A review of endocrine changes in anorexia nervosa

Adaptive Effects of Endocrine Hormones on Metabolism of Macronutrients during Fasting and Starvation: A Scoping Review

Food deprivation can occur for different reasons. Fasting (<24 h duration) occurs to meet religious or well-being goals. Starvation (>1-day duration) occurs when there is intentional (hunger strike or treatment of a medical condition) or unintentional (anorexia nervosa, drought, epidemic famine, war, or natural disaster) food deprivation. A scoping review was undertaken using the PubMed database to explore 1805 abstracts and review 88 eligible full-text articles to explore the adaptive relationships that emerge between cortisol, insulin, glucagon, and thyroid hormones on the metabolic pathways of macronutrients in humans during fasting and starvation. The collected data indicate that fasting and starvation prime the human body to increase cortisol levels and decrease the insulin/glucagon ratio and triiodothyronine (T3) levels. During fasting, increased levels of cortisol and a decreased insulin/glucagon ratio enhance glycogenolysis and reduce the peripheral uptake of glucose and glycogenesis, whereas decreased T3 levels potentially reduce glycogenolysis. During starvation, increased levels of cortisol and a decreased insulin/glucagon ratio enhance lipolysis, proteolysis, fatty acid and amino acid oxidation, ketogenesis, and ureagenesis, and decreased T3 levels reduce thermogenesis. We present a potential crosstalk between T3 and the above hormones, including between T3 and leptin, to extend their adaptive roles in the metabolism of endogenous macronutrients during food deprivation.

Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients With Severe Anorexia Nervosa

INTRODUCTION

Depression and anxiety are well-known comorbid conditions in patients with anorexia nervosa (AN). Hypercortisolemia in patients with AN may be pathogenic and contribute to depression and anxiety symptomatology.

OBJECTIVE

The aim of this study was to investigate short-term changes in cortisol levels and depression and anxiety symptomatology following intensive re-nutrition in patients with severe AN and hospitalized in a specialized unit. Furthermore, we investigated the potential association between cortisol levels and psychometric parameters.

METHODS

A total of 36 patients with AN were enrolled in the study. Nine dropped out before follow-up. Patients underwent paraclinical and psychometric examinations at admission and discharge. Measurements included plasma cortisol, cortisol binding globulin (CBG), 24-h urine cortisol, and self-report questionnaires regarding eating disorder, depression, anxiety, and stress symptoms. Patients were hospitalized in the unit for somatic stabilization and intensive re-nutrition. Mean admission length was 41 days. The study was registered at ClinicalTrials.gov (NCT02502617).

RESULTS

Cortisol levels in blood and urine did not change from admission to discharge in patients with severe AN. Symptoms of depression, anxiety, stress, and eating disorder remained elevated at discharge. There were no associations between changes in cortisol levels and changes in psychometrics.

DISCUSSION

Our results suggest that short-term intensive re-nutrition did not alter hypothalamic-pituitary-adrenal axis activity or mental health in patients with severe AN. Long-term stabilization and longer follow-up after hospital discharge may be needed to detect changes in cortisol levels and whether these changes are associated with depression and anxiety symptomatology. Greater knowledge about cortisol levels and mental health in patients with severe AN may help in the development of new treatment choices for the chronically ill patients. Future studies could investigate whether cortisol-lowering drugs have a therapeutic effect on mental health in AN.

Bone mineral density and oxidative stress in adolescent girls with anorexia nervosa

Oxidative stress appears to be involved in the pathogenesis of osteoporosis-a serious complication of anorexia nervosa (AN). We evaluated the oxidative status in adolescent girls with AN and its potential relationship with bone mineral density (BMD). Girls with AN (n = 43) and age-matched healthy controls (n = 20) underwent anthropometric and BMD examination. Markers of bone turnover, oxidative stress, and antioxidant status were measured. Participants with AN and controls did not differ in BMD at the lumbar spine (p = 0.17) and total body less head BMD (p = 0.08). BMD at the total hip was lower (p < 0.001) in the AN group compared with the controls. Levels of antioxidant status markers-ferric reduction antioxidant power, total antioxidant capacity, and reduced and oxidized glutathione ratio (all p < 0.001)-were significantly lower, whereas those of advanced oxidation protein products (AOPP), fructosamines, and advanced glycation end products (AGEs) (all p < 0.001) were higher in AN patients than in healthy controls. BMD and bone turnover markers were positively correlated with antioxidant status markers, while they were negatively correlated with AOPP, fructosamines, and AGEs levels.  Conclusion: This is the first study to assess a potential association between oxidative status and BMD in adolescents with AN. We demonstrated that in young girls, the imbalance of oxidative status and reduced BMD are concurrently manifested at the time of the diagnosis of AN. Disturbance of oxidative status could play a pathogenetic role in AN-associated decreased BMD. What is Known: • Osteoporosis is a serious complication of AN, and in affected adolescents may result in a permanent deficit in bone mass. • Oxidative and carbonyl stress may be involved in the development of bone loss. What is New: • Adolescents girls with AN have impaired antioxidant defense and increased oxidative damage to biomolecules. • Disturbance of oxidative status could affect bone loss and could contribute to decreased BMD in adolescent females with AN.

Brain Volume Loss, Astrocyte Reduction, and Inflammation in Anorexia Nervosa

Anorexia nervosa is the third most common chronic disease in adolescence and is characterized by low body weight, body image distortion, weight phobia, and severe somatic consequences. Among the latter, marked brain volume reduction has been linked to astrocyte cell count reduction of about 50% in gray and white matter, while neuronal and other glial cell counts remain normal. Exact underlying mechanisms remain elusive; however, first results point to important roles of the catabolic state and the very low gonadal steroid hormones in these patients. They also appear to involve inflammatory states of "hungry astrocytes" and interactions with the gut microbiota. Functional impairments could affect the role of astrocytes in supporting neurons metabolically, neurotransmitter reuptake, and synapse formation, among others. These could be implicated in reduced learning, mood alterations, and sleep disturbances often seen in patients with AN and help explain their rigidity and difficulties in relearning processes in psychotherapy during starvation.

Eating disorders and the risk of developing cancer: a systematic review

PURPOSE

Evidence concerning eating disorders as risk toward developing cancer is sparse. Energy restriction might be cancer protective, while malnutrition, vomiting, laxative and substance use might stimulate cancer development. We examined whether individuals with an eating disorder (not restricted to anorexia nervosa) had a different risk of developing cancer.

METHODS

A systematic search on Medline and Embase until 28th April 2020 identified relevant human original research publications, including all populations and all cancer types.

RESULTS

From 990 records, 6 case reports and 9 cohorts were included. Some cohorts found a decreased breast (3/5 studies) or cervical (1/2) cancer risk, while an increased esophageal (2/3), liver (1/1), brain (1/1 in men) and respiratory (2/4) cancer risk, but other cancer risks were non-significant, and an increased mortality overall (1/2), from breast (1/1), female genital (1/1) and skin (1/1) cancer in eating disorder patients. The case reports further described esophageal cancer and leukemia. No clear statistical differences in cancer risk were found depending on eating disorder type, perhaps due to the small sample size (n = 1783 for other than anorexia nervosa).

CONCLUSIONS

The literature on eating disorders and cancer risk is sparse with many gaps. Hormonal changes, sexual activity, nutritional status, vomiting and concomitant tobacco/alcohol abuse may explain increased/decreased cancer risk. Future large studies (now 1-366 cancer cases) that also include men (now 4.7%), bulimia nervosa (now 3.8%) and several cancer sites (now mainly breast cancer) are needed and should foresee longer follow-up time (now 5.4-15.2 years) and extensive confounder adjustment (now only age and sex).

LEVEL OF EVIDENCE

Level I, systematic review.

Clinical Trials Required to Assess Potential Benefits and Side Effects of Treatment of Patients With Anorexia Nervosa With Recombinant Human Leptin

The core phenotype of anorexia nervosa (AN) comprises the age and stage dependent intertwining of both its primary and secondary (i.e., starvation induced) somatic and mental symptoms. Hypoleptinemia acts as a key trigger for the adaptation to starvation by affecting diverse brain regions including the reward system and by induction of alterations of the hypothalamus-pituitary-“target-organ” axes, e.g., resulting in amenorrhea as a characteristic symptom of AN. Particularly, the rat model activity-based anorexia (ABA) convincingly demonstrates the pivotal role of hypoleptinemia in the development of starvation-induced hyperactivity. STAT3 signaling in dopaminergic neurons in the ventral tegmental area (VTA) plays a crucial role in the transmission of the leptin signal in ABA. In patients with AN, an inverted U-shaped relationship has been observed between their serum leptin levels and physical activity. Albeit obese and therewith of a very different phenotype, humans diagnosed with rare congenital leptin deficiency have starvation like symptoms including hypothalamic amenorrhea in females. Over the past 20 years, such patients have been successfully treated with recombinant human (rh) leptin (metreleptin) within a compassionate use program. The extreme hunger of these patients subsides within hours upon initiation of treatment; substantial weight loss and menarche in females ensue after medium term treatment. In contrast, metreleptin had little effect in patients with multifactorial obesity. Small clinical trials have been conducted for hypothalamic amenorrhea and to increase bone mineral density, in which metreleptin proved beneficial. Up to now, metreleptin has not yet been used to treat patients with AN. Metreleptin has been approved by the FDA under strict regulations solely for the treatment of generalized lipodystrophy. The recent approval by the EMA may offer, for the first time, the possibility to treat extremely hyperactive patients with AN off-label. Furthermore, a potential dissection of hypoleptinemia-induced AN symptoms from the primary cognitions and behaviors of these patients could ensue. Accordingly, the aim of this article is to review the current state of the art of leptin in relation to AN to provide the theoretical basis for the initiation of clinical trials for treatment of this eating disorder.

Predicting Menstrual Recovery in Adolescents With Anorexia Nervosa Using Body Fat Percent Estimated by Bioimpedance Analysis

OBJECTIVE

To identify the threshold of total body fat percentage (TBF%) required for the resumption of menses (ROM) in hospitalized female adolescents with anorexia nervosa (AN) using bioimpedance analysis (BIA).

METHODS

All female adolescents hospitalized with AN in our medical center were evaluated in a longitudinal prospective study during the years of 2012-2017. Anthropometric data, body fat measured by BIA, and hormonal determinants were collected periodically, in addition to routine medical and gynecological assessments.

RESULTS

Sixty-two participants presented with secondary amenorrhea, of which 20 remained with amenorrhea and 42 had ROM during hospitalization. At discharge, participants with ROM regained significantly more weight, and had higher mean body mass index (BMI), BMI standard deviation scores, and TBF% than those who remained with amenorrhea. Receiver operating characteristic analysis identified that a TBF% of 21.2% had the highest discriminative ability for ROM (sensitivity = 88%, specificity = 85%, positive predictive value = 93%). Compared with the anthropometric parameters, TBF% had the highest area under curve (AUC = .895), which significantly differed from that of BMI standard deviation scores (AUC = .643, p = .007) and body weight (AUC = .678, p = .03).

CONCLUSIONS

BIA is a safe and relatively simple method to assess the TBF% required for the return of balanced menstrual cycles in female adolescents with AN. The TBF% with the highest discriminative ability for menstrual resumption as assessed by BIA is 21.2%.

Stress, female reproduction and pregnancy

Stress is one of the commonest and underappreciated causes of reproductive frailty in women. The stress system leads to adaptive responses via mobilization of hormonal systems. Adaptability and resistance to stress are fundamental to life. The response to stressors depends on the type of stressor, the timing and duration of stress, the genetic predisposition, personality characteristics, and the way of coping with stress. The hypothalamic-pituitary-adrenal (HPA) axis has a direct inhibitory action on the hypothalamic-pituitary-ovarian (HPO) axis at multiple levels. Acute and chronic stress impairs reproduction, eventually acting on varying mechanisms. Undernutrition, over-training, and psychological stress contribute to hypothalamic amenorrhea via reduced HPO activity. In utero stress exposure is a significant predictor of subsequent adult telomere length. Some of the metabolic consequences of intrauterine growth restriction can be mitigated by ensuring early appropriate catch-up growth, while avoiding excessive weight gain if relative hypercortisolism is not installed. The effect of maternal stress on fetuses regarding fetal HPA axis responsiveness (increased or decreased) remains under investigation. Maternal stress and depression are associated with structural and functional changes of brain parts such as hippocampus. In utero stress modifies epigenetically components of the HPA axis which can be transmitted transgenerationally.

MECHANISMS IN ENDOCRINOLOGY: Anorexia nervosa and endocrinology: a clinical update

Anorexia nervosa is a syndrome, that is collections of symptoms, which is not defined by its etiology. The severe cases are intractable. The syndrome is associated with multiple, profound endocrine alterations which may be adaptive, reactive or etiologic. Adaptive changes potentially may be inappropriate in clinical settings such as inpatient intensive re-nutrition or in a setting with somatic comorbidity. Electrolyte levels must be closely monitored during the refeeding process, and the need for weight gain must be balanced against potentially fatal refeeding complications. An important focus of clinical research should be to identify biomarkers associated with different stages of weight loss and re-nutrition combined with psychometric data. Besides well-established peripheral endocrine actions, several hormones also are released directly to different brain areas, where they may exert behavioral and psychogenic actions that could offer therapeutic targets. We need reliable biomarkers for predicting outcome and to ensure safe re-nutrition, however, first of all we need them to explore the metabolism in anorexia nervosa to open new avenues with therapeutic targets. A breakthrough in our understanding and treatment of this whimsical disease remains. Considering this, the aim of the present review is to provide an updated overview of the many endocrine changes in a clinical perspective.

Body composition and menstrual status in adults with a history of anorexia nervosa-at what fat percentage is the menstrual cycle restored?

OBJECTIVE

To study the association between body composition measures and menstrual status in a large sample of adult patients with a history of anorexia nervosa and to calculate the predicted probability of resumption of menstrual function. Furthermore, to establish whether fat percentage is superior to body mass index in predicting the resumption of menses.

METHOD

One hundred and thirteen adult women with a history of anorexia nervosa underwent a dual energy X-ray absorptiometry (DXA) scan and completed questionnaires regarding medication prescription and menstrual function.

RESULTS

Fifty percent of patients were expected to resume their menstrual function at a body mass index of 19 kg m^-2 or a fat percentage of 23%. Twenty-five percent of patients were expected to resume their menstrual function at body mass index 14 kg m^-2 or fat percentage 11%. Fat percentage and body mass index were equally capable of predicting the resumption of menses.

DISCUSSION

Fat percentage and body mass index were positive predictors of the resumption of menses, however, body composition measured by dual energy X-ray absorptiometry was not superior to body mass index in predicting menstrual recovery, which is of great clinical relevance as body mass index is easier and cheaper to obtain. Body composition measures only account for one of numerous factors involved in the resumption of menses. Regression models based on our data had a R² value of 0.14, indicating that only 14% of the variation in menstrual recovery could be explained by the variables included. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:370-377).

The physiology of functional hypothalamic amenorrhea associated with energy deficiency in exercising women and in women with anorexia nervosa

An energy deficiency is the result of inadequate energy intake relative to high energy expenditure. Often observed with the development of an energy deficiency is a high drive for thinness, dietary restraint, and weight and shape concerns in association with eating behaviors. At a basic physiologic level, a chronic energy deficiency promotes compensatory mechanisms to conserve fuel for vital physiologic function. Alterations have been documented in resting energy expenditure (REE) and metabolic hormones. Observed metabolic alterations include nutritionally acquired growth hormone resistance and reduced insulin-like growth factor-1 (IGF-1) concentrations; hypercortisolemia; increased ghrelin, peptide YY, and adiponectin; and decreased leptin, triiodothyronine, and kisspeptin. The cumulative effect of the energetic and metabolic alterations is a suppression of the hypothalamic-pituitary-ovarian axis. Gonadotropin releasing hormone secretion is decreased with consequent suppression of luteinizing hormone and follicle stimulating hormone release. Alterations in hypothalamic-pituitary secretion alters the production of estrogen and progesterone resulting in subclinical or clinical menstrual dysfunction.

Salivary and serum insulin-like growth factor (IGF-1) assays in anorexic patients

OBJECTIVES

The purpose of this study was to measure the salivary and serum free IGF-1 concentration of patients with anorexia nervosa (AN) in comparison to an average population.

METHODS

A controlled clinical trial was designed for an age- and gender-matched group of 121 AN patients and 77 healthy individuals. A clinical examination was made and blood and salivary samples were taken during the acute stage of AN (BMI < 15 kg/m²) in the first week of hospitalization. An enzyme immunoassay (ELISA) suitable for measuring free IGF-1 was used.

RESULTS

Anorexic patients had significant reductions in salivary unstimulated flow rate (UFR), pH and free IGF-1 levels in their saliva and serum. Significant correlations between serum IGF-1 and BMI; salivary IGF-1 and UFR and pH were detected.

CONCLUSIONS

Salivary and serum IGF-1 analyses appear to be a reliable biochemical indicator of malnutrition in AN patients. Measurement of salivary IGF-1 levels would allow new perspectives in monitoring AN in its early stages.

Gastrointestinal Manifestations of Eating Disorders

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

The assessment of the impact of anorexia nervosa on the vocal apparatus in adolescent girls - A preliminary report

BACKGROUND

Chronic undernourishment in the course of anorexia nervosa leads to various metabolic and hormonal changes, which translates to the impaired functioning of the majority of systems and internal organs. The impact of eating disorders on the condition of the vocal apparatus has been described in the literature; nevertheless, it concerns mainly bulimia nervosa.

OBJECTIVES

assessment of the vocal apparatus in adolescent girls diagnosed with anorexia nervosa from the point of view of possible influence on the function and structure of the larynx, low body mass accompanying anorexia, as well as energy deficiency, hormonal and emotional disturbances.

MATERIALS AND METHODS

The research included 41 girls aged 12-19 years, diagnosed with anorexia, who were assessed for the condition of the vocal apparatus, using the perceptual assessment of voice according to GRBAS scale, videolarynostroboscopy, acoustic assessment, and voice self-assessment in Jacobson's VHI scale (voice handicap index).

RESULTS

The perceptual assessment of voice using the GRBAS scale revealed that changes in voice were mainly weak, asthenic in nature (70.73%) and there was also the feature of puffing perceived in voice (41.46%). In voice self-assessment with the use of VHI, most subjects seemed to point to changes of voice self-perception in emotional subscale (68%). Videolaryngostroboscopy revealed some features of functional disturbances of voice in more than half of subjects, mainly in the form of hyperfunctional dysphonia (31.78%). The maximal phonation time was significantly shorter, in proportion to duration of the primary disease. In the acoustic analysis, the decrease in the basic frequency F0 and narrowing of the voice scale were observed. 55% of older, post-adolescent patients presented with the structure of the larynx that was inappropriate for their age.

CONCLUSIONS

These results might indicate that anorexia nervosa could have led to the structural and functional changes in the vocal apparatus. Such disturbances may be explained by the hormonal dysfunctions as well as starvation. Hormonal substitution at the appropriate time might be beneficial for the structure and phonation function of the larynx in girls with AN.

Prawn Shell Chitosan Exhibits Anti-Obesogenic Potential through Alterations to Appetite, Affecting Feeding Behaviour and Satiety Signals In Vivo

The crustacean shells-derived polysaccharide chitosan has received much attention for its anti-obesity potential. Dietary supplementation of chitosan has been linked with reductions in feed intake, suggesting a potential link between chitosan and appetite control. Hence the objective of this experiment was to investigate the appetite suppressing potential of prawn shell derived chitosan in a pig model. Pigs (70 ± 0.90 kg, 125 days of age, SD 2.0) were fed either T1) basal diet or T2) basal diet plus 1000 ppm chitosan (n = 20 gilts per group) for 63 days. The parameter categories which were assessed included performance, feeding behaviour, serum leptin concentrations and expression of genes influencing feeding behaviour in the small intestine, hypothalamus and adipose tissue. Pigs offered chitosan visited the feeder less times per day (P<0.001), had lower intake per visit (P<0.001), spent less time eating per day (P<0.001), had a lower eating rate (P<0.01) and had reduced feed intake and final body weight (P< 0.001) compared to animals offered the basal diet. There was a treatment (P<0.05) and time effect (P<0.05) on serum leptin concentrations in animals offered the chitosan diet compared to animals offered the basal diet. Pigs receiving dietary chitosan had an up-regulation in gene expression of growth hormone receptor (P<0.05), Peroxisome proliferator activated receptor gamma (P<0.01), neuromedin B (P<0.05), neuropeptide Y receptor 5 (P<0.05) in hypothalamic nuclei and neuropeptide Y (P<0.05) in the jejunum. Animals consuming chitosan had increased leptin expression in adipose tissue compared to pigs offered the basal diet (P<0.05). In conclusion, these data support the hypothesis that dietary prawn shell chitosan exhibits anti-obesogenic potential through alterations to appetite, and feeding behaviour affecting satiety signals in vivo.

Uninephrectomy in Rats on a Fixed Food Intake Potentiates Both Anorexia and Circulating Cytokine Subsets in Response to LPS

Recent human studies have suggested that mild reduction in kidney function can alter immune response and increase susceptibility to infection. The role of mild reduction in kidney function in altering susceptibility to bacterial lipopolysaccharide (LPS) responses was investigated in uninephrectomized rats compared to Sham-operated controls rats 4 weeks after surgery. Throughout the 4 weeks, all rats were maintained under mild food restriction at 90% of ad libitum intake to ensure the same caloric intake in both groups. In comparison to Sham, uninephrectomy (UniNX) potentiated LPS-induced anorexia by 2.1-fold. The circulating anorexigenic cytokines granulocyte-macrophage colony stimulating factor, interferon-γ, tumor necrosis factor-α, and complement-derived acylation-stimulating protein were elevated after LPS in UniNX animals compared to Sham animals. Interleukin(IL)1β and IL6 pro-inflammatory cytokines were transiently increased. Anti-inflammatory cytokines IL4 and IL10 did not differ or had a tendency to be lower in UniNX group compared to Sham animals. LPS-induced anorexia was associated with increased anorexigenic neuropeptides mRNA for pro-opiomelanocortin, corticotrophin-releasing factor, and cocaine–amphetamine-regulated transcript in the hypothalamus of both Sham and UniNX groups, but at higher levels in the UniNX group. Melanocortin-4-receptor mRNA was markedly increased in the UniNX group, which may have contributed to the enhanced anorexic response to LPS of the UniNX group. In summary, UniNX potentiates pro-inflammatory cytokine production, anorexia, and selected hypothalamic anorexigenic neuropeptides in response to LPS.

Gastrointestinal symptoms and disorders in patients with eating disorders

The two most clinically serious eating disorders are anorexia nervosa and bulimia nervosa. A drive for thinness and fear of fatness lead patients with anorexia nervosa either to restrict their food intake or binge-eat then purge (through self-induced vomiting and/or laxative abuse) to reduce their body weight to much less than the normal range. A drive for thinness leads patients with bulimia nervosa to binge-eat then purge but fail to reduce their body weight. Patients with eating disorders present with various gastrointestinal disturbances such as postprandial fullness, abdominal distention, abdominal pain, gastric distension, and early satiety, with altered esophageal motility sometimes seen in patients with anorexia nervosa. Other common conditions noted in patients with eating disorders are postprandial distress syndrome, superior mesenteric artery syndrome, irritable bowel syndrome, and functional constipation. Binge eating may cause acute gastric dilatation and gastric perforation, while self-induced vomiting can lead to dental caries, salivary gland enlargement, gastroesophageal reflux disease, and electrolyte imbalance. Laxative abuse can cause dehydration and electrolyte imbalance. Vomiting and/or laxative abuse can cause hypokalemia, which carries a risk of fatal arrhythmia. Careful assessment and intensive treatment of patients with eating disorders is needed because gastrointestinal symptoms/disorders can progress to a critical condition.

Menstrual cycle recovery in patients with anorexia nervosa: the importance of insulin-like growth factor 1

BACKGROUND

Follow-up visits of patients recovering from anorexia nervosa (AN) have shown that some patients do not resume menstrual cycles despite returning to the normal weight for their age and height.

AIM

To verify whether leptin, insulin-like growth factor 1 (IGF-1) or another hormonal marker could be a good predictor of the return of menses.

PATIENTS AND METHODS

This prospective study included female adolescents diagnosed with AN or eating disorders not otherwise specified (EDNOS) and who were being treated in an ambulatory care unit during nutritional recovery. Body mass index and leptin, luteinizing hormone, estradiol and IGF-1 levels of these patients were evaluated. Blood samples were collected in the 1st (T1), 5th (T2), 10th (T3), 15th (T4) and 20th (T5) weeks of treatment. The hormone levels during nutritional recovery and at the time of the resumption of menses were analyzed.

RESULTS

The hormonal profiles improved after nutritional recovery, with IGF-1 correlating the most with the resumption of menses and nutritional recovery (p = 0.0001). At the resumption of menstruation, the patients showed IGF-1 levels >342.8 ng/ml.

CONCLUSION

IGF-1 was the best predictor of the return of menses in female adolescents with AN or EDNOS.

An investigation of the factor structure of the beck depression inventory-II in anorexia nervosa

Symptoms of depression frequently co-occur with eating disorders and have been associated with negative outcomes. Self-report measures such as the Beck Depression Inventory-II (BDI-II) are commonly used to assess for the presence of depressive symptoms in eating disorders, but the instrument's factor structure in this population has not been examined. The purposes of this study were to explore the factor structure of the BDI-II in a sample of individuals (N = 437) with anorexia nervosa undergoing inpatient treatment and to examine changes in depressive symptoms on each of the identified factors following a course of treatment for anorexia nervosa in order to provide evidence supporting the construct validity of the measure. Exploratory factor analysis revealed that a three-factor model reflected the best fit for the data. Confirmatory factor analysis was used to validate this model against competing models and the three-factor model exhibited strong model fit characteristics. BDI-II scores were significantly reduced on all three factors following inpatient treatment, which supported the construct validity of the scale. The BDI-II appears to be reliable in this population, and the factor structure identified through this analysis may offer predictive utility for identifying individuals who may have more difficulty achieving weight restoration in the context of inpatient treatment. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

Impact of speed and magnitude of weight loss on the development of brain trophic changes in adolescents with anorexia nervosa: a case control study

BACKGROUND

Anorexia nervosa commonly arises during adolescence and is associated with more than one medical morbidity. Abnormalities in brain structure (defined as "pseudoatrophy") are common in adolescents with anorexia nervosa; however, their correlations with endocrinological profiles and clinical parameters are still unclear. In particular, no study has described the impact of BMI (body mass index) variations (speed and magnitude of weight loss) on cerebral trophism changes.

METHODS

Eleven adolescents with anorexia nervosa and 8 healthy controls underwent cerebral MRI (magnetic resonance imaging) examination to obtain global and partial volumes (gray matter, white matter and cerebrospinal fluid) and clinical evaluation. The Mann-Whitney U test was used to compare partial volumes and clinical variables between cases and controls. The Spearman non-parametric test was performed in order to explore correlations between the variables studied.

RESULTS

The patients diagnosed with AN showed significantly increased cerebrospinal fluid (CSF) volumes and decreased total gray (GM) and white matter (WM) volumes. The degree of weight loss (deltaBMI) correlated inversely with the GM volume; the increase of CSF compartment correlated directly with the rapidity of weight loss (DeltaBMI/disease duration).

CONCLUSIONS

This study suggests a correlation between cerebral alterations in AN and the speed and magnitude of weight loss, and outlines its importance for the therapeutic treatment.

Short-term exercise combined with Acipimox administration induces an increase in plasma ACTH and its subsequent fall in the recovery phase in bulimic women

OBJECTIVE

Free fatty acids (FFA)-adrenocorticotropin (ACTH) feedback loop between adipose tissue and the hypothalamic-pituitary centers in the brain has been suggested to be affected by the exercise and by administration of anti-lipolytic drugs. Also leptin may be affected by exercise. Dysfunction of FFA-leptin-ACTH secretion might be involved in binge eating and subsequent purging as is the case in bulimia nervosa (BN).

METHODS

In the present single-blind, randomized study, we explored responses of plasma ACTH, leptin and FFA concentrations to exercise (45 min, 2 W/kg of lean body mass [LBM]) with Acipimox (Aci), an anti-lipolytic nicotinic acid analog, or placebo randomly received in nine women with BN and nine healthy women.

RESULTS

The exercise with Aci administration resulted in plasma ACTH (p<0.001) and leptin increase higher in BN patients and a decrease in the plasma FFA levels in both groups. The falling of plasma ACTH (p<0.01) levels in the post-exercise recovering phase (90-minute) with Aci administration is more expressed in BN patients. The exercise induced an increase in plasma ACTH (p<0.05) and FFA levels and a decrease in the plasma leptin level in both groups.

CONCLUSIONS

We demonstrated that the Aci-induced elevation in plasma ACTH (p<0.001) levels after the exercise higher in BN patients and that the falling of plasma ACTH (p<0.01) levels in the post-exercise recovering phase (90-minute) with Aci administration is suppressed only in BN patients, while Aci increased plasma leptin levels in this recovering phase more in BN patients. Therefore, these observations led us to suggesting that FFA-leptin-ACTH are involved in the dysregulation of neuroendocrine profile in this syndrome and that Aci affects a FFA-independent mechanism. In conclusion, Aci can be considered acceptable in the treatment of eating disorders, and it may also serve as an alternative low-dose dexamethasone suppression test (LDDST) in these patients.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000309886.

Preadipocyte Factor-1 Concentrations in Patients With Anorexia Nervosa: the Influence of Partial Realimentation

Preadipocyte factor-1 (Pref-1) is a member of epidermal growth-factor like family of proteins that regulates adipocyte and osteoblast differentiation. Experimental studies suggest that circulating Pref-1 levels may be also involved in the regulation of lipid and glucose metabolism and energy homeostasis. We hypothesized that alterations in Pref-1 levels may contribute to the ethiopathogenesis of anorexia nervosa or its underlying metabolic abnormalities. We measured Pref-1 concentrations and other hormonal, biochemical and anthropometric parameters in eighteen patients with anorexia nervosa and sixteen healthy women and studied the influence of partial realimentation of anorexia nervosa patients on these parameters. The mean duration of realimentation period was 46±2 days. At baseline, anorexia nervosa patients had significantly decreased body mass index, body weight, body fat content, fasting glucose, serum insulin, TSH, free T4, leptin and total protein. Partial realimentation improved these parameters. Baseline serum Pref-1 levels did not significantly differ between anorexia nervosa and control group (0.26±0.02 vs. 0.32±0.05 ng/ml, p=0.295) but partial realimentation significantly increased circulating Pref-1 levels (0.35±0.04 vs. 0.26±0.02 ng/ml, p<0.05). Post-realimentation Pref-1 levels significantly positively correlated with the change of body mass index after realimentation (r=0.49, p<0.05). We conclude that alterations in Pref-1 are not involved in the ethiopathogenesis of anorexia nervosa but its changes after partial realimentation could be involved in the regulation of adipose tissue expansion after realimentation.

Endocrine alterations are the main determinants of cardiac remodelling in restrictive anorexia nervosa

Objective. Anorexia nervosa is a condition of reduced hemodynamic load, characterized by varying degrees of cardiac remodelling, only in part related to reduced body mass; the mechanism for such variability, as well as its clinical significance, remains unknown. Aim of the study was to assess the possible influence of a great number of clinical, biochemical, and endocrine factors on cardiovascular parameters in restrictive anorexia nervosa. Method. Twenty-five female patients hospitalized for restrictive anorexia nervosa underwent extensive cardiovascular, clinical, and biochemical evaluation. Results. Height-adjusted and cardiac workload-matched left ventricular mass was significantly related to several endocrine parameters, blood pressure, and vasoreactivity. On multivariate analysis, IGF/GH ratio and systolic blood pressure were the only independent predictors of height-adjusted ventricular mass (adj-R(2) = 0.585; P = 0.001); when matching for cardiac workload, left ventricular mass was independently predicted only by GH and FT3 levels. All effects were independent of patient's weight and BMI. Conclusions. Indices of endocrine impairment seem to be the most relevant determinants of left ventricular hypotrophy in anorectic patients, apparently independent of reduced hemodynamic load and BMI. In particular, IGF/GH ratio and FT3 seem to particularly affect left ventricular mass in this population.

Anorexia nervosa versus hyperinsulinism: therapeutic effects of neuropharmacological manipulation

Background:

We have demonstrated that anorexia nervosa is underpinned by overwhelming adrenal sympathetic activity which abolishes the neural sympathetic branch of the peripheral autonomic nervous system. This physiological disorder is responsible for gastrointestinal hypomotility, hyperglycemia, raised systolic blood pressure, raised heart rate, and other neuroendocrine disorders. Therefore, we prescribed neuropharmacological therapy to reverse this central and autonomic nervous system disorder, in order to normalize the clinical and neuroendocrine profile.

Methods:

The study included 22 female patients with anorexia nervosa (10 restricted type, 12 binge-eating type) who received three months of treatment with amantadine 100 mg/day. We measured blood pressure, heart rate, and circulating neurotransmitters, (noradrenaline, adrenaline, dopamine, platelet serotonin, free plasma serotonin) during supine resting, one minute of orthostasis, and a five-minute exercise test before and after one, two, and three months of treatment with amantadine, a drug which abrogates adrenal sympathetic activity by acting at the C1(Ad) medullary nuclei responsible for this branch of the peripheral sympathetic activity.

Results:

We found the amantadine abolished symptoms of anorexia nervosa from the first oral dose onwards. Normalization of autonomic and cardiovascular parameters was demonstrated within the early days of therapy. Abrupt and sustained increases in the plasma noradrenaline:adrenaline ratio and disappearance of abnormal plasma glucose elevation were registered throughout the three-month duration of the trial. Significant and sustained increases in body weight were documented in all cases. No relapses were observed.

Conclusion:

We have confirmed our previously published findings showing that the anorexia nervosa syndrome depends on the hypomotility of the gastrointestinal tract plus hyperglycemia, both of which are triggered by adrenal sympathetic hyperactivity. The above neuroendocrine plus neuroautonomic and clinical disorders which underpinned anorexia nervosa were abruptly suppressed since the first oral dose of amantadine, a drug able to revert the C1(Ad) over A5(NA) pontomedullary predominance responsible for adrenal and neural sympathetic activity, respectively.

Towards a neurocircuitry in anorexia nervosa: evidence from functional neuroimaging studies

Functional neuroimaging is widely used to unravel changes in brain functioning in psychiatric disorders. In the current study, we review single-photon emission tomography (SPECT), positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) studies in anorexia nervosa (AN), a difficult-to-treat eating disorder with the highest mortality rate among psychiatric disorders. We discuss the role of the parietal cortex, anterior and subgenual cingulate cortex, frontal cortex and temporal lobe in light of the cardinal symptoms of AN. The insights of the current review may ultimately lead to the development of new treatments.

The endocrinopathies of anorexia nervosa

OBJECTIVE

To describe the hormonal adaptations and alterations in anorexia nervosa.

METHODS

We performed a PubMed search of the English-language literature related to the pathophysiology of the endocrine disorders observed in anorexia nervosa, and we describe a case to illustrate these findings.

RESULTS

Anorexia nervosa is a devastating disease with a variety of endocrine manifestations. The effects of starvation are extensive and negatively affect the pituitary gland, thyroid gland, adrenal glands, gonads, and bones. Appetite is modulated by the neuroendocrine system, and characteristic patterns of leptin and ghrelin concentrations have been observed in anorexia nervosa. A thorough understanding of refeeding syndrome is imperative to nutrition rehabilitation in these patients to avoid devastating consequences. Although most endocrinopathies associated with anorexia nervosa reverse with recovery, short stature, osteoporosis, and infertility may be long-lasting complications. We describe a 20-year-old woman who presented with end-stage anorexia nervosa whose clinical course reflects the numerous complications caused by this disease.

CONCLUSIONS

The effects of severe malnutrition and subsequent refeeding are extensive in anorexia nervosa. Nutrition rehabilitation is the most appropriate treatment for these patients; however, it must be done cautiously.

Systematic review and meta-analysis of the baseline concentrations and physiologic responses of gut hormones to food in eating disorders

BACKGROUND

Disturbances in gastrointestinal hormones have been widely identified in persons with eating disorders (EDs) and have been implicated in their clinical pathologies.

OBJECTIVE

The objective was to identify, critically examine, and summarize studies investigating the short-term response of gastrointestinal hormones to food in persons with an ED, including the subtypes anorexia nervosa and bulimia nervosa.

DESIGN

A priori inclusion and exclusion criteria were set and included a procedure in which a test meal or glucose load was given and blood hormone concentrations measured. All studies included a healthy control group for comparison. The outcome variable was defined as the mean difference between fasting plasma hormone concentrations and the maximum postprandial peak or nadir. The difference in baseline values between groups was also examined. Pooled standardized mean differences were calculated and analyzed where possible.

RESULTS

A total of 28 studies were identified, including sufficient studies to perform a meta-analysis for ghrelin, peptide YY, cholecystokinin, insulin, and pancreatic polypeptide. Persons with an ED had higher baseline concentrations of ghrelin (large effect), peptide YY (medium effect), and cholecystokinin (medium effect for ED, large effect for anorexia nervosa). The response of insulin to food was decreased in persons with an ED (medium effect). No further differences were found in the release of gut peptides to a standardized test meal.

CONCLUSIONS

All of the studies had low power for the different subtypes of EDs. High heterogeneity among the studies was observed, and limitations are discussed. The findings suggest that the physiologic changes observed in patients with EDs are highly variable and subject to multiple confounding factors.

Acromegaly with normal IGF-1 levels probably due to poorly controlled diabetes mellitus

Acromegaly is characterized by the somatic disfigurement and excessive production of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Here we report a patient with aromegaly and diabetes mellitus, who showed normal IGF-1 levels in spite of elevated GH levels. The patient was a 52-year-old woman with acromegalic manifestations. Serum GH level was elevated (32.4 ng/mL) with hyperglycemia (fasting plasma glucose, 277 mg/dL) and an extremely high level of glycosylated hemoglobin (HbA1c 17.7%), whereas serum IGF-1 level was within normal range (110 ng/mL, normal range 37-266). Brain magnetic resonance imaging detected a pituitary tumor, with involvement of the right cavernous sinus. Oral glucose tolerance test (OGTT) showed no suppression of serum GH. Thyrotropin-releasing hormone test showed paradoxical increases in serum GH. We therefore diagnosed acromegaly accompanied with diabetes mellitus. A large amount of insulin (34 units/day) was required to control the blood glucose level. The patient was treated with octreotide, a somatostatin analogue, followed by transsphenoidal surgery. After the surgery, serum GH levels were suppressed by OGTT, although basal serum GH levels remained to be high. Basal serum GH levels, however, were normalized 5 months later. Blood glucose became well controlled by the diet alone. In contrast, serum IGF-1 increased to the range of 219-233 ng/mL. Pre-operative serum IGF-1 levels were low probably due to poorly controlled diabetes mellitus. In conclusion, the presence of normal serum IGF-1 levels cannot exclude the diagnosis of acromegaly especially when the patient is accompanied by diabetes mellitus.

The effects of electrical stimulation or an electrolytic lesion in the mediodorsal thalamus of the rat on survival, body weight, food intake and running activity in the activity-based anorexia model

The glucose metabolism in the mediodorsal thalamus (MD) is increased in rats in the activity-based anorexia (ABA) model. In patients, electrical stimulation in hyperactive brain regions reduced symptoms in e.g. major depressive disorder and cluster headache. In two blinded randomised controlled experiments, we therefore examined the effects of high-frequency electrical stimulation and an electrolytic lesion in the MD in a validated rat model for anorexia nervosa. The ABA model was successfully replicated in all our experiments, with a reduction in body weight, food intake, and survival time and an increase in running activity. In a first experiment, we evaluated the effect of electrical stimulation or a curative lesion in the MD on survival, body weight, food intake and locomotor activity in ABA rats. Electrical MD stimulation or an electrolytic MD lesion did not improve the symptoms of rats in the ABA model, compared to control groups. In a second experiment, we investigated the effect of a preventive electrolytic lesion in the MD on rats in the ABA model. Although there was no significant improvement of survival, body weight and food intake, locomotor activity was significantly reduced in the lesion group compared to the control group. Apart from this positive effect on running activity, we found no convincing evidence for the suitability of the MD as a neuromodulation target for anorexia nervosa patients.

A cross-sectional and follow-up voxel-based morphometric MRI study in adolescent anorexia nervosa

The objective was to examine whether cerebral volumes are reduced, and in what regions, in adolescents with anorexia nervosa and to study changes after nutritional recovery. Twelve anorexia nervosa (DSM-IV) patients aged 11-17 consecutively admitted to an Eating Disorders Unit were assessed by means of psychopathological scales, neuropsychological battery and voxel-based morphometric (VBM) magnetic resonance imaging at admission and after 7 months' follow-up. Nine control subjects of similar age, gender and estimated intelligence level were also studied. The two groups showed differences in gray matter (F=22.2; p<0.001) and cerebrospinal fluid (CSF) (F=21.2; p<0.001) but not in white matter volumes. In anorexic patients, gray matter volume correlated negatively with the copy time from the Rey Complex Figure Test. In the regional VBM study several temporal and parietal gray matter regions were reduced. During follow-up there was a greater global increase in gray matter (F=10.7; p=0.004) and decrease in CSF (F=22.1; p=0.001) in anorexic patients. The increase in gray matter correlated with a decrease in cortisol (Spearman correlation=-0.73; p=0.017). At follow-up there were no differences in global gray matter (F=2.1; p=0.165), white matter (F=0.02, p=0.965) or CSF (F=1.8; p=0.113) volumes between both groups. There were still some smaller areas, in the right temporal and both supplementary motor area, showing differences between them in the regional VBM study. In conclusion, in adolescent anorexic patients gray matter is more affected than white matter and mainly involves the posterior regions of the brain. Overall gray matter alterations are reversible after nutritional recovery.

Research methodology: endocrinologic measurements in exercise science and sports medicine

OBJECTIVE

To provide background information on methodologic factors that influence and add variance to endocrine outcome measurements. Our intent is to aid and improve the quality of exercise science and sports medicine research endeavors of investigators inexperienced in endocrinology.

BACKGROUND

Numerous methodologic factors influence human endocrine (hormonal) measurements and, consequently, can dramatically compromise the accuracy and validity of exercise and sports medicine research. These factors can be categorized into those that are biologic and those that are procedural-analytic in nature.

RECOMMENDATIONS

Researchers should design their studies to monitor, control, and adjust for the biologic and procedural-analytic factors discussed within this paper. By doing so, they will find less variance in their hormonal outcomes and thereby will increase the validity of their physiologic data. These actions can assist the researcher in the interpretation and understanding of endocrine data and, in turn, make their research more scientifically sound.

Electrical stimulation in the lateral hypothalamus in rats in the activity-based anorexia model

Object

One quarter of patients with anorexia nervosa have a poor outcome and continue to suffer chronically or die. Electrical brain stimulation may be of therapeutic benefit in some of these patients; however, the brain target for inducing symptom relief is unknown. In this study, the authors evaluated the effects of acute and chronic electrical stimulation in the lateral hypothalamus on food intake, locomotor activity, and survival time in rats in an activity-based anorexia model.

Methods

In an acute experiment, the authors electrically stimulated at 100 Hz and 0, 25, 50 and 75% of the maximal stimulation amplitude (that is, the amplitude leading to severe side effects) in the lateral hypothalamus on consecutive days during 4 test sessions in 10 rats and evaluated food intake and locomotor activity. In a chronic experiment, they compared food intake, wheel revolutions, and survival time between 6 rats that underwent electrical stimulation in the lateral hypothalamus (50% of maximal stimulation amplitude) and 8 rats that did not undergo stimulation.

Results

In the acute experiment, overall electrical stimulation (25, 50, and 75% combined) and stimulation at 75% of the maximal stimulation amplitude significantly decreased the locomotor activity. However, if the authors omitted results of 1 rat, in which the electrode tip was not located in the lateral hypothalamus on one side but rather in the supraoptic chiasm, the remaining results did not yield significance. No other differences were observed.

Conclusions

When the findings of the current study are extrapolated to patients with anorexia nervosa, the authors do not expect major effects on symptoms with electrical stimulation at high frequency in the lateral hypothalamus.

Leptin does not mediate short-term fasting-induced changes in growth hormone pulsatility but increases IGF-I in leptin deficiency states

CONTEXT

States of acute and chronic energy deficit are characterized by increased GH secretion and decreased IGF-I levels.

OBJECTIVE

The objective of the study was to determine whether changes in levels of leptin, a key mediator of the adaptation to starvation, regulate the GH-IGF system during energy deficit.

DESIGN, SETTING, PATIENTS, AND INTERVENTION

We studied 14 healthy normal-weight men and women during three conditions: baseline fed and 72-h fasting (to induce hypoleptinemia) with administration of placebo or recombinant methionyl human leptin (r-metHuLeptin) (to reverse the fasting associated hypoleptinemia). We also studied eight normal-weight women with exercise-induced chronic energy deficit and hypothalamic amenorrhea at baseline and during 2-3 months of r-metHuLeptin treatment.

MAIN OUTCOME MEASURES

GH pulsatility, IGF levels, IGF and GH binding protein (GHBP) levels were measured.

RESULTS

During short-term energy deficit, measures of GH pulsatility and disorderliness and levels of IGF binding protein (IGFBP)-1 increased, whereas leptin, insulin, IGF-I (total and free), IGFBP-4, IGFBP-6, and GHBP decreased; r-metHuLeptin administration blunted the starvation-associated decrease of IGF-I. In chronic energy deficit, total and free IGF-I, IGFBP-6, and GHBP levels were lower, compared with euleptinemic controls; r-metHuLeptin administration had no major effect on GH pulsatility after 2 wk but increased total IGF-I levels and tended to increase free IGF-I and IGFBP-3 after 1 month.

CONCLUSIONS

The GH/IGF system changes associated with energy deficit are largely independent of leptin deficiency. During acute energy deficit, r-metHuLeptin administration in replacement doses blunts the starvation-induced decrease of IGF-I, but during chronic energy deficit, r-metHuLeptin administration increases IGF-I and tends to increase free IGF-I and IGFBP-3.

Neurobiology of anorexia and bulimia nervosa

Anorexia nervosa (AN) and bulimia nervosa (BN) are related disorders of unknown etiology that most commonly begin during adolescence in women. AN and BN have unique and puzzling symptoms, such as restricted eating or binge-purge behaviors, body image distortions, denial of emaciation, and resistance to treatment. These are often chronic and relapsing disorders, and AN has the highest death rate of any psychiatric disorder. The lack of understanding of the pathogenesis of this illness has hindered the development of effective interventions, particularly for AN. Individuals with AN and BN are consistently characterized by perfectionism, obsessive-compulsiveness, and dysphoric mood. Individuals with AN tend to have high constraint, constriction of affect and emotional expressiveness, ahendonia and asceticism, whereas individuals with BN tend to be more impulsive and sensation seeking. Such symptoms often begin in childhood, before the onset of an eating disorder, and persist after recovery, suggesting they are traits that create a vulnerability for developing an ED. There is growing acknowledgement that neurobiological vulnerabilities make a substantial contribution to the pathogenesis of AN and BN. Considerable evidence suggests that altered brain serotonin (5-HT) function contributes to dysregulation of appetite, mood, and impulse control in AN and BN. Brain imaging studies, using 5-HT specific ligands, show that disturbances of 5-HT function occur when people are ill, and persist after recovery from AN and BN. It is possible that a trait-related disturbance of 5-HT neuronal modulation predates the onset of AN and contributes to premorbid symptoms of anxiety, obsessionality, and inhibition. This dysphoric temperament may involve an inherent dysregulation of emotional and reward pathways which also mediate the hedonic aspects of feeding, thus making these individuals vulnerable to disturbed appetitive behaviors. Restricting food intake may become powerfully reinforcing because it provides a temporary respite from dysphoric mood. Several factors may act on these vulnerabilities to cause AN to start in adolescence. First, puberty-related female gonadal steroids or age-related changes may exacerbate 5-HT dysregulation. Second, stress and/or cultural and societal pressures may contribute by increasing anxious and obsessional temperament. Individuals with AN may discover that reduced dietary intake, by reducing plasma tryptophan availability, is a means by which they can modulate brain 5-HT functional activity and anxious mood. People with AN enter a vicious cycle which accounts for the chronicity of this disorder because caloric restriction results in a brief respite from dysphoric mood. However, malnutrition and weight loss, in turn, produce alterations in many neuropeptides and monoamine function, perhaps in the service of conserving energy, but which also exaggerates dysphoric mood. In summary, this article reviews findings in brain chemistry and neuroimaging that shed new light on understanding the psychopathology of these difficult and frustrating disorders.

Disturbances in gonadal axis in women with anorexia nervosa

Anorexia nervosa negatively affects multiple body systems including the reproductive system.

AIM

To assess the disturbances in the hypothalamic-pituitary-gonadal axis (HPG) and the relationship between the gonadotropins and body weight, duration of the disease and amenorrhea we studied 40 female anorexic patients (aged 14-31 years) with a body mass index (BMI) 15.14+/-1.80 kg/m(2) and a degree of weight loss 28.67+/-8.74%. Fifteen healthy, age-matched women with normal weight served as controls.

METHODS

We investigated the disturbances in the gonadotropin levels before and after stimulation with gonadotropin-releasing hormone (GnRH) 100 microg i.v. One week later 100 mg of clomiphene citrate (CC) was administered orally for 5 days.

RESULTS

Basal levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were significantly lower in the patients. The responses of LH to GnRH were diminished, but those of FSH were exaggerated. However, after clomiphene citrate administration, LH increased 5.4 times whereas FSH increased 1.7 times. The basal levels of LH were significantly correlated with body weight (r=+0.373, p<0.05), BMI (r=+0.385, p<0.01) and percentage of the weight loss (r=-0.356, p<0.05). FSH levels were positively correlated with the duration of the disease (r=+0.481, p<0.01) and amenorrhea (r=+0.540, p<0.01).

CONCLUSIONS

Our study demonstrates dissociation in the secretion of gonadotropins after hypothalamic stimulation in anorexic patients. It also reveals the relationship between alterations in the hormones of the HPG axis, not only with the changes in body weight, but also with the duration of the disease.

Metabolic and hormonal changes during the refeeding period of prolonged fasting

OBJECTIVE

The discovery of leptin, a hormone primarily involved in adaptation to fasting, led to an increased interest in appetite regulation and appetite-modulating hormones. Here, we present unique data from a case of extreme starvation and refeeding, showing changes in plasma concentrations of appetite-modulating and metabolic hormones as well as biochemical changes, and draw attention to the dangers of the refeeding syndrome.

PATIENTS AND METHODS

We studied the refeeding period of a 44-day voluntary fast uncomplicated by underlying disease. Biochemical and hormonal variables were compared with 16 matched subjects such that the BMI range of the controls covered the entire spectrum for the index subject's recovering BMI.

RESULTS

Lack of calorie intake with free access to water resulted in 25% loss of body weight. Haemoconcentration was observed and feeding was started with a low sodium, hypocaloric liquid formulation. During early refeeding, marked hypophosphataemia, haemodilution and slight oedema developed. Vitamins B1, B12 and B6 were depleted while serum free fatty acids, ketone bodies and zinc levels were abnormally high; abnormal liver function developed over the first week. The hormonal profile showed low IGF-I and insulin levels, and elevated IGF-binding protein-1 concentrations. Appetite-regulating hormones were either very low (leptin and ghrelin) or showed no marked difference from the control group (peptide YY, agouti-related peptide, alpha-melanocyte-stimulating hormone, neuropeptide Y and pro-opiomelanocortin). Appetite was low at the beginning of refeeding and a transient increase in orexin and resistin was observed coincidently with an increase in subjective hunger.

CONCLUSIONS

Our study illustrates the potential dangers of refeeding and provides a comprehensive insight into the endocrinology of prolonged fasting and the refeeding process.

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

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

The Circadian Variation of Cortisol Secretion in Patients with Anorexia Nervosa in Childhood and Adolescence after Recovery of Body Weight by Treatment Using Gas Chromatography/Mass Spectrometry in Selected Ion Monitoring

Anorexia nervosa (AN) is a chronic psychiatric disorder which is characterized by patient-induced weight loss. Complications in many organ systems can be seen in AN such as cardiovascular, gastrointestinal, and endocrine system including hypothalamic-pituitary-adrenal axis, even after recovery of body weight by treatment. Urinary steroid profile analysis using gas chromatography/mass spectrometry (GC/MS) in selected ion monitoring (SIM) has been reported to be useful for the diagnosis of abnormal steroidogenesis in newborn infants, childhood, and adults. The aim of this study was to analyze the circadian variation of cortisol secretion in patients with anorexia nervosa (AN) in childhood and adolescence after recovery of body weight by treatment using GC/MS in SIM. The subjects were 7 healthy young adults (20–23 yr of age, BMI 19.7–24.8 kg/m²) and 5 AN patients in childhood and adolescence (13–19 yr of age), who had recovered body weight by treatment (BMI 15.4–19.3 kg/m²; 3^rd–25^th to 50^th percentile). Urine samples were collected for 26 hours (from 21:00 to 23:00 next day) at each urination. In each sample, the cortisol metabolites were measured by GC/MS in SIM. The sum of all cortisol metabolites was calculated as mg/g creatinine. In all 5 AN patients in childhood and adolescence, the circadian variation of the sum of cortisol metabolites was observed and was similar to that in healthy young adults. Although our data are preliminary, in patients with AN in childhood and adolescence, who have recovered body weight by treatment, the circadian variation of cortisol secretion may be conserved.

Neuroendocrine effects of citalopram infusion in anorexia nervosa

Because of the role of serotonin (5HT) in regulating food intake and mood, several studies have focused their attention on the assessment of serotonergic activity in eating disorders, and in particular in anorexia nervosa, but the results have been inconsistent. Citalopram, a highly selective 5HT reuptake inhibitor, has been recently reported as a neuroendocrine probe to assess the serotonergic function in physiological and pathological conditions. We evaluated the adrenocorticotropic hormone (ACTH), cortisol, prolactin (PRL) and growth hormone (GH) secretion during placebo or citalopram IV infusion (20 mg over 120 min), in six women with anorexia nervosa restricter type, and in six healthy women, in order to test the hypothesis that this neurotransmitter system is abnormal in this group of patients. ACTH and PRL secretion was higher during citalopram infusion compared to placebo (p<0.05) in both groups, while cortisol secretion was higher during citalopram infusion only in healthy controls (p<0.05), but not in anorexic patients. GH levels were unaffected by citalopram in both groups. These results demonstrate that serotonergic activation by citalopram affects corticotroph and lactotroph but not somatotroph secretion in anorexic as well as in normal subjects. Our preliminary findings do not support the existence of remarkable alterations in the serotonergic control of anterior pituitary function in anorexia nervosa, while there seems to be an impairment of the adrenal function in this group of patients.