Endocrine abnormalities in anorexia nervosa

Comparative and Predictive Analysis of Clinical and Metabolic Features of Anorexia Nervosa and Bulimia Nervosa

Background

Eating disorders have become increasingly prevalent over the years; the age at which they appear has decreased, and they can lead to serious illness or death. Therefore, the number of studies on the matter has increased. Eating disorders like anorexia nervosa (AN) and bulimia nervosa (BN) are affected by many factors including mental illnesses that can have serious physical and psychological consequences. Accordingly, the present study aimed to compare the clinical and metabolic features of patients with AN and BN and identify potential biomarkers for distinguishing between the two disorders.

Methods

Clinical data of 41 participants who sought treatment for eating disorders between 2012 and 2022, including 29 AN patients and 12 BN patients, were obtained from NPIstanbul Brain Hospital in Istanbul, Turkey. The study included the clinical variables of both outpatient and inpatient treatments. Principal component analysis (PCA) was utilized to gain insights into differentiating AN and BN patients based on clinical characteristics, while machine learning techniques were applied to identify eating disorders.

Findings

The study found that thyroid hormone levels in patients with AN and BN were influenced by non-thyroidal illness syndrome (NTIS), which could be attributed to various factors, including psychiatric disorders, substance abuse, and medication use. Lipid profile comparisons revealed higher triglyceride levels in the BN group (P<0.05), indicating increased triglyceride synthesis and storage as an energy source. Liver function tests showed lower levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in BN patients (P<0.05), while higher prolactin levels (P<0.05) suggested an altered hypothalamic-pituitary-gonadal axis. Imbalances in minerals such as calcium and magnesium (P<0.05) were observed in individuals with eating disorders. PCA effectively differentiated AN and BN patients based on clinical features, and the Naïve Bayes (NB) model showed promising results in identifying eating disorders.

Conclusion

The findings of the study provide important insights into AN and BN patients' clinical features and may help guide future research and treatment strategies for these conditions.

Differential alterations of amygdala nuclei volumes in acutely ill patients with anorexia nervosa and their associations with leptin levels

BACKGROUND

The amygdala is a subcortical limbic structure consisting of histologically and functionally distinct subregions. New automated structural magnetic resonance imaging (MRI) segmentation tools facilitate the in vivo study of individual amygdala nuclei in clinical populations such as patients with anorexia nervosa (AN) who show symptoms indicative of limbic dysregulation. This study is the first to investigate amygdala nuclei volumes in AN, their relationships with leptin, a key indicator of AN-related neuroendocrine alterations, and further clinical measures.

METHODS

T1-weighted MRI scans were subsegmented and multi-stage quality controlled using FreeSurfer. Left/right hemispheric amygdala nuclei volumes were cross-sectionally compared between females with AN (n = 168, 12-29 years) and age-matched healthy females (n = 168) applying general linear models. Associations with plasma leptin, body mass index (BMI), illness duration, and psychiatric symptoms were analyzed via robust linear regression.

RESULTS

Globally, most amygdala nuclei volumes in both hemispheres were reduced in AN v. healthy control participants. Importantly, four specific nuclei (accessory basal, cortical, medial nuclei, corticoamygdaloid transition in the rostral-medial amygdala) showed greater volumetric reduction even relative to reductions of whole amygdala and total subcortical gray matter volumes, whereas basal, lateral, and paralaminar nuclei were less reduced. All rostral-medially clustered nuclei were positively associated with leptin in AN independent of BMI. Amygdala nuclei volumes were not associated with illness duration or psychiatric symptom severity in AN.

CONCLUSIONS

In AN, amygdala nuclei are altered to different degrees. Severe volume loss in rostral-medially clustered nuclei, collectively involved in olfactory/food-related reward processing, may represent a structural correlate of AN-related symptoms. Hypoleptinemia might be linked to rostral-medial amygdala alterations.

Thyroid dysfunction in children and adolescents affected by undernourished and overnourished eating disorders

Eating disorders (ED) are one of the most prevalent chronic disorders in adolescents and young adults, with a significantly increasing prevalence in younger children, particularly in girls. Even if obesity in essence is not framed as an eating disorder and has always been considered a separate pathology, ED and obesity could be considered part of a continuum. It has become evident that one condition can lead to another, such as binge eating disorder (BED) and bulimia nervosa, and that they share the same repercussions in terms of psychosocial, metabolic, and nutritional health. This narrative review aims to investigate the hypothalamic-pituitary-thyroid axis in undernourished and overnourished patients with ED, including obesity, in order to highlight the relationship between weight control and thyroid function and its effects and to consider therapeutic and preventive strategies in children and adolescents. Literature data report that thyroid alterations occur in patients with ED, both underweight and overweight, and represent a continuum of changes depending on the severity and time course of the disease involving the endocrine system. Considering the relevant role thyroid hormones (TH) play not only in energy expenditure (EE) but also in metabolic control and cardiovascular risks related to dysmetabolism and mood regulation, continuous monitoring of thyroid homeostasis in patients with ED is mandatory to prevent severe complications and to start early treatment when necessary.

Nutritional rickets presenting with developmental regression: a rare presentation of rickets

Rickets is a disorder of defective mineralisation of the growth plate. Vitamin D deficiency remains the leading cause of nutritional rickets worldwide.We present the case of a 3.5-year-old breastfed boy who presented with dental abscess when a history of developmental regression was noted. Clinical assessment revealed hypotonia, poor growth and stunting. Biochemistry identified hypocalcaemia (1.63mmol/L, [normal range (NR) 2.2-2.7mmol/L]), severe vitamin D deficiency (25hydroxyvitamin D 5.3nmol/L, [NR > 50nmol/L]) with secondary hyperparathyroidism (Parathormone 159pmol/L, [NR 1.6-7.5pmol/L]) and rickets on radiographs. Growth failure screening suggested hypopituitarism with central hypothyroidism and low IGF1 at baseline, however, dynamic tests confirmed normal axis. Management included nasogastric nutritional rehabilitation, cholecalciferol and calcium supplementation and physiotherapy. A good biochemical response in all parameters was observed within 3 weeks and reversal of developmental regression by 3 months from treatment. Developmental regression as a presentation of nutritional rickets is rare and requires a high index of suspicion.

Echocardiographic Abnormalities in Adults With Anorexia Nervosa

Anorexia nervosa (AN) is a psychiatric disorder that may lead to cardiac complications. The objective of this study was to evaluate global and regional longitudinal strain changes in patients affected by AN as an early marker of myocardial damage. We prospectively enrolled 48 consecutive patients with AN and 44 age-matched and gender-matched healthy controls. In all subjects, we performed echocardiography, including global longitudinal strain (GLS) measurement. A subset of 33 patients with AN had further echocardiographic examinations during the follow-up. Compared with healthy controls, patients with AN had a greater prevalence of pericardial effusion (9 of 48 vs 0 of 44, p = 0.003), a smaller left ventricular mass (63 ± 15 vs 99 ± 30 g, p < 0.001), a lower absolute value of GLS (-18.9 ± 2.8 vs -20.2 ± 1.8%, p = 0.010) and of basal LS (-15.4 ± 6.0 vs -19.4 ± 2.6%, p < 0.001). The bull's eye mapping showed a plot pattern with blue basal areas in 18 of 48 patients with AN versus 1 of 44 controls (p < 0.001). During the follow-up, of 13 patients with blue areas in the first bull's eye mapping, 11 recovered completely, and of 20 patients with a red bull's eye at the first examination, none presented blue areas at the second one. In conclusion, GLS is significantly altered in patients with AN, and a basal blue pattern on bull's eye mapping identifies more severe cases. These changes seem to be reversible.

Associations between pituitary-thyroid hormones and depressive symptoms in individuals with anorexia nervosa before and after weight-recovery

BACKGROUND

There is sound evidence that the hypothalamic-pituitary-thyroid axis plays a role in mood regulation. Alterations in this axis, particularly low triiodothyronine syndrome, are a common neuroendocrine adaptation to semi-starvation in patients with anorexia nervosa (AN), who also frequently suffer from co-existing depressive symptoms. We therefore aimed to investigate the associations between pituitary-thyroid function and psychopathology, in particular depressive symptoms, at different stages of AN using a combined cross-sectional and longitudinal study design.

METHODS

Pituitary-thyroid status (FT3, free triiodothyronine; FT4, free thyroxine; conversion ratio FT3/FT4; TSH, thyroid-stimulating hormone) was assessed in 77 young acutely underweight females with AN (acAN) and in 55 long-term weight-recovered individuals with former AN (recAN) in a cross-sectional comparison to 122 healthy controls (HC). Further, pituitary-thyroid status of 48 acAN was reassessed after short-term weight-restoration. We performed correlation analyses of pituitary-thyroid parameters with self-reported measures of psychopathology.

RESULTS

AcAN showed significantly lower FT3, FT4, FT3/FT4 ratio, and TSH levels compared to HC. Pituitary-thyroid alterations were partly reversed after short-term weight-restoration. RecAN still had lower FT3 concentrations than HC. Lower FT3 concentrations and FT3/FT4 ratios were associated with more severe depressive symptoms in acAN, occurring prominently in cases of manifest low triiodothyronine syndrome. Longitudinally increasing FT3/FT4 ratios (change scores) were inversely correlated with depressive and general psychiatric symptoms after short-term weight-restoration.

CONCLUSIONS

Our results suggest a potential modulation of the severity of depressive symptoms by temporarily decreased FT3 concentrations and inhibited thyroid hormone conversion (FT3/FT4 ratios) in acutely underweight AN. Associations between conversion ratios FT3/FT4 and psychopathology seem to persist across short-term weight-restoration. The findings of our study might have relevant clinical implications, ranging from thyroid monitoring to experimental low-dose thyroid hormone supplementation in certain patients with AN showing severe psychiatric impairment and overt thyroid hormone alterations.

Comparison of Five Different Criteria for Diagnosis of Subclinical Hypothyroidism in a Large-Scale Chinese Population

BACKGROUND

Several different criteria for subclinical hypothyroidism (SCH) have been used in the literature, but the performance of these criteria was unknown.

OBJECTIVE

This retrospective study was to evaluate the diagnostic criteria for SCH.

METHODS

Eligible participants were based on centration of thyroglobulin antibodies (TG-Ab), thyroid peroxidase antibodies (TPO-Ab), and five thyroid-related hormones including total thyroxine (TT4), total triiodothyronine (TT3), free thyroxine (FT4), free triiodothyronine (FT3), and thyroid-stimulating hormone (TSH). Euthyroid individuals were identified via specific criteria. Five different SCH diagnostic criteria were compared based on the distributions of those indicators. An appropriate TSH cut-off value was reconsidered.

RESULTS

The study included 145,015 participants. The number of SCH cases diagnosed using criterion 5 was significantly different compared to the cases diagnosed using criteria 1-4 (P<0.05) and had the highest positive proportions of TG-Ab and TPO-Ab. Analysis of 60,515 subjects with normal other thyroid hormones revealed a median TSH concentration of 2.04 mIU/L, and the P _2.5-P _97.5 CI was 0.48-7.03 mIU/L. When the threshold for TSH elevation was elevated from ≥4.5 mIU/L to ≥6.50 mIU/L, the number of diagnosed SCH cases decreased from 7.30% to 2.09% and the proportions of positive TG-Ab and TPO-Ab increased from 23.69% and 24.07% to 33.75% and 35.06%, respectively (P<0.01).

CONCLUSIONS

Combination of an elevated TSH and normal TT3, TT4, FT3, and FT4 concentrations is a must for the diagnosis of SCH. A new TSH threshold should be identified for better patient monitoring and management, according to the real-world characteristics of TSH distribution in Chinese population.

Altered Serum Immunological and Biochemical Parameters and Microbiota Composition in Patients With AN During Realimentation

Anorexia nervosa (AN) is a life-threatening psychiatric disorder with not well-described pathogenesis. Besides the genetic and sociological factors, autoimmunity is also considered to take part in AN pathogenesis. We evaluated general serological factors showing the physiological state of 59 patients with AN at hospital admission and their discharge. We detected the altered levels of some general biochemical and immunological parameters. We also detected decreased levels of appetite-regulating alpha-melanocyte stimulating hormone (α-MSH) in patients at hospital admission. Moreover, elevated anti-α-MSH IgM levels and decreased anti-α-MSH IgA levels were observed in patients with AN. Therefore, we analyzed the gut microbiota composition with special focus on α-MSH antigen-mimetic containing microbes from the Enterobacteriaceae family. We correlated gut bacterial composition with anti-α-MSH Ig levels and detected decreasing IgG levels with increasing alpha diversity. The upregulation of pro-inflammatory cytokines IL-6, IL-17, and TNF-α were detected in patients with AN both prior and after hospitalization. We also evaluated the treatment outcome and improvement was observed in the majority of patients with AN. We provide new data about various serum biochemical parameters and their changes during the patients' hospitalization, with emphasis on the immune system, and its possible participation in AN pathogenesis.

Predictors of Resumption of Menses in Anorexia Nervosa: A 4-Year Longitudinal Study

OBJECTIVE

Amenorrhea is a disabling medical consequence of anorexia nervosa (AN); therefore, resumption of menses (ROM) represents an important goal in the treatment for these patients. The aim of the present study was to evaluate possible clinical, psychopathological, and biological predictors of ROM, including age, body mass index (BMI), AN subtype, childhood abuse, duration of illness, general and eating disorder (ED)-specific psychopathology, and sex hormones.

METHODS

Fifty amenorrheic patients with AN were enrolled. Baseline clinical data and information on childhood abuse were collected. Questionnaires to evaluate general and ED-specific psychopathology were administered, and blood samples were drawn. All patients received treatment as usual and underwent regular follow-up visits for 4 years or until ROM. Time to ROM, BMI at last evaluation, and data regarding diagnostic crossover into bulimia nervosa were collected.

RESULTS

Twenty-nine (58.0%) patients recovered menses. Diagnostic crossover was associated with a higher probability of ROM (odds ratio = 10.3, p = .030). Time-to-event analysis showed that a shorter duration of illness (χ(1) = 11.00, p = .001), binge-eating/purging subtype (χ(1) = 7.01, p = .008), and history of childhood abuse (χ(1) = 4.03, p = .045) were associated with an earlier ROM. Furthermore, higher baseline ED-specific psychopathology was associated with a reduced likelihood for ROM, whereas higher general psychopathology and follicle-stimulating hormone levels predicted an earlier ROM (all, p < .050). Age, BMI, luteinizing hormone, and estrogen hematic levels had no predictive value with respect to ROM.

CONCLUSIONS

The present study provides data in support of an integrated model, emphasizing the importance of duration of illness, childhood abuse, and psychopathological characteristics of amenorrheic patients with AN in predicting ROM.

Changes of BMI, steroid metabolome and psychopathology in patients with anorexia nervosa during hospitalization

Anorexia nervosa (AN) is associated with various alterations including the dysfunction of the HPA axis and consequently the hypercortisolemia and deficit in sex hormones but the comprehensive evaluation of changes in circulating steroids during the hospitalization of AN patients is lacking. We investigated the effect of realimentation of women with AN during hospitalization on 45 circulating steroids, the relationships between BMI, its change during hospitalization and physical activity, on one side and initial levels and their changes for two adipokines, circulating steroids, anorexia-specific (hunger, appetite and satiety), and anorexia non-specific symptoms (anxiety, depression fatigue, sleep, and body pain) on the other side. We included 33 women with anorexia who were hospitalized for 38(35, 44) days (median with quartiles). The increase of BMI from the initial value 15.2 (13.2, 16.6) kg/m² was 1.69 (1.37, 2.66) kg/m². The patients with more severe anorexia showed higher activity in 7β-, and 16α-hydroxylation of androgen precursors, which declined during hospitalization. Otherwise, the 7α-hydroxylation activity is higher in AN patients with less severe malnutrition and the ratio of 5-androstene-3β,7α,17β-triol to 5-androstene-3β,7β,17β-triol increased during the realimentation. Our data allow to speculate that the intensive 7β-, and 16α- and possibly also the 7α-hydroxylation of C19 Δ⁵ steroids participate in the pathophysiology of anorexia by additional catabolism of substrates available for synthesis of active androgens and estrogens. However, the question remains whether the synthetic analogues of 7α/β- and 16α-hydroxy-steroids prevent the catabolism of the sex steroid precursors, or further activate the "energy wasting" mitochondrial thermogenic metabolism.

Severe iodine deficiency from dietary restriction and subsequent iodine excess from seaweed snack overuse in an adolescent with disordered eating

Individuals with disordered eating commonly exclude salt and animal products from their diets, which may predispose them to iodine deficiency even without significant weight loss. Overconsumption of dietary supplements and "natural" foods are also commonly observed among eating disorder patients. This report describes an adolescent female with disordered eating presenting with growth and pubertal delay, found to have severe iodine deficiency (urine iodine of 18 mcg/L) and abnormal thyroid function resulting from strict avoidance of salt and animal products despite adequate caloric intake. To avoid having to start eating animal products, she began consuming excessive quantities of seaweed supplements to increase her iodine intake resulting in excessive iodine levels (urine iodine of >1,500 mcg/L) and worsening of thyroid function. When her parents began supervising her nutritional intake, her abnormal iodine levels, abnormal thyroid function tests, and hypogonadotropic hypogonadism all resolved. This is the first report of both iodine deficiency and iodine excess developing from disordered eating behavior.

Directly measured free 25-hydroxy vitamin D levels show no evidence of vitamin D deficiency in young Swedish women with anorexia nervosa

PURPOSE

Anorexia nervosa (AN) is an eating disorder characterized by low fat mass complicated by osteoporosis. The role of circulating vitamin D in the development of bone loss in AN is unclear. Fat mass is known to be inversely associated with vitamin D levels measured as serum levels of total, protein-bound 25-hydroxyvitamin D, but the importance of directly measured, free levels of 25(OH)D has not been determined in AN. The aim of this study was to investigate vitamin D status, as assessed by serum concentrations of total and free serum 25(OH)D in patients with AN and healthy controls.

METHODS

In female AN patients (n = 20), and healthy female controls (n = 78), total 25(OH)D was measured by LC-MS/MS, and free 25(OH)D with ELISA. In patients with AN bone mineral density (BMD) was determined with DEXA.

RESULTS

There were no differences between patients and controls in total or free S-25(OH)D levels (80 ± 31 vs 72 ± 18 nmol/L, and 6.5 ± 2.5 vs 5.6 ± 1.8 pg/ml, respectively), and no association to BMD was found. In the entire group of patients and controls, both vitamin D parameters correlated with BMI, leptin, and PTH.

CONCLUSIONS

The current study did not demonstrate a vitamin D deficiency in patients with AN and our data does not support vitamin D deficiency as a contributing factor to bone loss in AN. Instead, we observed a trend toward higher vitamin D levels in AN subjects compared to controls. Measurement of free vitamin D levels did not contribute to additional information.

Serum Thyroid-Stimulating Hormone Levels and Body Mass Index Percentiles in Children with Primary Hypothyroidism on Levothyroxine Replacement

OBJECTIVE

To determine the association, if any, between thyroid-stimulating hormone (TSH) levels and body mass index (BMI) percentiles in children with primary hypothyroidism who are chemically euthyroid and on treatment with levothyroxine.

METHODS

This retrospective cross-sectional study consisted of a review of medical records from RUSH Medical Center and Stroger Hospital, Chicago, USA of children with primary hypothyroidism who were seen in the clinic from 2008 to 2014 and who were chemically euthyroid and on treatment with levothyroxine for at least 6 months. The patients were divided into two groups based on their TSH levels (0.34-<2.5 mIU/L and ≥2.5-5.6 mIU/L). The data were analyzed by Spearman rank correlation, linear regression, cross tabulation and chi-square, Mann-Whitney U test, and Kruskal-Wallis test.

RESULTS

One hundred and forty-six children were included, of which 26% were obese (BMI ≥95%), 21.9% overweight (BMI ≥85-<95%), and 52.1% of a healthy weight (BMI ≥5-<85%). There was a significant positive correlation between TSH and BMI percentiles (r=0.274, p=0.001) and a significant negative correlation between TSH and serum free T4 (r=-0.259, p=0.002). In the lower TSH group, 68.4% of the children had a healthy weight, while the percentage of obese children was 60.5% in the upper TSH group (p=0.012).

CONCLUSION

In children diagnosed with primary hypothyroidism who are chemically euthyroid on treatment with levothyroxine, there is a positive association between higher TSH levels and higher BMI percentiles. However, it is difficult to establish if the higher TSH levels are a direct cause or a consequence of the obesity. Further studies are needed to establish causation beyond significant association.

Biochemical Testing in Thyroid Disorders

This article summarizes the main principles for the appropriate use of laboratory testing in the diagnosis and management of thyroid disorders, as well as controversies that have arisen in association with some of these biochemical tests. To place a test in perspective, its sensitivity and accuracy should be taken into account. Ordering the correct laboratory tests facilitates the early diagnosis of a thyroid disorder and allows for timely and appropriate treatment. This article focuses on a comprehensive update regarding thyroid-stimulating hormone, thyroxine/triiodothyronine, thyroid autoantibodies, thyroglobulin, and calcitonin. Clinical uses of these biochemical tests are outlined.

The effect of CART on pituitary hormones release from cultured pituitary cells harvested from fasted and fed ad libitum male rats

Cocaine and Amphetamine-Regulated Transcript (CART) is widely expressed in the central nervous system and in several endocrine organs. CART is an important factor in the regulation of energy homeostasis. The aim of the study was to assess the role of CART in physiological response of pituitary cells in a course of starvation. The pituitary cells harvested from starved and fed ad libitum male rats were cultured for 48h and treated with: 0.1nM, 1nM, 10nM or 100nM doses of CART. The medium was collected after 60min and stored at -70°C until samples were further assayed for: LH, FSH, PRL, GH, TSH and ACTH. We revealed that in cultures of pituitary cells collected from fasted rats the basal levels of the examined hormones were reduced. Incubation of pituitary cells of non-starved rats with any dose of CART reduced the concentration of LH and TSH, while the levels of the other hormones were decreased after administration only specific doses of CART. In cells of fasted rats no change in the concentration of gonadotrophins was observed. The PRL level was increased only in the 1nM dose of CART, while the 10nM and 100nM CART doses markedly enhanced GH and TSH. Moreover, administration of 1nM, 10nM and 100nM of CART to cultured cells of fasted rats resulted in a significant rise of the ACTH. Our results indicate that CART can directly affect the physiological release of PRL, ACTH, TSH and GH in pituitary cells of starved animals. Moreover, CART did not alter the LH and FSH suppression level, which is correlated with food deprivation. This data stays in contrast with the already proposed role of CART as an anorexigenic hypothalamic factor.

Near-fatal Anorexia Nervosa in a Middle-aged Woman

Anorexia nervosa (AN) is a serious psychiatric disorder which typically occurs in young women; however, more and more cases in middle-aged women are being reported. The management of this complex disease requires a team approach, and full recovery occurs only in 50% of patients. Endocrine and metabolic complications are commonly observed, the latter of which may even be life-threatening, and require prompt and proper management. Infections, albeit reported, are not usually a major clinical problem in these patients. We herein report the case of a severely malnourished middle-aged woman with long-standing AN who was hospitalized with marked hypokalaemia (1.5 mEq/L) and rhabdomyolysis; during hospitalization she developed septic shock and acute respiratory distress syndrome, which required urgent admission to the intensive care unit. She underwent sedation and tracheal intubation for mechanical ventilation and was managed with combined therapies, which eventually led to a successful outcome. Life-threatening medical complications can occur not only in young women but in middle-aged women with AN as well and require a combined multidisciplinary approach.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identification and management of eating disorders in gynecology: menstrual health as an underutilized screening tool

Eating disorders are life-threatening conditions that disproportionately affect females, often during child-bearing years. Although the endocrinological and reproductive sequelae of these conditions often fall within the treatment purview of obstetrician-gynecologists, the assessment of eating pathology is challenging and often not part of routine clinical care. This commentary focuses on one of the common presenting symptoms of eating disorders in women, menstrual dysfunction, and discusses considerations for its clinical management in gynecology. Assessment of menstrual status provides a natural starting point for provider-patient discussion of disordered eating and weight behavior. Routine screening for eating disorders is critical and must be universal given the serious long-term consequences of these disorders.

A role for intestinal TLR4-driven inflammatory response during activity-based anorexia

Anorexia nervosa (AN) is associated with low-grade systemic inflammation and altered gut microbiota. However, the molecular origin of the inflammation remains unknown. Toll-like receptors are key regulators of innate immune response and their activation seems also to be involved in the control of food intake. We used activity-based anorexia (ABA) model to investigate the role of TLR4 and its contribution in anorexia-associated low-grade inflammation. Here, we found that ABA affected early the intestinal inflammatory status and the hypothalamic response. Indeed, TLR4 was upregulated both on colonic epithelial cells and intestinal macrophages, leading to elevated downstream mucosal cytokine production. These mucosal changes occurred earlier than hypothalamic changes driving to increased levels of IL-1β and IL-1R1 as well as increased levels of plasma corticosterone. Paradoxically, TLR4-deficient mice exhibited greater vulnerability to ABA with increased mortality rate, suggesting a major contribution of TLR4-mediated responses during ABA-induced weight loss.

Bone marrow adipose tissue: formation, function and regulation

The human body requires an uninterrupted supply of energy to maintain metabolic homeostasis and energy balance. To sustain energy balance, excess consumed calories are stored as glycogen, triglycerides and protein, allowing the body to continue to function in states of starvation and increased energy expenditure. Adipose tissue provides the largest natural store of excess calories as triglycerides and plays an important role as an endocrine organ in energy homeostasis and beyond. This short review is intended to detail the current knowledge of the formation and role of bone marrow adipose tissue (MAT), a largely ignored adipose depot, focussing on the role of MAT as an endocrine organ and highlighting the pharmacological agents that regulate MAT.

Expansion of Bone Marrow Adipose Tissue During Caloric Restriction Is Associated With Increased Circulating Glucocorticoids and Not With Hypoleptinemia

Bone marrow adipose tissue (MAT) accounts for up to 70% of bone marrow volume in healthy adults and increases further in clinical conditions of altered skeletal or metabolic function. Perhaps most strikingly, and in stark contrast to white adipose tissue, MAT has been found to increase during caloric restriction (CR) in humans and many other species. Hypoleptinemia may drive MAT expansion during CR but this has not been demonstrated conclusively. Indeed, MAT formation and function are poorly understood; hence, the physiological and pathological roles of MAT remain elusive. We recently revealed that MAT contributes to hyperadiponectinemia and systemic adaptations to CR. To further these observations, we have now performed CR studies in rabbits to determine whether CR affects adiponectin production by MAT. Moderate or extensive CR decreased bone mass, white adipose tissue mass, and circulating leptin but, surprisingly, did not cause hyperadiponectinemia or MAT expansion. Although this unexpected finding limited our subsequent MAT characterization, it demonstrates that during CR, bone loss can occur independently of MAT expansion; increased MAT may be required for hyperadiponectinemia; and hypoleptinemia is not sufficient for MAT expansion. We further investigated this relationship in mice. In females, CR increased MAT without decreasing circulating leptin, suggesting that hypoleptinemia is also not necessary for MAT expansion. Finally, circulating glucocorticoids increased during CR in mice but not rabbits, suggesting that glucocorticoids might drive MAT expansion during CR. These observations provide insights into the causes and consequences of CR-associated MAT expansion, knowledge with potential relevance to health and disease.

Interacting Neural Processes of Feeding, Hyperactivity, Stress, Reward, and the Utility of the Activity-Based Anorexia Model of Anorexia Nervosa

Anorexia nervosa (AN) is a psychiatric illness with minimal effective treatments and a very high rate of mortality. Understanding the neurobiological underpinnings of the disease is imperative for improving outcomes and can be aided by the study of animal models. The activity-based anorexia rodent model (ABA) is the current best parallel for the study of AN. This review describes the basic neurobiology of feeding and hyperactivity seen in both ABA and AN, and compiles the research on the role that stress-response and reward pathways play in modulating the homeostatic drive to eat and to expend energy, which become dysfunctional in ABA and AN.

Anorexia nervosa

Anorexia nervosa (AN) is a psychiatric condition characterized by severe weight loss and secondary problems associated with malnutrition. AN predominantly develops in adolescence in the peripubertal period. Without early effective treatment, the course is protracted with physical, psychological and social morbidity and high mortality. Despite these effects, patients are noted to value the beliefs and behaviours that contribute to their illness rather than regarding them as problematic, which interferes with screening, prevention and early intervention. Involving the family to support interventions early in the course of the illness can produce sustained changes; however, those with a severe and/or protracted illness might require inpatient nursing support and/or outpatient psychotherapy. Prevention programmes aim to moderate the overvaluation of 'thinness' and body dissatisfaction as one of the proximal risk factors. The low prevalence of AN limits the ability to identify risk factors and to study the timing and sex distribution of the condition. However, genetic profiles, premorbid features, and brain structures and functions of patients with AN show similarities with other psychiatric disorders and contrast with obesity and metabolic disorders. Such studies are informing approaches to address the neuroadaptation to starvation and the other various physical and psychosocial deficits associated with AN. This Primer describes the epidemiology, diagnosis, screening and prevention, aetiology, treatment and quality of life of patients with AN.

Hypothyroidism due to Hashimoto's thyroiditis masked by anorexia nervosa

Anorexia nervosa (AN) is typically associated with altered thyroid function tests, notably a low total and free T3 , and lower, but within normal range, free T4 and TSH. A 16-year-old girl with a four-year history of AN presented with elevated TSH that fluctuated with changes in weight. TSH was within normal limits (1.7-3.64 mIU/L) following periods of weight loss and elevated with weight gain (5.9-21.66 mIU/L). Antithyroperoxidase antibodies were markedly elevated, suggesting chronic Hashimoto's thyroiditis. Of note, the elevated TSH that would be expected in Hashimoto's thyroiditis was blunted by weight loss associated with AN. Physicians should be aware that AN may contribute to masking thyroid abnormalities in Hashimoto's thyroiditis.

The psychopharmacological management of eating disorders in children and adolescents

In this review we synthesised current literature on the psychopharmacological management of eating disorders (EDs) in children and adolescents (C&As). We focus specifically on anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). The treatment of EDs is determined by physical and psycho-social factors and needs. Pharmacological management should therefore be viewed and incorporated as one component of a multi-disciplinary comprehensive treatment plan for specific requirements of a patient depending on the stage of the disorder. As there is a dearth of studies evaluating the use of psychopharmacology for EDs in C&As we first review the findings from studies performed in adults and then discuss specific studies performed in C&As. We include information from reviews and treatment guidelines to assist the clinician with an approach to the use of psychopharmacological agents in the treatment of EDs in C&As.

End-stage anorexia nervosa in a young man: multifaceted metabolic, endocrine and infectious derangements managed in an internal medicine setting

Anorexia nervosa (AN) in males is an overlooked disease which requires early diagnosis and proper treatment. Clinical presentation is often severe and the risk of death is not negligible. We report the case of a young man with a 1-year history of AN who was admitted to our internal medicine department for a dramatic malnutrition (BMI: 10.5 kg/m(2)). Several biochemical and hormonal alterations were ascertained. Partial parenteral nutrition and a balanced diet were started. Asymptomatic refeeding syndrome occurred and was managed by enhanced electrolyte parenteral supplementation. Many hematologic abnormalities (anaemia, leukopenia and thrombocytopenia) were present and worsened during the occurrence of sepsis which required hemotransfusions and targeted parenteral antibiotics with improvement of both clinical condition and hematologic parameters. Bone marrow aspiration and cytofluorimetric evaluation showed hyperplasia and dysplasia of erythroid lineage and reduction of myeloid lineage. Significant body weight gain (+17 % vs. admission) was obtained and the patient was discharged with stable cardiovascular parameters and referred to an eating disorders centre where is currently followed.

Long-term physiological alterations and recovery in a mouse model of separation associated with time-restricted feeding: a tool to study anorexia nervosa related consequences

Background

Anorexia nervosa is a primary psychiatric disorder, with non-negligible rates of mortality and morbidity. Some of the related alterations could participate in a vicious cycle limiting the recovery. Animal models mimicking various physiological alterations related to anorexia nervosa are necessary to provide better strategies of treatment.

Aim

To explore physiological alterations and recovery in a long-term mouse model mimicking numerous consequences of severe anorexia nervosa.

Methods

C57Bl/6 female mice were submitted to a separation-based anorexia protocol combining separation and time-restricted feeding for 10 weeks. Thereafter, mice were housed in standard conditions for 10 weeks. Body weight, food intake, body composition, plasma levels of leptin, adiponectin, IGF-1, blood levels of GH, reproductive function and glucose tolerance were followed. Gene expression of several markers of lipid and energy metabolism was assayed in adipose tissues.

Results

Mimicking what is observed in anorexia nervosa patients, and despite a food intake close to that of control mice, separation-based anorexia mice displayed marked alterations in body weight, fat mass, lean mass, bone mass acquisition, reproductive function, GH/IGF-1 axis, and leptinemia. mRNA levels of markers of lipogenesis, lipolysis, and the brown-like adipocyte lineage in subcutaneous adipose tissue were also changed. All these alterations were corrected during the recovery phase, except for the hypoleptinemia that persisted despite the full recovery of fat mass.

Conclusion

This study strongly supports the separation-based anorexia protocol as a valuable model of long-term negative energy balance state that closely mimics various symptoms observed in anorexia nervosa, including metabolic adaptations. Interestingly, during a recovery phase, mice showed a high capacity to normalize these parameters with the exception of plasma leptin levels. It will be interesting therefore to explore further the central and peripheral effects of the uncorrected hypoleptinemia during recovery from separation-based anorexia.

Harmful effects of functional hypercortisolism: a working hypothesis

Functional hypercortisolism (FH) is caused by conditions able to chronically activate hypothalamic-pituitary-adrenal axis and usually occurs in cases of major depression, anorexia nervosa, bulimia nervosa, alcoholism, diabetes mellitus, simple obesity, polycystic ovary syndrome, obstructive sleep apnea syndrome, panic disorder, generalized anxiety disorder, shift work, and end-stage renal disease. Most of these states belong to pseudo-Cushing disease, a condition which is difficult to distinguish from Cushing's syndrome and characterized not only by biochemical findings but also by objective ones that can be attributed to hypercortisolism (e.g., striae rubrae, central obesity, skin atrophy, easy bruising, etc.). This hormonal imbalance, although reversible and generally mild, could mediate some systemic complications, mainly but not only of a metabolic/cardiovascular nature, which are present in these states and are largely the same as those present in Cushing's syndrome. In this review we aim to discuss the evidence suggesting the emerging negative role for FH.

Purging behavior modulates the relationships of hormonal and behavioral parameters in women with eating disorders

BACKGROUND/AIMS

There is ample consensus that there is a neurophysiological basis for eating disorders (ED). Traits of personality translate into behavioral traits, purging being a well-defined transversal example. The direct implication of steroid hormones on ED has seldom been studied, despite their effects on behavior.

METHODS

After psychological interview analysis, 57 ED female patients (31 purgative and 26 nonpurgative) and 17 female controls were studied. Metabolic parameters and analysis of androgen, estrogen and glucocorticoid hormones were determined in parallel to the psychopathological profile (EDI-2 and SCL-90-R) and anthropometric measurements.

RESULTS

Psychometric tests showed clear differences between ED and controls, but there were few hormonal-metabolic significant differences. In purgative ED there were repeated (significant) positive correlations with corticosteroid-binding globulin (CBG) and negative correlations with sex hormone-binding globulin (SHBG) versus eating and general psychopathology. In nonpurging ED there were positive correlations for deoxycortisol, free fatty acids and albumin and negative for aspartate aminotransferase and psychopathological traits.

CONCLUSION

The data suggest that CBG/corticosteroids and sexual hormones/SHBG are involved in purging behavior and its psychopathology and severity scores. Correlations of selected psychometric data and the CBG/SHBG levels in purging may eventually result in clinical markers. This approach may provide additional clues for understanding the pathogenesis of ED.

The expression of cytokines and chemokines in the blood of patients with severe weight loss from anorexia nervosa: an exploratory study

Anorexia nervosa (AN) is a serious, potentially life-threatening disorder characterized by severe weight loss, dysregulated eating, and often excessive exercise. While psychiatric illnesses such as depression are associated with increased levels of pro-inflammatory mediators, evidence for such disturbances in patients with AN has been less clear. In an exploratory study of possible disturbances in immune responses in AN, we assayed a panel of cytokines and chemokines in the blood of patients undergoing inpatient treatment, testing the hypothesis that metabolic disturbances in this disease would lead to a pattern of immune disturbances distinct from that of other psychiatric diseases. For this purpose, we evaluated patients by the Beck Depression Inventory-II (BDI-II) and the Eating Disorders Examination-Questionnaire and assessed cytokines and chemokines by enzyme-linked immunosorbent assays. Patients reported a moderate level of depression (mean BDI-II = 22.6) but exhibited few immunologic abnormalities of the kind associated with major depressive disorder [e.g., increased interleukin (IL)-6]; RANTES showed the most frequent elevations and was increased in 4 of the patients studied. Together, these findings suggest that features of AN such as loss of adipose tissue and excessive exercise may attenuate cytokine production and thus modulate the experience of illness that impacts on core features of disease.

Lack of association between peripheral activity of thyroid hormones and elevated TSH levels in childhood obesity

OBJECTIVE

An elevated thyroid stimulating hormone (TSH) level is a frequent finding in obese children, but its association with peripheral hormone metabolism is not fully understood. We hypothesized that in obesity, the changes in thyroid hormone metabolism in peripheral tissues might lead to dysregulation in the thyroid axis. The purpose of this study was to investigate the association of TSH with thyroid hormones in a group of obese children as compared to normal-weight controls.

METHODS

Serum TSH, free thyroxine (fT4) and free triiodothyronine (fT3) levels were measured in 101 obese children and in 40 controls. Serum reverse T3 (rT3) levels were also measured in a subgroup of 51 obese children and in 15 controls.

RESULTS

Serum TSH level was significantly higher in obese children compared to controls (2.78 vs. 1.99 mIU/L, p<0.001), while no difference was found in fT4, fT3, rT3 levels and in fT3/rT3 ratio. In the obese group, fT3 level positively correlated with fT4 (r=0.217, p=0.033) and inversely with rT3 (r=-0.288, p=0.045). However, thyroid hormone levels and TSH levels were not correlated.

CONCLUSION

In obese children, normal fT4, fT3 and rT3 levels suggest an undisturbed peripheral hormone metabolism. These levels show no correlation with elevated TSH levels.

Bone health in eating disorders

Eating disorders (EDs) put adolescents and young adults at risk for impaired bone health. Low bone mineral density (BMD) with ED is caused by failure to accrue peak bone mass in adolescence and bone loss in young adulthood. Although ED patients diagnosed with bone loss may be asymptomatic, some suffer bone pains and have increased incidence of fractures. Adolescents with ED are prone to increased prevalence of stress fractures, kyphoscoliosis and height loss. The clinical picture of the various EDs involves endocrinopathies that contribute to impaired bone health. Anorexia nervosa (AN) is characterized by low bone turnover, with relatively higher osteoclastic (bone resorptive) than osteoblastic (bone formation) activity. Bone loss in AN occurs in both the trabecular and cortical bones, although the former is more vulnerable. Bone loss in AN has been shown to be influenced by malnutrition and low weight, reduced fat mass, oestrogen and androgen deficiency, glucocorticoid excess, impaired growth hormone-insulin-like growth factor 1 axis, and more. Bone loss in AN may not be completely reversible despite recovery from the illness. Treatment modalities involving hormonal therapies have limited effectiveness, whereas increased caloric intake, weight gain and resumption of menses are essential to improved BMD.

Determinants of bone marrow adiposity: the modulation of peroxisome proliferator-activated receptor-γ2 activity as a central mechanism

Although the presence of adipocytes in the bone marrow is a normal physiological phenomenon, the role of these cells in bone homeostasis and during pathological states has not yet been fully delineated. As osteoblasts and adipocytes originate from a common progenitor, with an inverse relationship existing between osteoblastogenesis and adipogenesis, bone marrow adiposity often negatively correlates with osteoblast number and bone mineral density. Bone adiposity can be affected by several physiological and pathophysiological factors, with abnormal, elevated marrow fat resulting in a pathological state. This review focuses on the regulation of bone adiposity by physiological factors, including aging, mechanical loading and growth factor expression, as well as the pathophysiological factors, including diseases such as anorexia nervosa and dyslipidemia, and pharmacological agents such as thiazolidinediones and statins. Although these factors regulate bone marrow adiposity via a plethora of different intracellular signaling pathways, these diverse pathways often converge on the modulation of the expression and/or activity of the pro-adipogenic transcription factor peroxisome proliferator-activated receptor (PPAR)-γ2, suggesting that any factor that affects PPAR-γ2 may have an impact on the fat content of bone.

SIRT1 regulates adaptive response of the growth hormone--insulin-like growth factor-I axis under fasting conditions in liver

Adaptation under fasting conditions is critical for survival in animals. Sirtuin 1 (SIRT1), a protein deacetylase, plays an essential role in adaptive metabolic and endocrine responses under fasting conditions by modifying the acetylation status of various proteins. Fasting induces growth hormone (GH) resistance in the liver, leading to decreased serum insulin-like growth factor-I (IGF-I) levels as an endocrine adaptation for malnutrition; however, the underlying mechanisms of this action remain to be fully elucidated. Here we report that in vivo knockdown of SIRT1 in the liver restored the fasting-induced decrease in serum IGF-I levels and enhanced the GH-dependent increase in IGF-I levels, indicating that SIRT1 negatively regulates GH-dependent IGF-I production in the liver. In vitro analysis using hepatocytes demonstrated that SIRT1 suppresses GH-dependent IGF-I expression, accompanied by decreased tyrosine phosphorylation on signal transducer and activator of transcription (STAT) 5. GST pull-down assays revealed that SIRT1 interacts directly with STAT5. When the lysine residues adjacent to the SH2 domain of STAT5 were mutated, STAT5 acetylation decreased concomitant with a decrease in its transcriptional activity. Knockdown of SIRT1 enhanced the acetylation and GH-induced tyrosine phosphorylation of STAT5, as well as the GH-induced interaction of the GH receptor with STAT5. These data indicate that SIRT1 negatively regulates GH-induced STAT5 phosphorylation and IGF-I production via deacetylation of STAT5 in the liver. In addition, our findings explain the underlying mechanisms of GH resistance under fasting conditions, which is a known element of endocrine adaptation during fasting.

Insulin-like growth factor-I (IGF-I) and clinical nutrition

IGF-I (insulin-like growth factor-I) is a peptide hormone, produced predominantly by the liver in response to pituitary GH (growth hormone), which is involved in a wide variety of physiological processes. It acts in an endocrine, paracrine and autocrine manner to promote growth. The production of IGF-I signals the availability of nutrients needed for its anabolic actions. Recently, there has been growing interest in its role in health and disease. IGF-I has long been known to be regulated by nutrition and dysregulated in states of under- and over-nutrition, its serum concentrations falling in malnutrition and responding promptly to refeeding. This has led to interest in its utility as a nutritional biomarker. A considerable evidence base supports utility for measurement of IGF-I in nutritional contexts. Its concentration may be valuable in providing information on nutritional status, prognosis and in monitoring nutritional support. However, it is insufficiently specific for use as a screening test for under nutrition as its serum concentration is influenced by many factors other than nutritional status, notably the APR (acute-phase response) and endocrine conditions. Concentrations should be interpreted along with clinical findings and the results of other investigations such as CRP (C-reactive protein). More recently, there has been interest in free IGF-I which holds promise as a nutritional marker. The present review covers nutritional regulation of IGF-I and its dysregulation in disease, then goes on to review recent studies supporting its utility as a nutritional marker in clinical contexts. Although not currently recommended by clinical guidelines, it is likely that, in time, measurement of IGF-I will become a routine part of nutritional assessment in a number of these contexts.

Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association

OBJECTIVE

Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.

METHODS

The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incorporated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines-2010 update.

RESULTS

Topics addressed include the etiology, epidemiology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered.

CONCLUSIONS

Fifty-two evidence-based recommendations and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medical practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations. The standard treatment is replacement with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.

The role of adiponectin multimers in anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) continues to be a refractory disease because of its unknown pathogenesis. The role of adiponectin in AN has not been clarified. Moreover, few reports have described the relations between adiponectin isoforms and AN in the physical and psychological states. Therefore, we measured plasma adiponectin and its isoforms levels in patients with AN to examine their roles in AN.

METHODS

Eighteen women participated in this study: nine patients with AN and nine age-matched healthy controls. We examined plasma adiponectin and its isoforms levels in all subjects and administered three types of psychological test to patients with AN: the Eating Disorders Inventory-2, the Maudsley Obsessional-Compulsive Inventory, and the Beck Depression Inventory-2.

RESULTS

We found that the percentage of high-molecular-weight (HMW) to total adiponectin (%HMW) was significantly low and the percentage of low-molecular-weight (LMW) to total adiponectin (%LMW) was significantly high in the AN group compared with the control group. The %HMW positively and the %LMW negatively correlated with body mass index in the entire study population. The %HMW was also positively correlated with psychological symptoms such as social insecurity or cleaning evaluated with the Eating Disorders Inventory-2 or the Maudsley Obsessional-Compulsive Inventory.

CONCLUSIONS

Our study indicates that all adiponectin isoforms should be evaluated in patients with AN in addition to total adiponectin. The decreased %HMW and the increased %LMW that were correlated with the body mass index and some components of psychopathology in our patients may indicate a complex role of adiponectin isoforms in maintaining energy homeostasis and emotion during extreme malnourishment.

A rat in the labyrinth of anorexia nervosa: contributions of the activity-based anorexia rodent model to the understanding of anorexia nervosa

Activity-based anorexia (ABA) is an analogous animal model of anorexia nervosa where food-restricted rats develop excessive running activity when given free access to a running wheel; their body weight sharply decreases, and finally self-starvation and death ensue unless animals are removed from the experimental conditions. The parallel of this animal model with major signs in the human disorder has been the focus of much attention from researchers and clinicians as a platform for translational research. The paper reviews the historical antecedents of ABA, research characterizing its occurrence, and its main limitations and strengths as a model of AN. As a symptomatic model of AN, the ABA model can provide clinicians with innovative and alternative routes for improving the treatment of AN.

Postprandial oxytocin secretion is associated with severity of anxiety and depressive symptoms in anorexia nervosa

OBJECTIVE

Anorexia nervosa, a psychiatric disorder characterized by self-induced starvation, is associated with endocrine dysfunction and comorbid anxiety and depression. Animal data suggest that oxytocin may have anxiolytic and antidepressant effects. We have reported increased postprandial oxytocin levels in women with active anorexia nervosa and decreased levels in weight-recovered women with anorexia nervosa compared to healthy controls. A meal may represent a significant source of stress in patients with disordered eating. We therefore investigated the association between postprandial oxytocin secretion and symptoms of anxiety and depression in anorexia nervosa.

METHOD

We performed a cross-sectional study of 35 women (13 women with active anorexia nervosa, 9 with weight-recovered anorexia nervosa, and 13 healthy controls). Anorexia nervosa was diagnosed according to DSM-IV-TR criteria. Serum oxytocin and cortisol and plasma leptin levels were measured fasting and 30, 60, and 120 minutes after a standardized mixed meal. The area under the curve (AUC) and, for oxytocin, postprandial nadir and peak levels were determined. Anxiety and depressive symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory II (BDI-II). The study was conducted from January 2009 to March 2011.

RESULTS

In women with anorexia nervosa, oxytocin AUC and postprandial nadir and peak levels were positively associated with STAI trait and STAI premeal and postmeal state scores. Oxytocin AUC and nadir levels were positively associated with BDI-II scores. After controlling for cortisol AUC, all of the relationships remained significant. After controlling for leptin AUC, most of the relationships remained significant. Oxytocin secretion explained up to 51% of the variance in STAI trait and 24% of the variance in BDI-II scores.

CONCLUSIONS

Abnormal postprandial oxytocin secretion in women with anorexia nervosa is associated with increased symptoms of anxiety and depression. This link may represent an adaptive response of oxytocin secretion to food-related symptoms of anxiety and depression.

Ghrelin: central and peripheral implications in anorexia nervosa

Increasing clinical and therapeutic interest in the neurobiology of eating disorders reflects their dramatic impact on health. Chronic food restriction resulting in severe weight loss is a major symptom described in restrictive anorexia nervosa (AN) patients, and they also suffer from metabolic disturbances, infertility, osteopenia, and osteoporosis. Restrictive AN, mostly observed in young women, is the third largest cause of chronic illness in teenagers of industrialized countries. From a neurobiological perspective, AN-linked behaviors can be considered an adaptation that permits the endurance of reduced energy supply, involving central and/or peripheral reprograming. The severe weight loss observed in AN patients is accompanied by significant changes in hormones involved in energy balance, feeding behavior, and bone formation, all of which can be replicated in animals models. Increasing evidence suggests that AN could be an addictive behavior disorder, potentially linking defects in the reward mechanism with suppressed food intake, heightened physical activity, and mood disorder. Surprisingly, the plasma levels of ghrelin, an orexigenic hormone that drives food-motivated behavior, are increased. This increase in plasma ghrelin levels seems paradoxical in light of the restrained eating adopted by AN patients, and may rather result from an adaptation to the disease. The aim of this review is to describe the role played by ghrelin in AN focusing on its central vs. peripheral actions. In AN patients and in rodent AN models, chronic food restriction induces profound alterations in the « ghrelin » signaling that leads to the development of inappropriate behaviors like hyperactivity or addiction to food starvation and therefore a greater depletion in energy reserves. The question of a transient insensitivity to ghrelin and/or a potential metabolic reprograming is discussed in regard of new clinical treatments currently investigated.

Pituitary immunoexpression of ghrelin in anorexia nervosa

Ghrelin, an orexigenic hormone, is known to occur in the normal anterior pituitary where its physiologic role is uncertain but may include promotion of appetite. We sought to investigate anticipated differences in adenohypophysial and neurohypophysial ghrelin immunoexpression between normal subjects and patients with anorexia nervosa who had succumbed to complications of the disease. We hypothesized that the glands of anorexia nervosa patients would show relative diminished action in ghrelin content. The study included 12 autopsy-derived pituitaries of anorexia nervosa and 10 control glands. The streptavidin-biotin-peroxidase complex method and double immunohistochemical staining method were used to determine which cell types expressed both ghrelin and adenohypophysial hormones. Nontumorous control pituitaries were also obtained at autopsy. In anorexia nervosa and control adenohypophyses, ghrelin was mainly localized in somatotrophs and to a lesser extent in corticotrophs and gonadotrophs. Ghrelin accumulated within nerve fibers and Herring bodies in the neurohypophysis and pituitary stalk. In the controls, ghrelin expression was apparent in only a few cases. It was mild and only along few nerve fibers. In the adenohypophyses of anorexia nervosa patients, ghrelin was not depleted. It appears that in these patients, ghrelin is transported in excess from the hypothalamic neurohypophysial tract to the neurohypophysis.

Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association

BACKGROUND

Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.

METHODS

The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incorporated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines-2010 update.

RESULTS

Topics addressed include the etiology, epidemiology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered.

CONCLUSIONS

Fifty-two evidence-based recommendations and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medical practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations. The standard treatment is replacement with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.

Plasma sodium level is associated with bone loss severity in women with anorexia nervosa: a cross-sectional study

BACKGROUND

Anorexia nervosa is a psychiatric disorder characterized by restrictive eating, low body weight, and severe bone loss. Recent data show a deleterious relationship between low circulating sodium levels and bone mass, and relative or absolute hyponatremia is a known complication of anorexia nervosa. Clinical studies of other medical conditions associated with hyponatremia suggest that detrimental effects of low sodium levels on health are seen even within the normal range. We hypothesized that women with anorexia nervosa and relatively low plasma sodium levels would have lower bone mineral density (BMD) than those with higher plasma sodium levels.

METHOD

In a cross-sectional study (January 1, 1997-December 31, 2009) of 404 women aged 17 to 54 years (mean ± standard error of the mean [SEM] age = 25.6 ± 0.3 years) who met DSM-IV criteria for anorexia nervosa, we measured BMD using dual-energy x-ray absorptiometry. Bone mineral density was compared in women with plasma sodium levels < 140 mmol/L (midpoint of normal range) versus those with plasma sodium levels ≥ 140 mmol/L and in women with hyponatremia (plasma sodium < 135 mmol/L) versus those without. The study was conducted at the Neuroendocrine Unit of Massachusetts General Hospital, Boston.

RESULTS

Women with plasma sodium levels < 140 mmol/L had significantly lower BMD and t and z scores versus those with plasma sodium levels ≥ 140 mmol/L at the anterior-posterior (AP) spine (mean ± SEM z scores = -1.6 ± 0.1 vs -1.3 ± 0.1, P = .004) and total hip (mean ± SEM z scores = -1.2 ± 0.1 vs -0.9 ± 0.1, P = .029). In a model controlling for age, BMI, psychiatric drug use, and disease duration, differences in BMD and t and z scores remained significant at the AP spine. Women with hyponatremia had significantly lower BMD and t and z scores versus those without hyponatremia at the AP spine (mean ± SEM z scores = -2.2 ± 0.3 vs -1.3 ± 0.1, P = .009), lateral spine (mean ± SEM z scores = -2.4 ± 0.4 vs -1.5 ± 0.1, P = .031), and total hip (mean ± SEM z scores = -2.5 ± 0.5 vs -1.0 ± 0.1, P < .0001). In a model controlling for age, BMI, psychiatric drug use, and disease duration, differences in BMD and z and t scores remained significant at all sites.

CONCLUSIONS

These data suggest that relative plasma sodium deficiency may contribute to anorexia nervosa-related osteopenia.

Food-restricted and dehydrated-induced anorexic rats present differential TRH expression in anterior and caudal PVN. Role of type 2 deiodinase and pyroglutamyl aminopeptidase II

TRH synthesized in hypothalamic paraventricular nucleus (PVN) regulates thyroid axis function and is also implicated in anorexigenic effects. Under energy deficit, animals present decreased PVN TRH expression and release, low TSH levels, and increased appetite. Dehydration-induced anorexia (DIA) model allows insight into underlying mechanisms of feeding regulation. Animals drinking a 2.5% NaCl solution for 7 d present body weight reduction; despite their negative energy balance, they avoid food and have increased PVN TRH expression and TSH serum levels. These findings support an inhibiting role of PVN TRH in feeding control. We compared TRH expression by in situ hybridization in PVN subdivisions of 7-d dehydrated male rats to those of a pair-fed group (forced food-restricted) with similar metabolic changes than DIA, but motivated to eat, and to controls. We measured peripheral deiodinase activities, and expression and activity of medial basal hypothalamic type 2 deiodinase and pyroglutamyl-aminopeptidase II, to understand their regulating role in PVN TRH changes between food restriction and anorexia. TRH mRNA levels increased in anterior (aPVN) and medial-caudal subdivisions in DIA rats, whereas it decreased in medial PVN in both experimental groups. We confirmed the nonhypophysiotropic nature of aPVN TRHergic cells by injecting ip fluorogold tracer. Findings support a subspecialization of TRHergic hypophysiotrophic cells that responded differently between anorexic and food-restricted animals; also, that aPVN TRH participates in food intake regulation. Increased type 2 deiodinase activity seemed responsible for low medial PVN TRH synthesis, whereas increased medial basal hypothalamic pyroglutamyl-aminopeptidase II activity in DIA rats might counteract their high TRH release.

The insulin-like growth factor system and nutritional assessment

Over recent years there has been considerable interest in the role of the insulin-like growth factor (IGF) system in health and disease. It has long been known to be dysregulated in states of under- and overnutrition, serum IGF-I levels falling in malnourished patients and responding promptly to nutritional support. More recently, other proteins in this system have been observed to be dysregulated in both malnutrition and obesity. Currently no biochemical marker is sufficiently specific for use in screening for malnutrition, but levels may be valuable in providing information on nutritional status and in monitoring of nutritional support. All have limitations as nutritional markers in that their serum levels are influenced by factors other than nutritional status, most importantly the acute phase response (APR). Levels should be interpreted along with clinical findings and the results of other investigations such as C-reactive protein (CRP). This paper reviews data supporting the use of proteins of the IGF system as nutritional markers.

Peptide tyrosine tyrosine levels are increased in patients with urea cycle disorders

Nutritional management is essential for patients with inborn errors of metabolism, such as urea cycle disorders (UCDs). Lack of appetite is common in these patients and can lead to underconsumption of calories, catabolism, and subsequently loss of metabolic control. The etiology of anorexia in these patients is largely unexplored. The neuroendocrine hormone peptide tyrosine tyrosine (PYY), secreted postprandially from endocrine cells of the ileum and colon, induces feelings of satiety and decreases food intake. While plasma PYY levels have been characterized in a number of populations, they have not been examined in UCD patients. In a retrospective study, plasma PYY concentrations were measured in UCD (n=42) patients and controls (n=28) via an ELISA to determine if levels of this anorexigenic hormone are altered in this patient population. Median PYY levels were significantly higher in UCD patients compared to controls (p=3.5×10(-5)). Body mass index was significantly associated with increased PYY levels in controls (p=0.02), while UCD diagnosis subtype was associated with PYY levels (p=1×10(-3)) in cases. Median PYY levels were significantly lower in ornithine carbamoyltransferase deficient patients compared with all other UCD subtypes (p=9×10(-3)), but significantly higher compared to controls (p=1.6×10(-3)). Overall, this study demonstrates that UCD cases have increased PYY levels compared to controls, suggesting that regulation of PYY may be altered in these patients. These observations may lead to a better understanding of the development of anorexia in UCD patients.