a highly specialized nutrition unit between January 2011 and August 2017 for severe malnutrition treatment in the context of anorexia nervosa. Results: Three hundred and seventy-four patients (360 (96%) women, 14 (4%) men), age: 31.3 ± 12.9 years, Body Mass Index (BMI): 12.5 ± 1.7 kg/m² were included; 253 (68%) patients had AN-R subtype while, 121 (32%) had AN-BP. Zinc had the highest deficiency prevalence 64.3%, followed by vitamin D (54.2%), copper (37.1%), selenium (20.5%), vitamin B1 (15%), vitamin B12 (4.7%), and vitamin B9 (8.9%). Patients with AN-BP type had longer disease duration, were older, and had a lower left ventricular ejection fraction (LVEF) (p < 0.001, p = 0.029, p = 0.009), when compared with AN-R type, patients who instead, had significantly higher Alanine Aminotransferase (ALT) and Brain Natriuretic Peptide (BNP) levels (p < 0.001, p < 0.021). In the AN-BP subgroup, as compared to AN-R, lower selenium (p < 0.001) and vitamin B12 plasma concentration (p < 0.036) were observed, whereas lower copper plasma concentration was observed in patients with AN-R type (p < 0.022). No significant differences were observed for zinc, vitamin B9, vitamin D, and vitamin B1 concentrations between the two types of AN patients. Conclusion: Severely malnourished AN patients have many micronutrient deficiencies. Differences between AN subtypes are identified. Micronutrients status of AN patients should be monitored and supplemented to prevent deficiencies related complications and to improve nutritional status. Prospective studies are needed to explore the symptoms and consequences of each deficiency, which can aggravate the prognosis during recovery.

Relationship between polyunsaturated fatty acid and eating disorders: Systematic review and meta-analysis

OBJECTIVES

Eating disorders result in poor nutrition, poor physical conditions and even suicidality and mortality. Although polyunsaturated fatty acids (PUFAs) have attracted attention in the emerging field of nutritional psychiatry, their role in eating disorders remains unknown. This meta-analysis investigates the differences of PUFA levels between patients with eating disorders and healthy controls, and the potentially beneficial effects of PUFAs in such patients.

METHODS

We conducted a systematic literature search and meta-analysis under the random effects model.

RESULT

Eleven studies were included in the current meta-analysis. Compared with controls, 379 patients with eating disorders had significantly higher plasma levels of alpha-linolenic acid, eicosapentaenoic acid, stearidonic acid, osbond acid, palmitoleic acid, oleic acid, and total omega-3 fatty acids; and lower levels of total omega-6 fatty acids and omega-6/omega-3 ratio. Eating disorders were associated with significantly higher red blood cell membrane levels of palmitoleic acid and oleic acid and lower levels of adrenic acid, arachidonic acid, and total omega-6 fatty acids. In addition, PUFA supplements were associated with a benefit to body weight outcomes but not disease severity and mood symptoms in interventional trials.

DISCUSSION

This meta-analysis indicates abnormal levels of PUFAs in peripheral blood tissues in patients with eating disorders. The relationship between PUFAs and eating disorders should be interpreted cautiously considering the specific lipid metabolism under starvation state. To investigate the role of PUFAs on psychopathological and therapeutic effects in eating disorders, further larger clinical studies are warranted.

Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews

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.

Body image disturbances, fear and associations with the amygdala in anorexia nervosa

Background

Anorexia nervosa (AN) is a severe illness with a high mortality rate which mainly affects young women. Studies found a localized volume loss of the amygdala in patients with AN, a brain region responsible for affective responses. Patients with AN were found to have body image distortions, and suffer from the comorbid disorders depression, anxiety disorder, and obsession. Therefore, the purpose of this study was to analyze a possible connection between comorbidities, body image disturbances, and the volume of the amygdala in patients with AN.

Methods

In this study 21 females suffering from restrictive-type AN and 21 age-matched normal controls (NC) were tested. Demographic data as well as body image perceptions and comorbidities were assessed. Volumes of cortical structures were measured with a magnetic resonance (MR) scanner. Analyses of variance were conducted to analyze group differences, and correlations between the volume of the amygdala and comorbidities and body image perceptions were calculated.

Results

The results showed a significantly lower grey matter volume in the amygdala in AN patients compared to the NC. Persons with AN showed more body image disturbances and suffered more often from depression, and phobias than NC. The volume of the amygdala showed a non-significant mid-level association with phobia and with uncertainty concerning their body in AN patients.

Conclusion

The study indicates that phobic anxiety and body image in patients with AN could be related to the volume of the amygdala. The results contribute to a better understanding of the pathophysiology of the disease.

[Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich]

Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich Abstract. The serious physical mental and psychosocial morbidity due to anorexia nervosa is often perceived by sufferers as less serious than from their environment. Doctors and other healthcare professionals are therefore confronted with the difficulty that urgent medical treatment is considered as unnecessary or even threatening by those affected. Although patients with anorexia nervosa usually wish to improve their condition, they are usually only able to tolerate treatment aimed at normalizing eating behavior and gaining weight in response to high external pressure. In view of this situation, an interdisciplinary team with experience in these treatments is required to treat these patients. Close cooperation is necessary to ensure a supporting treatment framework.

Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States

OBJECTIVE

To examine psychiatric and somatic correlates of DSM-5 eating disorders (EDs)-anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED)-in a nationally representative sample of adults in the United States.

METHOD

A national sample of 36,309 adult participants in the national epidemiologic survey on alcohol and related conditions III (NESARC-III) completed structured diagnostic interviews (AUDADIS-5) to determine psychiatric disorders, including EDs, and reported 12-month diagnosis of chronic somatic conditions. Prevalence of lifetime psychiatric disorders and somatic conditions were calculated across the AN, BN, and BED groups and a fourth group without specific ED; multiple logistic regression models compared the likelihood of psychiatric/somatic conditions with each specific ED relative to the no-specific ED group.

RESULTS

All three EDs were associated significantly with lifetime mood disorders, anxiety disorders, alcohol and drug use disorders, and personality disorders. In all three EDs, major depressive disorder was the most prevalent, followed by alcohol use disorder. AN was associated significantly with fibromyalgia, cancer, anemia, and osteoporosis, and BED with diabetes, hypertension, high cholesterol, and triglycerides. BN was not associated significantly with any somatic conditions.

CONCLUSIONS

This study examined lifetime psychiatric and somatic correlates of DSM-5 AN, BN, and BED in a large representative sample of U.S. adults. Our findings on significant associations with other psychiatric disorders and with current chronic somatic conditions indicate the serious burdens of EDs. Our findings suggest important differences across specific EDs and indicate some similarities and differences to previous smaller studies based on earlier diagnostic criteria.

Altered host-gut microbes symbiosis in severely malnourished anorexia nervosa (AN) patients undergoing enteral nutrition: An explicative factor of functional intestinal disorders?

BACKGROUND

Functional intestinal disorders (FIDs) are frequently observed in patients with anorexia nervosa (AN). Relationship between FIDs and a potential gut microbiota dysbiosis has been poorly explored.

OBJECTIVE

We aimed to determine an association between FIDs severity and dysbiosis of the intestinal microbiota in a severely malnourished patient population with AN undergoing enteral nutrition.

DESIGN

Faecal microbiota of AN (DSM IVr criteria) female inpatients were collected and compared to healthy controls based on 16S rRNA profiling. The severity of FIDs was evaluated in patients and healthy controls using Francis Score.

RESULTS

Thirty-three patients (BMI: 11,7 ± 1,5; Age: 32 ± 12) and 22 healthy controls (BMI: 21 ± 2; age: 36 ± 12) were included. A marked dysbiosis was identified in AN patients compared to healthy controls (p = 0.03). Some potentially pathogenic bacterial genera (Klebsiella, Salmonella) were more abundant in AN patients whereas, other bacterial symbionts (Eubacterium and Roseburia) involved in immune balance were significantly less abundant in patients than controls. Severity of FIDs was strongly correlated with several microbial genera (r = -0.581 for an unknown genus belonging to Peptostreptococcaceae family; r = 0.392 for Dialister, r = 0.444 for Robinsoniella and r = 0.488 for Enterococcus). Other associations between dysbiosis, clinical and biological characteristics were identified including severity of undernutrition (BMI).

CONCLUSION

Observed gut microbiota dysbiosis in malnourished patients with anorexia nervosa is correlated with the severity of FIDs and other metabolic disturbances, which strongly suggests an altered host-microbe symbiosis.

Role of antidepressants in the treatment of adults with anorexia nervosa

Introduction:

Anorexia nervosa (AN) is a severe psychiatric disorder that is difficult to treat and is associated with frequent relapses and high mortality rates. Psychiatric symptomatology (eg, depression, anxiety, obsessive-compulsive disorder/behaviors) are common comorbidities. This review provides current information about safety and efficacy of antidepressant therapy for management of AN in adults.

Methods:

A literature review of randomized controlled trials, open-label studies, and case reports with adults or adults/adolescents was conducted. PubMed and Medline were searched using anorexia management and treatment, antidepressants, selective serotonin reuptake inhibitors (SSRIs), fluoxetine, sertraline, citalopram, and mirtazapine in AN, relapse prevention in AN, and psychotropic medications in AN.

Results:

The role and utility of antidepressants in AN were published in double-blind, placebo-controlled studies; open-label trials; and a retrospective study. Antidepressants should not be used as sole therapy for AN although their use for confounding symptomatology makes discerning efficacy difficult as they are given together with other therapies. Neurobiological changes due to starvation and AN itself complicate results interpretation. For safety, tricyclic antidepressants and monoamine oxidase inhibitors are not recommended, and bupropion is contraindicated. Use of SSRIs during acute treatment lacks efficacy. Use of SSRIs—primarily fluoxetine and to some extent citalopram, sertraline, or mirtazapine—may aid in relapse prevention and improvement of psychiatric symptomatology in weight-restored anorexic patients.

Discussion:

Health care professionals should use clinical judgment regarding fluoxetine or possibly citalopram, sertraline or mirtazapine as adjunctive treatment to psychotherapy for relapse prevention, improvement of depressive and anxiety symptoms, and/or obsessive-compulsive behaviors unresolved with nutritional rehabilitation and psychotherapy.

Impact of somatic severity on long-term mortality in anorexia nervosa

PURPOSE

Anorexia nervosa (AN) is a severe pathology on account of the high levels of associated morbidity and mortality. This study aimed to assess whether time in somatic intensive care unit, justified by a patient's somatic condition in the course of hospital care, has any relationship with patient outcome in terms of mortality in the long term.

METHODS

195 patients were hospitalised for AN between April 1996 and May 2002, 97 were re-assessed 9 years later on average.

RESULTS

Out of 195 patients hospitalised for AN between April 1996 and May 2002, 29 had required transfer to intensive care. Mortality at 9 years was 20 times higher in the group having been transferred to intensive care, irrespective of the duration of follow-up.

CONCLUSION

The clinical seriousness of the somatic condition during hospitalisation for AN is a risk factor for excess mortality in the medium term.

Description of an intensive nutrition therapy in hospitalized adolescents with anorexia nervosa

OBJECTIVE

To describe an intensive nutrition therapy for hospitalized adolescents and young adults with anorexia nervosa (AN) in terms of body weight, body composition, energy balance and food related anxiety.

METHOD

Twenty-six young females, 16-24years of age, with AN were invited to participate at admission to a specialized eating disorder unit in Göteborg, Sweden. Intensive nutrition therapy comprised 12weeks on a structured meal plan. Six meals were served daily, in combination with high-energy liquid nutritional supplements from start. Energy and nutrient intakes, energy expenditure, body composition and food related anxiety were measured during the study. A 3-month follow-up of body weight and food related anxiety was conducted.

RESULTS

Twenty-one patients participated. The total daily energy intake was, during the first week of treatment, (mean±SD) 3264±196kcal (74kcal/kg), and decreased gradually during treatment to 2622±331kcal (49kcal/kg). Total daily energy expenditure was initially 1568±149kcal and increased gradually to 2034±194kcal. Patients gained on average 9.8±2.1kg and body mass index increased from 15.5±0.9 to 19.0±0.9kg/m(2). Body fat increased from 13±6% to 26±6%. Fat free mass remained unchanged, but skeletal muscle mass increased from 16.7±2.0 to 17.6±2.4kg, p=0.009. Patients' food related anxiety decreased significantly during treatment and was still unchanged 3months later.

CONCLUSION

The presented intensive nutrition therapy with initially high energy and nutrient intakes produced substantial weight gain, increased fat and muscle mass and decreased food related anxiety in AN patients, without any clinical side effects.