Reduced body fat in long-term followed-up female patients with anorexia nervosa

A multicenter, randomized controlled study on the efficacy of agomelatine in ameliorating anhedonia, reduced motivation, and circadian rhythm disruptions in patients with major depressive disorder (MDD)

OBJECTIVE

To evaluate the clinical efficacy and safety of Agomelatine in improving symptoms in patients with major depressive disorder (MDD), providing more scientific evidence for the treatment of depression, and offering more effective therapeutic options for patients.

METHODS

A total of 180 MDD patients in acute phase from 10 psychiatric hospitals of Grade three in Zhejiang Province were enrolled in this 12-week study with the competitive and consecutive pattern, and they were randomized into two different groups treated with flexible-dosage antidepressants of selective serotonin reuptake inhibitors (SSRI) or agomelatine, respectively. The subjects were evaluated with psychological scales of HAMD-17, HAMA, SHAPS for anhedonia, MFI-20 for fatigue, PQSI for sleep quality and MEQ for disturbances in chronobiologic rhythms at baseline, 2, 4, 8 and 12-weekend points, and TESS was used for side-effect. The results were analyzed with repeated measurement analysis of variance.

RESULTS

The two groups each had 90 participants, and there were no significant differences at baseline. The scores of various assessment scales showed statistically significant time main effects during the visits (P < 0.01). The Agomelatine group demonstrated faster efficacy within 2 weeks, with better improvement in SHAPS, MEQ, and PSQI compared to the SSRIs group. However, the remission rate at 12 weeks was lower in the Agomelatine group than in the SSRIs group (63.3% and 72.2%), but the difference between the groups was not statistically significant. The Agomelatine group had fewer adverse reactions (14.4% and 16.7%), but there was a slightly higher incidence of liver function impairment (6.7% and 4.4%), with no statistically significant difference between the groups.

CONCLUSION

Agomelatine, as a novel antidepressant, shows certain advantages in improving depression and anxiety symptoms and is comparable to SSRIs in terms of safety. However, its long-term efficacy and safety on MDD or other depressive subtypes still require further observation and research.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Physical Activity in Eating Disorders: A Systematic Review

Abnormally high levels of physical activity have been documented throughout the literature in patients with eating disorders (ED), especially those diagnosed with anorexia nervosa (AN). Yet no clear definition, conceptualization, or treatment of the problematic use of physical activity (PPA) in ED patients exists. The aim of this review is to propose a new classification of PPA, report the prevalence, triggers, predictors, maintainers and other related factors of PPA in ED patients, in addition to proposing a comprehensive model of the development of PPA in AN. A total of 47 articles, retrieved from Medline and Web of Science, met the inclusion criteria and were included in the analysis. As a result, the new approach of PPA was divided into two groups (group 1 and group 2) according to the dimension (quantitative vs qualitative approach) of physical activity that was evaluated. The prevalence of PPA in ED was reported in 20 out of 47 studies, the comparison of PPA between ED versus controls in 21 articles, and the links between PPA and psychological factors in ED in 26 articles, including depression (16/26), anxiety (13/26), obsessive–compulsiveness (9/26), self-esteem (4/26), addictiveness (1/26), regulation and verbal expression of emotions (1/26) and anhedonia (1/26). The links between PPA and ED symptomatology, PPA and weight, body mass index (BMI) and body composition in ED, PPA and age, onset, illness duration and lifetime activity status in ED, PPA and ED treatment outcome were reported in 18, 15, 7, 5 articles, respectively. All of the factors have been systematically clustered into group 1 and group 2. Results focused more on AN rather than BN due to the limited studies on the latter. Additionally, a model for the development of PPA in AN patients was proposed, encompassing five periods evolving into three clinical stages. Thus, two very opposite components of PPA in AN were suggested: voluntarily PPA increased in AN was viewed as a conscious strategy to maximize weight loss, while involuntarily PPA increased proportionally with weight-loss, indicating that exercise might be under the control of a subconscious biological drive and involuntary cognition.

Genetics of eating disorders

Disordered eating behavior is the core symptom of the complex disorders anorexia nervosa and bulimia nervosa. Twin and family studies derive high heritability estimates. Hence, substantial genetic influences on the etiology can be assumed for both. Initially, candidate gene studies pertaining to the monoaminergic neurotransmitter systems and to body weight regulation comprised the core of the genetic analyses. Unfortunately, confirmed, solid findings substantiated in meta-analyses are rare, so that eventually none of these associations is unequivocal. Thus, systematic, genome-wide approaches emerged to identify genes with no a priori evidence for their involvement in eating disorders. Genome-wide association studies have hinted to formerly unknown genetic regions. However, significant genome-wide findings have not yet been reported.

Somatic problems and self-injurious behaviour 18 years after teenage-onset anorexia nervosa

The aim of this study was to study long-term outcome of physical health and self-injurious behaviour (SIB) in anorexia nervosa (AN). Fifty-one adolescent-onset AN cases, originally recruited after community screening, and 51 matched controls (COMP) were interviewed regarding somatic problems and SIB and physically examined 18 years after AN onset, at mean age 32 years. Six individuals had an eating disorder (ED). No one had died. The AN group weighed less than the COMP group. The frequency of somatic problems did not differ between groups. Dental enamel lesions and shorter than expected stature occurred only in the AN group. Dysdiadochokinesis was overrepresented in the AN group and age of AN onset was lower among those with the neurological deficit. Severe SIB occurred only in the AN group, predominantly during adolescence. To conclude, somatic problems were common in both groups. Most individuals in the AN group had recovered from their ED, but weight revealed a persistent restricted eating behaviour.

Changes in physical fitness, bone mineral density and body composition during inpatient treatment of underweight and normal weight females with longstanding eating disorders

The purpose of this study was to examine changes in aerobic fitness, muscular strength, bone mineral density (BMD) and body composition during inpatient treatment of underweight and normal weight patients with longstanding eating disorders (ED). Twenty-nine underweight (BMI < 18.5, n = 7) and normal weight (BMI ≥ 18.5, n = 22) inpatients (mean (SD) age: 31.0 (9.0) years, ED duration: 14.9 (8.8) years, duration of treatment: 16.6 (5.5) weeks) completed this prospective naturalistic study. The treatment consisted of nutritional counseling, and 2 × 60 min weekly moderate intensive physical activity in addition to psychotherapy and milieu therapy. Underweight patients aimed to increase body weight with 0.5 kg/week until the weight gain goal was reached. Aerobic fitness, muscular strength, BMD and body composition were measured at admission and discharge. Results showed an increase in mean muscular strength, total body mass, fat mass, and body fat percentage, but not aerobic capacity, among both underweight and normal weight patients. Lumbar spine BMD increased among the underweight patients, no changes were observed in BMD among the normal weight patients. Three out of seven underweight patients were still underweight at discharge, and only three out of nine patients with excessive body fat (i.e., >33%) managed to reduce body fat to normal values during treatment. These results calls for a more individualized treatment approach to achieve a more optimal body composition among both underweight and normal to overweight patients with longstanding ED.

Eating disorders: the current status of molecular genetic research

Anorexia nervosa (AN) and bulimia nervosa (BN) are complex disorders characterized by disordered eating behavior where the patient's attitude towards weight and shape, as well as their perception of body shape, are disturbed. Formal genetic studies on twins and families suggested a substantial genetic influence for AN and BN. Candidate gene studies have initially focused on the serotonergic and other central neurotransmitter systems and on genes involved in body weight regulation. Hardly any of the positive findings achieved in these studies were unequivocally confirmed or substantiated in meta-analyses. This might be due to too small sample sizes and thus low power and/or the genes underlying eating disorders have not yet been analyzed. However, some studies that also used subphenotypes (e.g., restricting type of AN) led to more specific results; however, confirmation is as yet mostly lacking. Systematic genome-wide linkage scans based on families with at least two individuals with an eating disorder (AN or BN) revealed initial linkage regions on chromosomes 1, 3 and 4 (AN) and 10p (BN). Analyses on candidate genes in the chromosome 1 linkage region led to the (as yet unconfirmed) identification of certain variants associated with AN. Genome-wide association studies are under way and will presumably help to identify genes and pathways involved in these eating disorders. The elucidation of the molecular mechanisms underlying eating disorders might improve therapeutic approaches.

Genetic findings in anorexia and bulimia nervosa

Anorexia nervosa (AN) and bulimia nervosa (BN) are complex disorders associated with disordered eating behavior. Heritability estimates derived from twin and family studies are high, so that substantial genetic influences on the etiology can be assumed for both. As the monoaminergic neurotransmitter systems are involved in eating disorders (EDs), candidate gene studies have centered on related genes; additionally, genes relevant for body weight regulation have been considered as candidates. Unfortunately, this approach has yielded very few positive results; confirmed associations or findings substantiated in meta-analyses are scant. None of these associations can be considered unequivocally validated. Systematic genome-wide approaches have been performed to identify genes with no a priori evidence for their relevance in EDs. Family-based scans revealed linkage peaks in single chromosomal regions for AN and BN. Analyses of candidate genes in one of these regions led to the identification of genetic variants associated with AN. Currently, an international consortium is conducting a genome-wide association study for AN, which will hopefully lead to the identification of the first genome-wide significant markers.

Genetic epidemiology, endophenotypes, and eating disorder classification

OBJECTIVE

To explore how genetic epidemiology has informed the identification of endophenotypes and how endophenotypes may inform future classification of eating disorders.

METHOD

Literature review and synthesis.

RESULTS

Although a number of endo- and subphenotypes have been suggested for eating disorders, few reach the rigorous definitions developed for candidate endophenotypes.

CONCLUSION

Further study of endophenotypes and subphenotypes for eating disorders may assist with developing a more homogenous classification system that more closely reflects underlying biological mechanisms, and provides a clearer focus for the development of coherent models and treatments.

A 2-year prospective study of bone metabolism and bone mineral density in adolescents with anorexia nervosa

Osteopenia and osteoporosis are complications of adolescent anorexia nervosa (AN) and may result in a permanent deficit of bone mass in adulthood. It is still unclear if a complete catch-up in bone mineral density (BMD) is possible after weight rehabilitation in AN. METHODS. We investigated bone formation (bAP, PICP), bone resorption (CTX) and BMD (lumbar spine, femoral neck) along with endocrinological parameters in 19 girls with AN (14.4 +/- 1.6 years) and in 19 healthy controls for 2 years after inpatient re-feeding. RESULTS. Re-feeding normalised bone formation activity in patients. The pattern of bone turnover in patients after 2 years was similar to the pattern healthy controls had shown 2 years before. BMD of patients was significantly lower than in controls and did not change throughout the entire study. CONCLUSIONS. Weight rehabilitation leads to prolonged normalization of bone turnover in adolescent AN. Since we could not observe a "catch up" effect in BMD of girls with AN in a 2-year follow-up, BMD of these patients needs to be carefully monitored until adulthood to detect early osteoporosis.

The role of leptin in anorexia nervosa: clinical implications

Leptin is a hormone with pleiotropic functions affecting several tissues. Because leptin has a crucial role in the adaptation of an organism to semi-starvation, anorexia nervosa (AN) serves as a model disorder to elucidate the functional implications of hypoleptinaemia; vice versa, several symptoms in patients with this eating disorder are related to the low leptin levels, which are characteristic of acute AN. Weight gain in AN patients can induce relative hyperleptinaemia in comparison to controls matched for body mass index; circulating leptin concentrations in AN patients thus transverse from subnormal to supranormal levels within a few weeks. We review findings on leptin secretion in AN and focus on implications, particularly for the hypothalamus-pituitary-gonadal axis, bone mineral density and physical hyperactivity. Undoubtedly, the elucidation of leptin's function as a trigger of diverse neuroendocrine adaptations to a restricted energy intake has substantially advanced our knowledge of the pathogenesis of distinct symptoms of AN, including amenorrhoea that represents one of the four diagnostic criteria. The fact that hypoleptinaemia can induce hyperactivity in a rat model for AN has led to a series of studies in AN patients, which support the notion that application of leptin to severely hyperactive patients might prove beneficial.

Leptina e sua influência na patofisiologia de distúrbios alimentares

A leptina é uma proteína secretada pelos adipócitos com papel regulador em vários sistemas do organismo, como sistema imune, respiratório e reprodutivo, bem como no balanço energético via ação hipotalâmica. Sua ação primária ocorre no núcleo hipotalâmico arqueado, no qual inicia uma cascata de eventos para inibição da ingestão energética e aumento do gasto energético. As concentrações de leptina são influenciadas pela adiposidade, fatores hormonais e nutricionais. A restrição e os episódios de compulsão alimentar, presentes na anorexia nervosa e bulimia, respectivamente, são considerados, na literatura científica, fatores determinantes na leptinemia. Seus níveis também alterados no tratamento desses distúrbios alimentares sugerem uma relação entre as alterações neuroendócrinas e conseqüentes modificações nos sinais de fome e saciedade, com a patogenia ou manutenção dos quadros clínicos. Trabalhos têm encontrado impacto dessas alterações na saúde dos pacientes, em curto e longo prazos. Esta revisão tem como objetivo esclarecer quais são as funções da leptina nos tecidos nervoso e periférico, quais os mecanismos que interferem na sua concentração nos distúrbios alimentares e como isso reflete na saúde do paciente anoréxico ou bulímico.

Bone density 11 years after anorexia nervosa onset in a controlled study of 39 cases

OBJECTIVE

To evaluate bone mineral density (BMD) and body composition 11 years after the onset of anorexia nervosa (AN).

METHOD

Thirty-nine AN subjects (36 females, 3 males), selected from a population-based sample, and 46 matched controls (COMP; 43 females, 3 males) were examined by using double-energy X-ray absorptiometry (DXA). Only 2 women still had AN. None of the men had AN.

RESULTS

The females in the AN and COMP groups did not differ regarding BMD, nor was there a difference across female groups concerning body mass index (BMI). The female AN group had a significantly lower percentage of body fat. BMD among females in the AN group was related to lowest BMI ever. There was an inverse relationship between lumbar BMD and AN duration.

DISCUSSION

Low BMD is not overrepresented among weight-restored AN patients at long-term follow-up compared with healthy women. However, the inverse relationship between BMD and AN duration may be indicative of a risk for osteopenia in patients with subchronic and chronic AN.

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

OBJECTIVE

To analyze the body composition of a group of patients fulfilling DSM-IV criteria for bulimia nervosa (BN), comparing the patients who had a history of DSM-IV anorexia nervosa (AN) with those without such a history to determine (1) whether both groups differed in terms of body composition and (2) whether the differences between groups could be the consequence of the past condition.

METHODS

The sample consisted of 104 patients, 43 with prior AN (BN-AN group) and 61 without a history of AN (BN-nonAN). The patients were assessed using anthropometric and bioelectrical methods: height and weight, body circumferences, abdominal diameter, skinfold thickness, and body impedance analysis. In a later phase and to test the influence of current low weight on the results, two experimental groups were created: the first group was composed of the patients from the BN-AN group who had a normal body mass index (BMI range in this group, 20.1-23.4 kg/m2; n = 23); the second group consisted of 23 patients from the BN-nonAN group in the same BMI range. In both phases unpaired sample t tests were performed for statistical analysis.

RESULTS

More than 40% of the bulimic patients with a history of AN had a BMI less than 20. They had a lower percentage of body fat, lower muscle mass, and higher percentage of extracellular water. Nevertheless, most of these differences disappeared in the second phase of the analysis, when only the patients within a normal weight range were compared.

DISCUSSION

According to these results, a significant number of bulimic patients with a history of AN tend to retain some clinical traits of the past condition and could be viewed as remaining in a "subclinical anorexic status": they are thinner and seem to have less difficulties in maintaining low weight than patients without a history of AN. Nevertheless, in patients who have reached a normal weight after AN, all these differences disappear. This fact raises some important questions related to the boundaries between AN and BN, the shifting from one to another, or when AN patients really recover.

Evidence for metabolic and endocrine abnormalities in subjects recovered from anorexia nervosa

Subjects with anorexia nervosa (AN) at low weight display metabolic, endocrine, and behavioral abnormalities. Whether these various differences are a consequence of the condition and persist after recovery is unclear. We tested the hypothesis that abnormalities in the insulin and leptin axes and in the desire to eat persisted in subjects who had recovered from AN in terms of body mass index (BMI) and menstrual function. Endocrine, metabolic, and psychological parameters were assessed by sampling under fasting conditions and serially in response to a standard meal. Subjects included 18 females recovered from AN and 18 female controls and measures included plasma insulin, leptin, glucose and beta-hydroxybutyrate (beta-HBA) concentrations together with desire to eat. Fasting glucose concentrations were normal in both groups, but fasting insulin concentrations were significantly lower and the fasting glucose/insulin ratio significantly higher in the recovered subjects. The glucose concentration was significantly higher at the end of the meal period in the recovered group. The peak increase of insulin during the meal was significantly less in the recovered group and in response to the meal, glucose/insulin ratios were significantly higher for the first 45 minutes indicating a delayed insulin response. Fasting beta-HBA concentrations were not significantly different between groups, but postmeal decreases were significant and larger in the recovered AN group. Fasting and meal-related leptin concentrations were not significantly different between the groups and in both groups were correlated with BMI. In controls, but not in recovered subjects, the reported desire to eat was correlated with plasma glucose and leptin concentrations. The insulin, glucose and beta-HBA data indicated the presence of insulin hypersensitivity in the recovered subjects. As the insulin response to the meal was blunted and apparently delayed, there may be a persistent alteration in pancreatic function as a long-term pathological consequence of the anorexia. Alternatively, these data indicate a possible trait marker for AN.

Opposite modifications in circulating leptin and soluble leptin receptor across the eating disorder spectrum

Leptin is thought to modulate feeding behaviour, body weight and energy metabolism by acting through specific cellular receptors. Derangements of leptin production have been repeatedly reported in patients with anorexia nervosa (AN) or bulimia nervosa (BN), but no information has been provided on the functional status of leptin receptors in these disorders. Therefore, we measured plasma levels of leptin and its soluble receptor (Ob-Re) in a total of 130 women, including 22 patients with AN, 45 patients with BN, 18 patients with the binge-eating disorder (BED), 12 non-binge eating obese women and 33 healthy women. Circulating leptin was drastically reduced in underweight anorexics and normal-weight bulimics, but increased in overweight BED patients and non-binge-eating obese women. Conversely, plasma levels of Ob-Re were significantly increased in patients with AN or BN, but decreased in BED and non-binge-eating obese women. Significant inverse correlations were detected between plasma levels of leptin and those of Ob-Re in all the subject groups, except in non-binge-eating obese subjects. These results show, for the first time, that opposite modifications occur in circulating levels of leptin and Ob-Re across the eating-disorder spectrum. The relevance of these findings to the pathophysiology and treatment of eating disorders remains to be elucidated.

Leptin in anorexia nervosa and bulimia nervosa: importance of assay technique and method of interpretation

Studies of the role of leptin in patients with anorexia nervosa and bulimia nervosa have conflicted in their data and interpretation. Such differences may be a result of the assay methods used or the way results are compared with those from normal controls. To investigate these possibilities, we analyzed serum leptin levels in anorexic, bulimic, obese, and control individuals, thereby spanning the full range of human body weights, using three frequently employed commercial kits. Kits from Linco (St Louis, MO) and DSL (Webster, TX) employ a radioimmunoassay method, and the R&D Systems kit (Minneapolis, MN) uses an enzyme-linked immunosorbent assay. We found that the three kits provide results that are highly linearly correlated with each other and remarkably linearly related to percent ideal body weight (%IBW) over more than three orders of magnitude (Linco, r = 0.90; R&D, r = 0.87; DSL, r = 0.86). For very low leptin levels, the more sensitive kits from R&D and Linco appeared to give more reliable results. Measurement method does not appear to explain the literature conflicts. We found that patients with anorexia nervosa have serum leptin values that lie above the line extrapolated from the %IBW/leptin curve generated from analysis of all non-anorexic patients. Therefore, in anorexia nervosa, inappropriately high leptin levels for %IBW may contribute to a blunted physiologic response to underweight and consequent resistance to dietary treatment. By contrast, most bulimic patients have leptin levels significantly below those predicted from the same %IBW/leptin curve. The relative leptin deficiency in bulimic subjects may contribute to food-craving behavior. We propose that using the %IBW/ leptin curve can facilitate identification of true pathophysiologic abnormalities in eating-disordered individuals and provide a basis for the design of therapeutic interventions or monitoring of response to treatment.

Candidate gene polymorphisms in eating disorders

Anorexia nervosa and bulimia nervosa are complex disorders characterized by disordered eating behaviour. Attitudes towards weight and shape as well as the perception of body shape are disturbed. A substantial genetic influence on these disorders has been suggested by formal genetic studies. Obsessive-compulsive behaviour, perfectionism and anxious personality traits seem to occur premorbidly in several patients. Disturbances of neurotransmitter, neuropeptide and neuroendocrine systems have been reported in acutely ill and followed-up patients. Hence, these systems might be involved in the etiology of these eating disorders.Genetic studies on candidate genes have mainly focussed on the serotonergic system and on genes involved in body weight regulation. Up to now, polymorphisms and variations in various genes (e.g. genes for 5-HT receptors, leptin gene, melanocortin MC(4) receptor gene) have been assessed for association and transmission disequilibrium pertaining to anorexia nervosa and/or bulimia nervosa. Most of the studies yielded negative results. Four studies of a polymorphism (-1438 G/A) within the promoter of the 5-HT(2A) gene (5-HT(2A)) revealed an association of the A-allele to anorexia nervosa. However, three studies could not confirm this result. Furthermore, a meta-analysis did not support the positive association. Currently, combined efforts within the European Union will answer the question of whether or not the A-allele is involved in the predisposition to anorexia nervosa. A transmission disequilibrium test is being performed in about 300 trios consisting of a patient with anorexia nervosa and both parents. As candidate gene approaches did not unequivocally identify susceptibility genes (alleles) for anorexia nervosa or bulimia nervosa, systematic model-free genome-wide screenings should also be performed in order to identify currently unknown genes involved in eating disorders. This kind of approach has already been initiated for anorexia nervosa. Genetic research on eating disorders will hopefully lead to new pharmacological treatment strategies.