Cardiac changes in anorexia nervosa

Exploring the internal medicine comorbidities associated with eating disorders: correlation between disease severity and cardiac abnormalities in adolescent patients with anorexia nervosa

Anorexia Nervosa (AN) is a psychiatric disorder characterized by caloric restriction, weight loss, and fear of gaining weight. Cardiac complications are among the most severe medical consequences. Despite the importance of regular cardiac assessments, there is a lack of standardized protocols for timing and patient selection. This retrospective cohort study has aimed to assess the correlation between AN severity, Body Mass Index, weight loss percentage, and cardiac abnormalities in pediatric patients. A total of 123 patients admitted to a child and adolescent psychiatry unit between January 2019 and March 2022 were included. Data on demographics, clinical characteristics, cardiac evaluations were collected from electronic health records. The study revealed a prevalence of cardiac abnormalities in 57.7% of patients, with bradycardia being the most common (49.5%), followed by QTc prolongation (4%) and pericardial effusion (4%). However, no significant correlation was found between AN severity and cardiac alterations, suggesting that disease severity alone is not a reliable predictor of cardiac risk. The study highlights the need for individualized risk assessment and targeted cardiac evaluations based on specific risk factors rather than disease severity alone. Early diagnosis and comprehensive care contribute to better outcomes, emphasizing the importance of multidisciplinary approaches in managing AN.

Longitudinal trends of body composition in Anorexia Nervosa: Cardiac functioning impacts the restoration of fat-free mass at three-months follow-up

BACKGROUND AND AIMS

Predictors of outcomes are needed in order to improve the clinical management of patients with Anorexia Nervosa (AN). The present study evaluated whether cardiac dysfunction might be associated with different longitudinal outcomes of AN.

METHODS AND RESULTS

A sample of 35 patients with AN (11 restricting, 24 binge-purging- age range 16-28 years old) and 42 healthy controls (18-29 years old) were evaluated in terms of psychometric variables, Body Mass Index (BMI), body composition (by bioimpedance analysis, namely: Fat-Free Mass - FFM, Fat Mass - FM, Body Cell Mass - BCM, Phase Angle - PhA) and cardiac functioning (left ventricular ejection fraction - LVEF; global longitudinal strain - LVGLS). FM was significantly and negatively associated with eating psychopathology (weight and shape concerns, b -0.523, p 0.029; and shape concerns b -0.578, p0.015), while cardiac dysfunction (LVGLS > -18%) was positively associated with dietary restraints (b 1.253, p 0.043). LVEF, in turn, was positively associated with BCM (b 0.721, p 0.008) and FFM (b 0.779, p 0.039). Cardiac dysfunction negatively impacted the effect of nutritional rehabilitation, as those patients reporting reduced LVGLS showed lower FFM (b -4.410, p 0.011), FM (b -1.495, p 0.003) and BCM (b -2.205, p 0.015) at follow-up after three months.

CONCLUSION

These preliminary results showed that cardiac functioning might represent an early predictor of cachexia and chronicity, while body composition seems to be a more accurate measure for evaluating the recovery process of patients with AN.

Beyond Menstrual Dysfunction: Does Altered Endocrine Function Caused by Problematic Low Energy Availability Impair Health and Sports Performance in Female Athletes?

Low energy availability, particularly when problematic (i.e., prolonged and/or severe), has numerous negative consequences for health and sports performance as characterized in relative energy deficiency in sport. These consequences may be driven by disturbances in endocrine function, although scientific evidence clearly linking endocrine dysfunction to decreased sports performance and blunted or diminished training adaptations is limited. We describe how low energy availability-induced changes in sex hormones manifest as menstrual dysfunction and accompanying hormonal dysfunction in other endocrine axes that lead to adverse health outcomes, including negative bone health, impaired metabolic activity, undesired outcomes for body composition, altered immune response, problematic cardiovascular outcomes, iron deficiency, as well as impaired endurance performance and force production, all of which ultimately may influence athlete health and performance. Where identifiable menstrual dysfunction indicates hypothalamic-pituitary-ovarian axis dysfunction, concomitant disturbances in other hormonal axes and their impact on the athlete's health and sports performance must be recognized as well. Given that the margin between podium positions and "losing" in competitive sports can be very small, several important questions regarding low energy availability, endocrinology, and the mechanisms behind impaired training adaptations and sports performance have yet to be explored.

A prospective observational study comparing rates of medical instability between adolescents with typical and atypical anorexia nervosa

BACKGROUND

Recognition of atypical anorexia nervosa (AAN) has challenged underweight as a defining factor of illness severity in anorexia nervosa (AN). The present study aimed to compare rates of medical instability in adolescents with underweight (AN) and non-underweight (AAN) anorexia nervosa.

METHODS

The study examined assessment data from specialist eating disorder services in the UK between January and December 2022. Participants (n = 205) aged 11-18 years were recruited across eight eating disorder clinics and diagnosed with AN (n = 113) or AAN (n = 92) after clinical assessment. Parameters associated with risk of medical instability were compared between AN and AAN groups, using t tests and regression analysis.

RESULTS

Rates of bradycardia and hypotension did not differ significantly between AN and AAN groups (p = 0.239 and p = 0.289). Although white blood cell counts were lower in the AN group, rates of leukopaenia could not be statistically compared as a result of there being too few counts in at least one group. No incidences of hypophosphataemia were found in the sample. A significant regression equation was found for percentage median body mass index, but not rate of weight loss, as a predictor of blood pressure, serum phosphorous and magnesium.

CONCLUSIONS

Our findings indicate that medical instability occurs across a range of body weights in young people with AN and AAN. Although certain parameters of risk such as blood pressure, serum phosphorous and magnesium may be worsened at lower weight, both AN and AAN are serious mental health conditions that can lead to medical instability.

Carotid wave analysis in young adults with a history of adolescent anorexia nervosa: a case control study

BACKGROUND

Anorexia nervosa (AN) is associated with abnormalities that may increase the risk of future cardiovascular disease. This study assessed the cardiovascular health of individuals who recovered from AN during adolescence by conducting wave power analysis.

METHODS

Former AN patients discharged from the Royal Children's and Monash Children's Hospitals (N = 17) in Melbourne, Australia underwent ultrasound imaging of the right carotid artery. Wave power analysis was conducted to assess biomechanical interactions of the cardiovascular system. Patient measures were compared to healthy controls (N = 51).

RESULTS

Eighty-eight percent of the former AN patients and controls were female, aged approximately 25 years, with a healthy body mass index. Mean carotid flow and pulsatility index were not different between groups. Carotid arterial strain and distensibility were lower, and the wave speed and beta stiffness index higher in the former AN patients. Characteristic impedance was not different nor were the forward and backward wave amplitudes. However, wave reflection indices (ratios of backward-to-forward compression wave area, and wave-related effect on pressure and hydraulic power) were 12-18% lower in the former AN patients (p < 0.05).

CONCLUSIONS

Increased carotid artery stiffness and reduced wave reflection are evident in young adults who recovered from adolescent AN. This may relate to an adaptive process that helps to maintain or restore flow and characteristic impedance despite increased vessel stiffness, with this warranting future investigation.

Shared genetic risk between anorexia nervosa and cardiovascular disease events: Evidence from genome-wide association studies

OBJECTIVE

Cardiovascular complications occur in up to 80% of patients with anorexia nervosa (AN), yet the underlying mechanisms warrant further investigation. We assessed the genetic correlation (rg ) between AN and cardiovascular disease (CVD) events to inform whether elevated cardiovascular risk among individuals with AN is due to shared genetic effects.

METHOD

We used genome-wide association study summary statistics for AN (N = 72,517), AN with binge eating (N = 12,630), AN without binge eating (N = 12,516), and six CVD events (N = 390,142 to 977,323). We calculated the rg s via linkage disequilibrium score regression and corrected for multiple testing using false discovery rate.

RESULTS

Significant rg s emerged between AN with heart failure (rg  = -0.11, SE = 0.05, q = .04) and myocardial infarction (rg  = -0.10, SE = 0.03, q = .01). AN with binge eating had a significant rg with myocardial infarction (rg  = -0.15, SE = 0.06, q = .02). No significant rg emerged between AN without binge eating and any CVD event.

DISCUSSION

Some loci affect the liability to AN and CVD in opposite directions and the shared genetic effects may not be consistent across all CVD events. Our results provide further evidence suggesting that the elevated cardiovascular risk in AN may not be due to shared genetic underpinnings, but more likely a downstream consequence of the disease.

[Medical complications in anorexia and bulimia nervosa]

Anorexia nervosa and bulimia nervosa are eating disorders associated with life-threatening multisystemic medical complications. This narrative review aimed to present the medical complications most related to these disorders. In anorexia nervosa, many of them are linked to malnutrition and underweight, usually reversible with renutrition and weight restoration, although refeeding can also be linked to some medical complications. Purging behaviors observed in the anorexia nervosa binge-purging subtype and bulimia nervosa have been mainly related to hydrolectrolyte and acid-base disturbances, in addition to local complications. Thus, an early identification and therapeutic intervention of these disorders is considered crucial. Integral medical monitoring should be ensured to prevent potential serious complications from the early stages, with the involvement of physicians, psychologists, nutritionists, and other specialists in a multidisciplinary approach according to the patient's needs.

Cardiac involvement and its clinical significance in patients with anorexia nervosa

Cardiac complications are a major concern in patients with anorexia nervosa (AN) which contribute to morbidity and mortality. However, limited information exists regarding risk factors for the development of these complications. Our objective was to investigate the prevalence and associated risk factors of cardiac involvement among children and adolescents with AN admitted to a tertiary pediatric hospital. We collected demographic, clinical, and laboratory data from individuals with AN hospitalized between 2011 and 2020 in Schneider Children's Medical Center in Israel. Diagnosis was based on established criteria (DSM-5). Patients with other co-morbidities were excluded. Cardiac investigations included electrocardiograms (ECG) and echocardiograms. We conducted correlation tests between cardiac findings and clinical and laboratory indicators. A total of 403 AN patients (81.4% were females) with a median age of 15 ± 2 years were included in the study. Sinus bradycardia was the most common abnormality, observed in 155 (38%) participants. Echocardiogram was performed in 170 (42.2%) patients, of whom 37 (22%) demonstrated mild cardiac aberrations. Among those aberrations, 94.6% could be attributed to the current metabolic state, including pericardial effusion (15.3%) and valve dysfunction (8.8%). Systolic or diastolic cardiac dysfunction, tachyarrhythmias, or conduction disorders were not observed. Patients with new echocardiographic aberration had significantly lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension was higher in this group.

CONCLUSIONS

The prevalence of cardiac involvement, except for sinus bradycardia, was notably low in our cohort. The presence of cardiac aberrations is correlated with several clinical variables: lower body mass index (BMI) and the presence of amenorrhea and hypotension at admission. Patients presenting with these variables may be at high risk for cardiac findings per echocardiography. Dividing the patients into high and low risk groups may enable targeted evaluation, while avoiding unnecessary cardiac investigations in low-risk patients.

WHAT IS KNOWN

• Cardiac involvement in anorexia nervosa (AN) patients is a major concern, which contributes to morbidity and mortality. • It is unknown which patients are prone to develop this complication.

WHAT IS NEW

• Cardiac complications in our cohort are less frequent compared to previous studies, and it is correlated with lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension.

Fifteen-minute consultation: Recognition and management of eating disorders presenting to the emergency department

Eating disorder presentations in children and young people during the COVID-19 pandemic have increased, and this has become a common presentation to paediatric emergency departments (EDs). We cover a structured approach on identifying and managing these presentations within the ED including history taking, what to look for on examination, what investigations are needed and how to decide who requires admission to hospital.

Long-term cardiovascular consequences of adolescent anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with maladaptive cardiovascular changes. This study investigated whether individuals who recovered from AN during adolescence experience long-term cardiovascular risk in early adulthood.

METHODS

Former AN patients discharged from the Royal Children's and Monash Children's Hospital Eating Disorder Services in Melbourne, Australia underwent cardiovascular testing. Measurements were performed using an oscillometric device for blood pressure and pulse wave velocity, ultrasound for carotid wall structure/function, resting electrocardiogram for heart-rate variability, and the EndoPat 2000 (Itamar) system for endothelial function. Patient measures were compared to healthy controls and/or normal thresholds.

RESULTS

Ninety-one percent of the former AN patients (N = 22) and controls (N = 66) were female, aged approximately 25 years, with a healthy body mass index. The mean time interval from AN recovery to participation was 7.4 years. Pulse wave velocity was lower in the former AN patients than controls. Carotid intima-media thickness was not different; however, carotid distensibility and compliance were lower, and the elastic modulus higher in the former AN patients. Greater vagal tone was observed and endothelial dysfunction was evident in 46% of the former patients.

CONCLUSIONS

Young adults who recovered from adolescent AN exhibit persistent cardiovascular adaptations. Routine cardiovascular monitoring could manage potential disease risk.

IMPACT

Cardiovascular complications are common in patients with anorexia nervosa (AN) and population studies have revealed that developmental adaptations in response to undernutrition have long-term consequences for cardiovascular health. In this study of young adults treated for AN during adolescence, there was evidence of increased carotid artery stiffness, reduced aortic stiffness, vagal hyperactivity, and endothelial dysfunction in early adulthood when compared to healthy controls. It is important to consider the cardiovascular health of patients with AN beyond achieving medical stability. Interventions that monitor cardiovascular health could minimise the burden of future cardiovascular disease.

Low Energy Availability (LEA) and Hypertension in Black Division I Collegiate Athletes: A Novel Pilot Study

The purpose of this study was to investigate the relationship between low energy availability (LEA) and nutritional content with high blood pressure (HBP) in African American Division I athletes. Twenty-three D1 African American pre-season athletes were recruited to participate. HBP was defined as >120 systolic blood pressure (BP) and <80 diastolic BP. Athletes self-reported nutritional intake using a non-consecutive 3-day food recall which was then reviewed by a sports dietitian. LEA was evaluated as total energy intake-total daily energy expenditure (TDEE), which was predicted. Additionally, micronutrients were evaluated. A statistical analysis relied on Spearman correlation (R), standardized mean difference with 95% confidence interval, mean ± SD, and odds ratios (OR). Correlation values were categorized: 0.20-0.39 = low; 0.40-0.69 = moderate; 0.70-1.0 = strong. A moderate relationship was observed between HBP and LEA (R = 0.56) with 14/23 having HBP. Of the 14 athletes observed with HBP, 78.5% (11/14) were calorically deficient (-529 ± 695 kcal) with an OR of 7.2. Micronutrient intake deficiencies were ubiquitous among the 23 HBP athletes: poly-unsaturated fatty acid -29.6%; omega-3 -26.0%; iron -46.0%; calcium -25.1%; and sodium -14.2%, amongst others. LEA and micronutrient deficiencies may contribute to HBP in Black D1 athletes, which has been shown to be the most common modifiable risk factor to decrease the risk of sudden cardiac death.

'It stopped you thinking about food' - The experiences of mealtimes and attending a post-meal support group for young people with anorexia nervosa

Anorexia nervosa presents as an international public health concern as it is the mental health problem with the greatest risk of mortality, and the average age of onset is decreasing. For those experiencing anorexia nervosa, mealtimes have long been recognized as a difficult and distressing time when young people need additional support. However, the post mealtime period can be associated with even greater distress, yet there is little research on interventions to support young people in this vulnerable time, and even less on how young people experience these interventions. This study, therefore, explores young peoples' perceptions of mealtimes and a post mealtime support group. Using a qualitative descriptive design, telephone interviews were conducted with a purposive sample of six young people who participated in a post-meal support group while an inpatient in a Child and Adolescent Mental Health Unit. Using a semi-structured interview guide, participants were asked about their experiences of this support group and their perceptions of how to improve this intervention. Content analysis resulted in the development of three themes: 'The Challenges of Mealtimes and Post Mealtimes', 'The Benefits of Post-meal Support Groups', and 'Improving Unhelpful Aspects of Post-meal Support Groups'. Findings are reported in accordance with COREQ guidelines and suggest that for young people experiencing anorexia nervosa, post mealtimes are often more distressing than the meal itself and that participants found post-meal support groups to be a helpful intervention in reducing post-mealtime distress. Post-meal support groups can be improved by ensuring a consistent approach from staff and providing staff with the training and knowledge required to support those affected by eating disorders.

Identifying latent classes of Relative Energy Deficiency in Sport (RED-S) consequences in a sample of collegiate female cross country runners

OBJECTIVE

The purpose of this study was to identify patterns of clustering of the 10 health consequences identified in the Relative Energy Deficiency in Sport (RED-S) framework among collegiate female Cross-Country runners. We also assessed risk characteristics associated with each cluster.

METHODS

This randomly sampled population included 211 current National Collegiate Athletics Association (NCAA) Division I (DI) female cross country runners who completed a quantitative survey. We used latent class analysis (LCA) to group athletes into mutually exclusive classes based on shared response patterns of RED-S consequences. We computed descriptive statistics to identify demographics, personal characteristics, disordered eating and emotional health characteristics associated with each class.

RESULTS

The average age of the sample was 21 years with mean body mass index 20.4 kg/m². The LCA identified three unique classes of potential RED-S presentations: (1) low probability of RED-S consequences; (2) complex physical and psychological concerns with a higher burden of cardiovascular concern and (3) very high probability of anxiety with high burden of menstrual disturbance, bone injury and gastrointestinal concern. All classes were characterised by high levels of menstrual disturbance and distinguished by the number and burden of other potential RED-S consequences and in reported abuse history, emotional regulation and perfectionism.

CONCLUSION

This study identified a high burden of menstrual disturbance in NCAA D1 cross country runners, and three unique presentations of RED-S consequences. Future research is warranted to better understand how early prevention and intervention strategies may mitigate RED-S consequences in distance runners.

Assessment and management of cardiovascular complications in eating disorders

BACKGROUND

Eating disorders (EDs) are serious conditions predominantly affecting adolescents and young adults (AYAs) and pose a considerable threat to their health and wellbeing. Much of this increased morbidity and mortality is linked to medical compromise, especially cardiovascular abnormalities. Rates of presentation to both community and inpatient medical settings have increased in all age groups following the Covid-19 pandemic and subsequent "lockdowns", with patients presentations being more medically compromised compared to previous years. This has implications for clinicians with regard to the performance of competent cardiovascular assessments and management of findings.

AIMS

This paper is a practical resource for clinicians working with AYAs in whom EDs may present. It will provide a brief summary of the physiological context in which cardiovascular complications develop, systematically outline these complications and suggest a pragmatic approach to their clinical evaluation.

METHODS

Relevant literature, guidelines and academic texts were critically reviewed. Conclusions were extracted and verified by a Child and Adolescent Psychiatrist and Adolescent Paediatrician, with suitable expertise in this clinical cohort.

CONCLUSIONS

The cardiovascular complications in EDs are primarily linked to malnutrition, and patients presenting with Anorexia Nervosa are most often at greatest risk of structural and functional cardiac abnormalities, including aberrations of heart rate and rhythm, haemodynamic changes and peripheral vascular abnormalities. Other cardiovascular abnormalities are secondary to electrolyte imbalances, as seen in patients with Bulimia Nervosa. More recently defined EDs including Avoidant/Restrictive Food Intake Disorder and Binge Eating Disorder are also likely associated with distinct cardiovascular complications though further research is required to clarify their nature and severity. Most cardiovascular abnormalities are fully reversible with nutritional restoration, and normalisation of eating behaviours, including the cessation of purging, though rare cases are linked to cardiac deaths. A detailed clinical enquiry accompanied by a thorough physical examination is imperative to ensure the medical safety of AYAs with EDs, and should be supported by an electrocardiogram and laboratory investigations. Consideration of cardiovascular issues, along with effective collaboration with acute medical teams allows community clinicians identify those at highest risk and minimise adverse outcomes in this cohort.

Medical and physiological complications of exercise for individuals with an eating disorder: A narrative review

Individuals with eating disorders (ED) experience prolonged malnutrition, binge episodes, and compensatory behaviours that affect every organ system. Psychological and physiological symptoms are worsened with comorbid dysfunctional exercise, seen in up to 80% of those with an ED. Although return to exercise is an important component of treatment and recovery, little is known about the contraindications and risks of exercise engagement specific to those with an ED. This paper provides a comprehensive narrative review of the medical and physiological complications of engaging in exercise during ED treatment and outlines when exercise may be contraindicated or used in modified or cautionary ways. We conducted a literature search on MEDLINE, PubMed, and PsychArticles to identify relevant articles, which yielded six categories of medical and physiological complications of ED that may be exacerbated by exercise: energy availability, cardiovascular health, electrolyte abnormalities, biomedical function markers, sex hormones, and body composition. We summarize the evidence for these complications for readers and offer an initial set of recommendations for incorporating exercise during ED treatment based on our findings. This review may serve as a resource for members of ED treatment teams to help evaluate more readily and confidently whether exercise is safe for individual patients and when modifications and caution may be warranted.

Early echocardiographic evaluation of children admitted to the emergency department for anorexia nervosa during the COVID-19 pandemic

PURPOSE

Anorexia nervosa (AN) is the most frequent eating disorder (ED), whose cardiac complications may have life-threatening consequences for both the physical and psychological health of affected children. In this study, we reported and analysed the echocardiographic anomalies found in pediatric patients diagnosed with AN.

METHODS

We reported the demographic and clinical characteristics of children aged 8 to 18 years, who were diagnosed with AN and underwent a complete cardiological evaluation at the Emergency Department of the Bambino Gesù Children's Hospital, IRCCS, Rome between the 1st January 2021 and the 30th June 2021. Furthermore, we compared the patients according to the presence of pericardial effusion and a BMI (body mass index) cut-off 14.5 kg/m2.

RESULTS

Forty-nine patients were included in the study. The mean age was 15.1 years. Most patients were female (89.8%). The mean length of hospitalization was 18 days. The mean BMI at admission was 14.8 kg/m2, with a median weight loss of 9 kg in the last year. Eleven patients (22.4%) presented with cardiovascular signs or symptoms at admission. Most patients had pericardial effusion on heart ultrasound, with a mean thickness of 6 mm (SD ± 4). The LV (left ventricle) thickness over age was significantly higher in patients with pericardial effusion, with a Z score of -2.0 vs -1.4 (p = 0.014). The administration of psychiatric drugs was significantly more frequent in patients with a lower BMI (37.5% vs 12%, p = 0.038).

CONCLUSION

Our study suggests that a non-urgent baseline echocardiographic evaluation with focus on left-ventricular wall thickness and mass in children with anorexia nervosa is advisable.

LEVEL III

Evidence obtained from cohort or case-control analytic studies.

Cardiac Complications Associated with Eating Disorders in Children: A Multicenter Retrospective Study

PURPOSE

Eating disorders often result in somatic complications, including cardiac abnormalities. Cardiac abnormalities may involve any part of the heart, including the cardiac conduction system, and can lead to sudden cardiac death. The current study aimed to evaluate the incidence of cardiac complications in pediatric patients with eating disorders and their associated factors.

METHODS

We retrospectively analyzed patients aged 10-18 years who were diagnosed with DSM-V (Diagnostic and Statistical Manual of Mental Disorder-V) eating disorders and underwent electrocardiography (ECG) and/or echocardiography between January 2015 and May 2020.

RESULTS

In total, 127 patients were included, of whom 113 (89.0%) were female. The median body mass index (BMI) was 15.05±3.69 kg/m². Overall, 74 patients (58.3%) had ECG abnormalities, with sinus bradycardia being the most common abnormality (91.9%). Patients with ECG abnormalities had significantly lower BMI (14.35±2.78 kg/m² vs. 16.06± 4.55 kg/m², p<0.001) than patients without ECG abnormalities, as well as lower phosphorus and higher cholesterol levels. Among the 46 patients who underwent echocardiographic evaluation, 23 (50.0%) had echocardiographic abnormalities, with pericardial effusion being the most common (60.9%). The median left ventricular mass (LVM) and ejection fraction were 67.97±21.25 g and 66.91±28.76%, respectively. LVM and BMI showed a positive correlation (r=0.604, p<0.001). After weight gain, the amount of pericardial effusion was reduced in 3 patients, and 30 patients presented with normal ECG findings.

CONCLUSION

Cardiac abnormalities are relatively frequent in patients with eating disorders. Physicians should focus on this somatic complication and careful monitoring is required.

Cardiac Remodeling and Its Determinants in Anorexia Nervosa Adolescents: Impact of Weight Recovery

Cardiovascular alterations in anorexia nervosa (AN) adolescents include bradycardia and decreased systolic blood pressure and left ventricular mass. However, their determinants remain poorly understood. We assessed the associations between morphological and functional left ventricular (LV) remodeling, autonomic control by heart rate variability (HRV) analysis, thyroid hormones and brain natriuretic peptide (BNP) levels in AN female adolescents without or with weight recovery (WR). Fifty-nine female adolescents including 16 AN patients without WR (mean age 13.9 years (10−16)), 10 AN patients with WR (15.7 years (12−18)) and 33 controls (14.1 years (10−18)) underwent night heart rate (HR) recording to measure HRV (and especially SD1/SD2, the ratio between instantaneous (SD1) and long-term (SD2) standard deviation of R-R intervals, reflecting sympatho-vagal balance), speckle tracking echocardiography to assess LV global longitudinal strain (GLS) and blood test for dosage of tri-iodothyronine (T3) hormone and NT-proBNP. Compared to controls, AN patients without WR presented with lower HR (55 ± 7 vs. 68 ± 6 bpm; p < 0.001), parasympathetic hyperactivity, and higher GLS (−19.2 ± 1.8 vs. −16.9 ± 2.8%; p = 0.009). These alterations were partly abolished in AN patients with WR. In a multivariate regression analysis, T3 was the main factor explaining the variance of SD1/SD2, a sympatho-vagal balance marker. NT-proBNP levels were not correlated with cardiac alterations. AN patients had parasympathetic hyperactivity linked with their rate of T3, and a higher GLS. These alterations were partly restored in AN patients with WR.

High levels of physical activity in female adolescents with anorexia nervosa: medical and psychopathological correlates

PURPOSE

While overexercise is commonly described in patients who experience anorexia nervosa (AN), it represents a condition still underestimated, especially in the paediatric population.

METHOD

The present study aims at assessing the possible associations between levels of physical activity (PA) and clinical features, endocrinological data and psychopathological traits in a sample of 244 female adolescents hospitalised for AN subdivided into two groups according to PA levels (high PA vs. no/low PA). The two groups were compared through multivariate analyses, while multiple regression analysis was conducted to determine whether physical activity predict specific outcomes.

RESULTS

No significant differences were found between the two groups in terms of last Body Mass Index (BMI) before illness, BMI at admission and disease duration, while a difference emerged in delta BMI(rapidity of weight loss), significantly higher in high-PA group (p = 0.021). Significant differences were observed in Free triiodothyronine- (p < 0.001), Free thyroxine (p = 0.046), Follicle-stimulating hormone (p = 0.019), Luteinising hormone (p = 0.002) levels, with values remarkably lower in high-PA group. Concerning psychopathological scales, the high-PA group showed worst Children's Global Assessment Scale (CGAS) scores (p = 0.035). Regression analyses revealed that higher PA predicts higher delta BMI (p = 0.021), presence of amenorrhea (p = 0.003), lower heart rate (p = 0.012), lower thyroid (Free triiodothyronine p < 0.001, Free thyroxine p = 0.029) and gynaecological hormones' levels (Follicle-stimulating hormone p = 0.023, Luteinising hormone p = 0.003, 17-Beta estradiol p = 0.041). Concerning psychiatric measures, HPA predicts worst scores at CGAS (p = 0.019), and at scales for evaluation of alexithymia (p = 0.028) and depression (p = 0.004).

CONCLUSIONS

Results suggest that high levels of physical activity in acute AN associate with worst clinical conditions at admission, especially in terms of endocrinological and medical features.

LEVEL OF EVIDENCE

Level III.

To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

Recognising and managing eating disorders in the emergency department

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Recommendations and Nutritional Considerations for Female Athletes: Health and Performance

Optimal nutrition is an important aspect of an athlete’s preparation to achieve optimal health and performance. While general concepts about micro- and macronutrients and timing of food and fluids are addressed in sports science, rarely are the specific effects of women’s physiology on energy and fluid needs highly considered in research or clinical practice. Women differ from men not only in size, but in body composition and hormonal milieu, and also differ from one another. Their monthly hormonal cycles, with fluctuations in estrogen and progesterone, have varying effects on metabolism and fluid retention. Such cycles can change from month to month, can be suppressed with exogenous hormones, and may even be manipulated to capitalize on ideal timing for performance. But before such physiology can be manipulated, its relationship with nutrition and performance must be understood. This review will address general concepts regarding substrate metabolism in women versus men, common menstrual patterns of female athletes, nutrient and hydration needs during different phases of the menstrual cycle, and health and performance issues related to menstrual cycle disruption. We will discuss up-to-date recommendations for fueling female athletes, describe areas that require further exploration, and address methodological considerations to inform future work in this important area.

Arterial stiffness in underweight and weight-restored anorexia nervosa

Cardiovascular complications have been demonstrated in patients with anorexia nervosa (AN) in both the state of starvation and during weight restoration, however, the underlying mechanisms remain unclear. The current study aimed to assess arterial stiffness via carotid-femoral pulse wave velocity (cfPWV) in the acute and weight-restored states of AN. The study also aimed to determine the association between psychological distress and cfPWV. The sample included 37 participants; 10 participants with AN, 17 who were weight-restored (AN-WR; minimum body mass index >18.5 for at least 12 months) and 10 healthy controls (HCs). cfPWV via applanation tonometry was conducted to assess arterial stiffness. Psychological distress was assessed using the depression anxiety stress scale (DASS-21) and the state-trait anxiety inventory (STAI). Between-group comparisons were performed to determine differences between groups, a two-stage hierarchical regression model was performed to determine the contribution of physiological and psychological variables on cfPWV and correlation analyses were also performed. Vascular stiffness was significantly increased in the AN and AN-WR groups, relative to HCs. The total DASS score was the only significant predictor of cfPWV across the sample. There were positive associations between cfPWV and depression, anxiety and stress, as assessed by the DASS. Furthermore, cfPWV was positively associated with STAI trait anxiety. Arterial stiffness was increased in individuals in the acute and weight-restored states of AN, demonstrating early signs of the development of arteriosclerotic cardiovascular disease. Increased arterial stiffness was associated with increased psychological distress, which may be a contributing mechanism to the increased cardiovascular risk in AN.

Autonomic Nervous System Function in Anorexia Nervosa: A Systematic Review

Background: Autonomic nervous system (ANS) dysfunction has been suggested to contribute to the high prevalence of cardiovascular complications in individuals with anorexia nervosa (AN), yet has not been thoroughly investigated. The current review aimed to synthesize the evidence of basal ANS function in individuals with a current diagnosis of AN and those with a previous diagnosis who had achieved weight restoration, as compared to controls. Methods: A systematic review of nine databases was conducted and studies that were published in a peer-review journal, in English, that included at least one assessment of ANS function in individuals with a current or previous diagnosis of AN were selected. Forty-six studies were included with a total of 811 participants with a current diagnosis of AN and 123 participants with a previous diagnosis of AN. Results: ANS function was assessed through heart rate variability (n = 27), orthostatic challenge, blood pressure variability or baroreflex sensitivity (n = 11), adrenergic activity (n = 14), skin conductance level (n = 4), and pupillometry (n = 1). Individuals with AN demonstrated increased parasympathetic activity and decreased sympathetic activity, suggestive of autonomic dysregulation. Following weight restoration, autonomic function trended toward, or was equivalent to, control levels. Discussion: Autonomic dysregulation is indicated through a range of assessments in individuals with AN. Future investigations should utilize a variety of assessments together in order to conclusively establish the nature of autonomic dysfunction in AN, and following extended weight restoration. Moreover, investigation into the co-occurrence of ANS function and cardiovascular risk is required.

Skeletal Deformities in Osterix-Cre;Tgfbr2f/f Mice May Cause Postnatal Death

Transforming growth factor β (TGFβ) signaling plays an important role in skeletal development. We previously demonstrated that the loss of TGFβ receptor II (Tgfbr2) in Osterix-Cre-expressing mesenchyme results in defects in bones and teeth due to reduced proliferation and differentiation in pre-osteoblasts and pre-odontoblasts. These Osterix-Cre;Tgfbr2^f/f mice typically die within approximately four weeks for unknown reasons. To investigate the cause of death, we performed extensive pathological analysis on Osterix-Cre- (Cre-), Osterix-Cre+;Tgfbr2^f/wt (HET), and Osterix-Cre+;Tgfbr2^f/f (CKO) mice. We also crossed Osterix-Cre mice with the ROSA26mTmG reporter line to identify potential off-target Cre expression. The findings recapitulated published skeletal and tooth abnormalities and revealed previously unreported osteochondral dysplasia throughout both the appendicular and axial skeletons in the CKO mice, including the calvaria. Alterations to the nasal area and teeth suggest a potentially reduced capacity to sense and process food, while off-target Cre expression in the gastrointestinal tract may indicate an inability to absorb nutrients. Additionally, altered nasal passages and unexplained changes in diaphragmatic muscle support the possibility of hypoxia. We conclude that these mice likely died due to a combination of breathing difficulties, malnutrition, and starvation resulting primarily from skeletal deformities that decreased their ability to sense, gather, and process food.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

T-wave morphology among medically treated patients with Anorexia Nervosa

Anorexia nervosa (AN) has the highest rate of mortality of any psychiatric disorder, and cardiovascular complications occur in up to 80% of patients with AN and account for up to 30% of mortality. A controversy exists as to whether patients with AN are prone to develop electrocardiographic abnormalities related to repolarization. We aim to study previously unexplored T wave morphology markers in medically-treated patients with AN. Fifty-eight patients with AN (32 with restricting type and 26 with binge-eating/purging type) and 82 healthy controls were included in the study. ECGs were conducted under strict conditions and total cosine R-to-T (TCRT) and T-wave morphology dispersion (TMD) were computed according to accepted standards for a random beat and for an averaged beat. Forty-six AN patients were hospitalized (79.3%) during the study for a mean duration of 1.5 ± 1.1 months. AN patients had comparable QTc, TCRT, mean TMD, TMDpre, TMDpost and TCRTc values to those of healthy adults. Flattened T wave occurred slightly more often among AN patients than in controls (1.57 ± 1.23 leads affected compared with 1.11 ± 0.80 leads, respectively, p = 0.017). QTc, TCRT and TMD parameters' values were unaffected by the clinical type of AN. In conclusion, weight-restored AN patients are characterized by T wave flattening, but normal other T wave morphology parameters, which seemingly reflects an overall low risk of repolarization-associated ventricular arrhythmias. Long-term follow-up studies should be conducted to evaluate the prognostic significance of these novel repolarization markers in untreated patients or early in the refeeding phase.

Role of Neuroendocrine, Immune, and Autonomic Nervous System in Anorexia Nervosa-Linked Cardiovascular Diseases

Anorexia nervosa represents a severe mental disorder associated with food avoidance and malnutrition. In patients suffering from anorexia nervosa, cardiovascular complications are the main reason leading to morbidity and mortality. However, the origin and pathological mechanisms leading to higher cardiovascular risk in anorexia nervosa are still unclear. In this aspect, the issue of exact pathological mechanisms as well as sensitive biomarkers for detection of anorexia nervosa-linked cardiovascular risk are discussed. Therefore, this review synthesised recent evidence of dysfunction in multiple neuroendocrine axes and alterations in the immune system that may represent anorexia nervosa-linked pathological mechanisms contributing to complex cardiovascular dysregulation. Further, this review is focused on identification of non-invasive biomarkers for the assessment of increased cardiovascular risk in anorexia nervosa that can be linked to a clinical application. Complex non-invasive assessment of cardiovascular autonomic regulation—cardiac vagal control (heart rate variability), sympathetic vascular activity (blood pressure variability), and cardiovascular reflex control (baroreflex sensitivity)—could represent a promising tool for early diagnosis, personalized therapy, and monitoring of therapeutic interventions in anorexia nervosa particularly at a vulnerable adolescent age.

Medical Complications of Anorexia Nervosa

OBJECTIVE

The purpose of this study was to describe the medical complications of anorexia nervosa (AN) to enable a consult-liaison psychiatrist to be familiar with these complications when involved with the care of a hospitalized patient with AN.

METHODS

Comprehensive PubMed search of English language publications of adult patients with AN was carried out using keywords, phrases, and medical subject headings of anorexia nervosa-medical complications, cardiac, osteoporosis, gastrointestinal, hematological, and endocrine. The database search was restricted by time of publication of studies from 2005 to 2020.

RESULTS

Every organ system can be adversely affected by AN. Most are fully reversible with time and informed medical care. A multidisciplinary team is needed to optimally care for patients who are hospitalized as a result of the medical complications of their AN.

CONCLUSIONS

Consult-liaison psychiatrists are asked to help in the care of patients with AN who are admitted to a hospital because of a medical complication of their illness. Being familiar with these complications and their treatments will optimize their hospital stays and the care provided. In addition, involving other relevant ancillary services is an important care consideration.

Physical health and symptoms of relative energy deficiency in female fitness athletes

INTRODUCTION

Competing in aesthetic sports increases the risk of low energy availability and associated health impairments. Fitness physique sport is a popular, but understudied aesthetic sport. We evaluated health and symptoms of relative energy deficiency in sport (RED-s) in female fitness athletes (FA) and female references (FR) during a competitive season.

METHODS

Totally, 25 FA and 26 FR, mean (SD) age of 28.9 (5.7), were included. Assessments were at baseline (T1), 2-weeks pre-competition (T2), and 1-month post-competition (T3), by dual-energy x-ray absorptiometry scan, indirect calorimetry, diet registration, The Low Energy Availability in Females Questionnaire, The Beck Depression Inventory, and Eating Disorder Examination Questionnaire (EDE-Q).

RESULTS

A history of eating disorders was reported by 35% FA and 12% FR. There were no between-group differences at T1, besides less mean (99% CI) fat mass (FM) of 3.1 kg (-0.4, 6.5) in FA (P = .02). At T2, FA had lower BW of 6.7 kg (-12.0, -1.3), fat mass of -9.0 kg (-12.5, -5.5), and resting heart rate of -8.0 beats per minute (-14.5, -1.5) compared to FR (P ≤ .006). FA reduced resting metabolic rate by -191 kcal (-11, -371) and increased symptoms of gastrointestinal dysfunction (GD) by 1.4 points (0.3, 2.5) and prevalence of amenorrhea from 8% to 24%, (P < .003). At T3, there was a between-group difference in fat mass, and a high number of FA with amenorrhea and GD.

CONCLUSION

Manifestation of symptoms of RED-s, some with persistence one-month post-competition, raises concern for the health of FA and those complying with the fit body ideal.

Characteristics and clinical trajectories of patients meeting criteria for avoidant/restrictive food intake disorder that are subsequently reclassified as anorexia nervosa

OBJECTIVE

To examine the initial assessment profiles and early treatment trajectories of youth meeting the criteria for avoidant/restrictive food intake disorder (ARFID) that were subsequently reclassified as anorexia nervosa (AN).

METHOD

A retrospective cohort study of patients assessed and treated in a tertiary care eating disorders (ED) program was completed.

RESULTS

Of the 77 included patients initially meeting criteria for ARFID, six were reclassified as having AN (7.8%) at a median rate of 71 days after the first assessment. Patients in this cohort presented at very low % treatment goal weight (median 71.6%), self-reported abbreviated length of illness (median 6 months), and exhibited low resting heart rates (median 46 beats per minute). Nutrition and feeding focused worries related more to general health as opposed to specific weight and shape concerns or fears at assessment in half of those reclassified with AN. Treatment at the 6-month mark varied among patients, but comprised family and individual therapy, as well as prescription of psychotropic medication.

CONCLUSION

Prospective longitudinal research that utilizes ARFID-specific as well as traditional eating disorder diagnostic measures is required to better understand how patients with restrictive eating disorders that deny fear of weight gain can be differentiated and best treated.

Assessment of left ventricular systolic and diastolic functions in severely malnourished children

Background

Malnourished children endure many changes in body composition and lose heart and skeletal muscle mass. Diastolic dysfunction is one of the major causes of heart failure with preserved ejection fraction.

Aim

To assess left ventricular systolic and diastolic functions in children with severe acute malnutrition using tissue Doppler imaging technique and to evaluate the effect of nutritional rehabilitation.

Patients and Methods

A follow-up case-control study conducted on 60 severely malnourished children (WHZ < -3SD) and 120 age and sex-matched healthy children as a control group. Tissue Doppler imaging (TDI) was done for all included malnourished children at admission and for control to measure left ventricular systolic and diastolic functions. Nutritional rehabilitation was done according to WHO protocol and tissue doppler was repeated after rehabilitation when (WHZ > -2SD) to detect any changes in systolic or diastolic functions.

Results

Systolic function was normal in malnourished children and control. Grade I diastolic dysfunction was detected in 40% and grade II in 30% of severely malnourished children in comparison to 100% normal diastolic function in control group. No correlations between diastolic dysfunction and either anthropometric measurements, electrolyte disturbances or Hb% in malnourished children before nutritional rehabilitation. Mortality from sepsis with associated ventricular dysfunction grade II documented in 3.3% of malnourished children. After nutritional rehabilitation diastolic function improved significantly as 65.6% of children attained normal diastolic function, 31% grade1 and 3.4% grade II. Positive correlations between diastolic function and WAZ, HAZ, WHZ and MUAC after rehabilitation.

Conclusion

Severe acute malnutrition affects diastolic function in children which is reversible in most of these cases with rehabilitation. TDI is an easy and practical method for detection and follow-up of ventricular function in malnourished children.

QTc Interval and Risk of Cardiac Events in Adults With Anorexia Nervosa: A Long-Term Follow-Up Study

BACKGROUND

The literature contains several cases of anorexia nervosa (AN) patients with prolonged QTc interval. However, the risk of prolonged QTc interval is controversial and the risk of cardiac events in AN patients has yet to be investigated.

METHODS

We estimated the difference in mean QTc interval and relative risk of borderline prolonged QTc (>440 ms) and prolonged QTc (>460 ms) between 430 adult women AN patients and 123 healthy controls using 3 correction formulas. In a follow-up study, we estimated the risk of a primary end point (a composite of ventricular tachycardia, aborted cardiac arrest, and cardiac arrest) in AN patients compared with a population-based cohort derived from the Danish Civil Register.

RESULTS

Mean QTc for AN patients was 408 ms (Hodges), 402 ms (Fridericia), and 399 ms (Bazett). Hodges' found a slightly increased mean QTc (6.8 ms, 95% confidence interval, 1.6-12.0; P=0.01) and percentage with QTc >440 ms in AN patients (relative risk, 3.7, 95% confidence interval, 1.4-10.3; P=0.01), not observed with Fridericia's and Bazett's formulas. There was no difference in the risk of QTc >460 ms between AN patients and healthy controls. During a median follow-up of 10.1 years, AN patients had an increased risk of the primary end point compared with the population-based cohort (hazard ratio, 10.4, 95% confidence interval, 2.6-41.6; P=0.001). However, absolute numbers were small with cumulative incidences of 0.5% and 0.07%, respectively, after 10 years. No events occurred in any AN patient with QTc >440 ms. All-cause mortality was also significantly increased in AN patients compared with the population-based cohort (hazard ratio, 11.2, 95% confidence interval, 5.1-24.5; P<0.001).

CONCLUSIONS

Overall, there was no difference in mean QTc interval or risk of prolonged QTc between AN patients and healthy controls. However, AN patients had a notably increased all-cause mortality, as well as an increased risk of cardiac events, which was not related to the baseline QTc interval.

Facets of shared decision-making on drug treatment for adults with an eating disorder

Shared decision-making (SDM) means that clinicians and the patient make decisions about the treatment together. Regarding drug treatment in eating disorders (EDs), such decisions may include psychopharmacological treatment for the ED itself, medications for potential co-morbid psychiatric disorders, pharmacological strategies to alleviate the health consequences of an ED, or 'pro re nata' (PRN) medication which is given in acute care when required. Decisions regarding drug treatment in EDs should be specific in terms of the active pharmacological substance, its dose, its route of administration, and the duration of treatment. Decisions should be made with regard to the specific health risks of patients with EDs and the entire treatment approach, and should take alternative measures, additional therapies, and specific combinations of therapies into account. The differences in the expectations of patients, carers, and clinicians towards drug treatment, the lack of specific suggestions in clinical practice guidelines, and the lack of approved psychopharmacological treatment options make SDM necessary, but also a challenge. However, SDM may be limited due to the patient's impaired insight or limited capacity due to the ED. Thus, the legal framework must be taken into consideration.

Anorexia nervosa and heart disease: a systematic review

Anorexia nervosa (AN) is an eating disorder that most frequently afflicts females in adolescence. In these subjects, cardiovascular complications are the main cause of morbidity and mortality. Aim of this review is to analyze the hemodynamic, pro-arrhythmic and structural changes occurring during all phases of this illness, including re-feeding. A systematic literature search was performed on studies in the MEDLINE database, from its inception until September 2017, with PUBMED interface focusing on AN and cardiovascular disease. This review demonstrated that the most common cardiac abnormalities in AN are bradycardia and QT interval prolongation, which may occasionally degenerate into ventricular arrhythmias such as Torsades des Pointes or ventricular fibrillation. As these arrhythmias may be the substrate of sudden cardiac death (SCD), they require cardiac monitoring in hospital. In addition, reduced cardiac mass, with smaller volumes and decreased cardiac output, may be found. Furthermore, mitral prolapse and a mild pericardial effusion may occur, the latter due to protein deficiency and low levels of thyroid hormone. In anorectic patients, some cases of hypercholesterolemia may be present; however, conclusive evidence that AN is an atherogenic condition is still lacking, although a few cases of myocardial infarction have been reported. Finally, refeeding syndrome (RFS), which occurs during the first days of refeeding, may engender a critically increased risk of acute, life-threatening cardiac complications.

The Role of Cardiac Magnetic Resonance Imaging in Severe Anorexia Nervosa

Objective

Anorexia nervosa (AN) patients are at an increased risk of developing cardiac complications including bradyarrhythmias, systolic dysfunction, pericardial effusions, and sudden cardiac death. Although previous echocardiographic studies in AN patients have demonstrated a reduction in overall left ventricular (LV) mass, systolic dysfunction, and silent pericardial effusions, little is known about the role of cardiac magnetic resonance imaging (CMR) in assessing this patient population. The objective of this study was to assess cardiac indices and the presence of myocardial fibrosis in AN patients.

Methods

Between 2014 and 2015, a cross-sectional pilot study of 16 female patients who met the Diagnostic and Statistics Manual of Mental Disorders, fifth edition (DSM-5) criteria for AN was conducted at a single tertiary care center. Baseline characteristics including age, weight, food restriction behavior, over-exercise, self-induced vomiting, and laxative abuse were collected in the study population. Electrocardiography, transthoracic echocardiography (TTE), and CMR were performed.

Results

The mean age was 17 years (range: 13-22 years). There were no conduction abnormalities as the average PR interval was 152 ms (range: 130-190 ms) and QTc was 413 ms (range: 360-450 ms). Using TTE, the left ventricular ejection fraction (LVEF) was 54 ± 4% with a lower LV mass/body surface area (BSA) of 56 ± 7g/m² in AN patients as compared to controls. Using CMR, both the mean LVEF of 52 ± 9% and LV mass/BSA of 45 ± 4g/m² were lower in AN patients as compared to controls. Using CMR, both right ventricular ejection fraction (RVEF) of 50 ± 10% and a right ventricular (RV) mass/BSA of 18 ± 3g/m² were smaller in AN patients as compared to controls. There was no evidence of late gadolinium enhancement (LGE) in the study population.

Conclusions

Young patients with AN have lower cardiac mass and volumes with no evidence of myocardial fibrosis.

Echocardiographic Assessment of Ventricular Function During Exercise in Adolescent Female Patients With Anorexia Nervosa

BACKGROUND

Patients with anorexia nervosa (AN) have altered physiologic responses to exercise. The aim of this study was to investigate exercise capacity and ventricular function during exercise in adolescent patients with AN.

METHODS

Sixty-six adolescent female patients with AN and 21 adolescent female control subjects who exercised to volitional fatigue on a semisupine ergometer, using an incremental step protocol of 20 W every 3 min, were retrospectively studied. Heart rate, blood pressure, and echocardiographic Doppler indices were measured at rest and during each stage of exercise. Fractional shortening, rate-corrected mean velocity of circumferential fiber shortening, stress at peak systole, cardiac output, and cardiac index were calculated. Minute ventilation, oxygen consumption, carbon dioxide production, and respiratory exchange ratio were measured using open-circuit spirometry.

RESULTS

Patients with AN had significantly lower body mass index (16.7 vs 19.7 kg/m², P < .001), total work (1,126 vs 1,914 J/kg, P < .001), and test duration (13.8 vs 20.8 min, P < .001) compared with control subjects. Peak minute ventilation, oxygen consumption, and carbon dioxide production were significantly decreased in patients with AN. Heart rate, systolic blood pressure, cardiac index, fractional shortening, and rate-corrected mean velocity of circumferential fiber shortening demonstrated similar patterns of increase with progressive exercise between groups but were decreased at peak exercise in patients with AN. Body mass index percentile, age, peak oxygen consumption, and peak cardiac output were independently associated with exercise duration.

CONCLUSIONS

Adolescent patients with AN have reduced exercise capacity and peak cardiovascular indices compared with control subjects but normal patterns of cardiovascular response during progressive exercise. Systolic ventricular function is maintained during exercise in adolescents with AN.

Gelatinous Transformation of Bone Marrow in a Patient with Anorexia Nervosa: An Uncommon but Reversible Etiology

BACKGROUND Anorexia nervosa is a relatively frequently encountered eating disorder. Beyond its psychiatric significance, it is associated with multiple hematological features such as cytopenia. It can be related to gelatinous transformation of the bone marrow. CASE REPORT We describe the case of a 20-year-old male admitted for rapid involuntarily weight loss. He presented with extreme bradycardia with a heart rate of 30 beats per minute with recent psychomotor impairment. Routine laboratory tests showed pancytopenia, and cytolysis on liver function tests. Cardiac investigations did not reveal abnormalities except for sinus bradycardia. Bone marrow aspirate revealed hypo-cellular marrow with infiltration by gelatinous substance. In addition, bone marrow biopsy showed fat cell atrophy along with loss of hematopoietic elements in areas of gelatinous transformation. During the patient's hospital stay, he had a restrictive oral diet. Thus, after consulting with a psychiatric specialist, a diagnosis of anorexia nervosa complicated with gelatinous transformation of bone marrow, bradycardia, and acute hepatitis was made. After psychiatric treatment and nutritional care, the patient regained weight, had a normal heart rate and normal liver function tests, and his full blood count and bone marrow examination were within normal range. CONCLUSIONS Gelatinous transformation of bone marrow can be the revealing feature of anorexia nervosa and some potentially reversible associations might prove life threatening if misdiagnosed. Furthermore, lack of suspicion can lead to unwarranted investigations increasing the cost incurred in healthcare delivery. Our patient had 3 systems involved: cardiac, hepatic, and hematological systems. Gelatinous transformation of bone marrow, although a rare condition, must be considered in such patients.

Medical findings in 1,026 consecutive adult inpatient-residential eating disordered patients

OBJECTIVE

Eating disorders are associated with multiple medical complications. We report contemporary medical data, for newly admitted adult inpatient and residential level of care patients.

METHOD

Medical records of a transdiagnostic sample of 1,026 patients, with eating disorders, were retrospectively reviewed for the presence of a broad array of medical complications at time of admission. The prevalence of physiologically relevant medical complications was assessed across major eating disorder categories.

RESULTS

Of the patients, 93.6% were female, and they had an average age of 28.1 (SD = 10.1, range 17-69). The average admission body mass index was 16.1 (SD = 2.3). The prevalence of abnormal laboratory values varied by eating disorder subtype. In patients with anorexia nervosa-restricting subtype, 51.4% had low prealbumin, 36.1% were leukopenic, 34.3% had osteoporosis, 30.0% vitamin D deficiency, 16.8% metabolic alkalosis, 16.0% had hyponatremia, 14.2% hypokalemia, and 7.1% hypoglycemia. These patients had normal average QTc intervals. In patients with anorexia nervosa-binge purging subtype, 42.4% had hypokalemia, 33.3% metabolic alkalosis, osteoporosis in 21.1%, and they had longer QTc intervals (433.9 ms, p < .001). Only 6.0% of patients with anorexia nervosa had hypophosphatemia. Patients with bulimia nervosa demonstrated hypokalemia in 26.2%, and metabolic alkalosis in 23.4%; the QTc interval was longer than in AN-R patients (437.9 ms, p < .001), but still in the normal range.

DISCUSSION

Numerous medical complications are associated with severe eating disorders. As the severity increases, the number of complications increase and are related to the presence or absence of purging behaviors.

Advanced research on deep brain stimulation in treating mental disorders

Deep brain stimulation is a method that involves using an electric stimulus on a specific target in the brain with stereotaxis. It is a minimally invasive, safe, adjustable and reversible nerve involvement technology. At present, this technique is widely applied to treat movement disorders and has produced promising effects on mental symptoms, including combined anxiety and depression. Deep brain stimulation has therefore been employed as a novel treatment for depression, obsessive-compulsive disorder, habituation, Tourette's syndrome, presenile dementia, anorexia nervosa and other refractory mental illnesses. Many encouraging results have been reported. The aim of the present review was to briefly describe the mechanisms, target selection, side effects, ethical arguments and risks associated with deep brain stimulation. Although deep brain stimulation is a developing and promising treatment, a large amount of research is still required to determine its curative effect, and the selection of patients and targets must be subjected to strict ethical standards.

Characterization and correlates of exercise among adolescents with anorexia nervosa and bulimia nervosa

OBJECTIVE

To characterize exercise behaviors among adolescents with anorexia nervosa (AN), atypical AN, or bulimia nervosa (BN), and determine associations between exercise and medical risk.

STUDY DESIGN

Cross-sectional electronic medical records of all patients evaluated by the Eating Disorder Program at Stanford between January 1997 and February 2011 were retrospectively reviewed.

RESULTS

1,083 subjects (961 females, 122 males; mean age 15.6) met eligibility criteria. Most patients (89.7%) reported exercise (mean 7.0 h per week over mean 5.4 days per week) prior to presentation. Running (49.9%), calisthenics (40.7%), walking (23.4%), soccer (20.9%), and swimming (18.2%) were the most common exercises; a majority (60.6%) reported team sport participation. Males were less likely to report team exercise (p = .005). Bradycardia (heart rate <50) at presentation was associated with team sport participation (adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.02-2.72) and hours of exercise per week (AOR 1.05, 95% CI 1.02-1.09), controlling for diagnosis, sex, age, duration of illness, rate of weight loss, and percent median body mass index (%mBMI).

DISCUSSION

Adolescents with AN, atypical AN, and BN reported high levels of exercise. Females reported more team sport participation. Greater exercise frequency and team sport participation were associated with bradycardia. Further studies assessing the relationship between exercise and bradycardia may help inform the medical management of adolescents with these eating disorders who are more physically active.

Gender and age differences in cardiovascular complications in anorexia nervosa patients

BACKGROUND

Anorexia nervosa (AN) is characterized by severe malnutrition and electrolyte imbalances. Differences in cardiovascular complications between males and females with AN have not been studied. Additionally, coronary artery disease (CAD) prevalence and cardiovascular complications in patients with AN >65years have not been reported.

METHODS

AN patients>18years were identified in the Nationwide Inpatient Sample 2009-2010 database using the Ninth Revision of International Classification of Disease code 307.1. Demographics, risk factors, and cardiovascular event rates were compared to general population data.

RESULTS

CAD incidence was lower in all AN patients compared to the general population (4.4% vs 18.4%, p<0.001). Despite AN males having higher prevalences of hypertension and diabetes than AN females, there was no difference in CAD. AN males had higher rates of cardiac arrests, arrhythmias, and heart failure. Interestingly, 4.3% of patients with AN were >65years old. When compared to the general population>65years, older AN patients had lower rates of CAD (35% vs 16%; p<0.001). Older AN patients still had higher CAD rates compared to the general population under 65 (8.6%) and AN patients under 65 (4%; p<0.001). Older AN patients had a lower incidence of heart failure (24% vs 16%; p=0.04), and a trend towards less arrhythmias (30% vs 21%; p=0.08).

CONCLUSIONS

Our data suggests that male AN patients experienced more cardiac arrests, arrhythmias, and heart failure than female AN patients. Additionally, older AN patients have a decreased incidence of CAD and heart failure compared to the general population>65years old.