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

Anthropometry, body composition and chronic disease risk factors among Zambian school-aged children who experienced severe malnutrition in early childhood

There is limited information as to whether people who experience severe acute malnutrition (SAM) as young children are at increased risk of overweight, high body fat and associated chronic diseases in later life. We followed up, when aged 7-12 years, 100 Zambian children who were hospitalised for SAM before age 2 years and eighty-five neighbourhood controls who had never experienced SAM. We conducted detailed anthropometry, body composition assessment by bioelectrical impedance and deuterium dilution (D2O) and measured blood lipids, Hb and HbA1c. Groups were compared by linear regression following multiple imputation for missing variables. Children with prior SAM were slightly smaller than controls, but differences, controlling for age, sex, socio-economic status and HIV exposure or infection, were significant only for hip circumference, suprailiac skinfold and fat-free mass index by D2O. Blood lipids and HbA1c did not differ between groups, but Hb was lower by 7·8 (95 % CI 0·8, 14·7) g/l and systolic blood pressure was 3·4 (95 % CI 0·4, 6·4) mmHg higher among the prior SAM group. Both anaemia and high HbA1c were common among both groups, indicating a population at risk for the double burden of over- and undernutrition and associated infectious and chronic diseases. The prior SAM children may have been at slightly greater risk than the controls; this was of little clinical significance at this young age, but the children should be followed when older and chronic diseases manifest.

Eating disorders and carbohydrate metabolism interrelations

Introduction: Eating disorders are characterised by persistent disturbances in eating behavior, resulting in severe carbohydrate homeostasis changes. The aim of the study is to review mutual correlations between eating disorders, with emphasis on anorexia nervosa, and carbohydrate metabolism, including glycemia and the levels of relevant hormones.

Material and methods: A priori general inclusion criteria were established and included patients with eating disorders or with glucose metabolism disorders. A MEDLINE database review was carried out. Relevant articles have been extracted and approved by supervisor.

Results: 40 studies got included in the review. Patients with active anorexia nervosa display low levels of fasting and postprandial glucose, decreased lipid metabolism, and decreased pancreatic endocrine activity. Insulin levels remain changed even after patient’s re-nourishment – insulin response tends to be delayed and decreased compared to patients without anorexia history. Eating disorders are associated with poorer glycemic control and a higher percentage of diabetic complications in patients with pre-existing diabetes – mostly type I. There are also reports of higher carbohydrate metabolism disturbances among patients with eating disorders.

Conclusions: Carbohydrate metabolism disorders and eating disorders are clearly interrelated, although data on the nature of these relationships are still lacking. Treatment of eating disorders is not possible without normalizing eating patterns, thus also carbohydrate metabolism. However, it is not usual to monitor the mental state in terms of eating disorders potential development in patients during the treatment of carbohydrate disorders. According to existing data, this approach should be changed due to the risk of anorexia nervosa and other eating disorders in this group.

Association of postnatal severe acute malnutrition with pancreatic exocrine and endocrine function in children and adults: a systematic review

Severe acute malnutrition may lead both concurrently and subsequently to malabsorption and impaired glucose metabolism from pancreatic dysfunction. We conducted a systematic review to investigate the associations of current and prior postnatal wasting malnutrition with pancreatic endocrine and exocrine functions in humans. We searched PubMed, Google Scholar, Web of Science and reference lists of retrieved articles, limited to articles in English published before 1 February 2022. We included sixty-eight articles, mostly cross-sectional or cohort studies from twenty-nine countries including 592 530 participants, of which 325 998 were from a single study. Many were small clinical studies from decades ago and rated poor quality. Exocrine pancreas function, indicated by duodenal fluid or serum enzymes, or faecal elastase, was generally impaired in malnutrition. Insulin production was usually low in malnourished children and adults. Glucose disappearance during oral and intravenous glucose tolerance tests was variable. Upon treatment of malnutrition, most abnormalities improved but frequently not to control levels. Famine survivors studied decades later showed ongoing impaired glucose tolerance with some evidence of sex differences. The similar findings from anorexia nervosa, famine survivors and poverty- or infection-associated malnutrition in low- and middle-income countries (LMIC) lend credence to results being due to malnutrition itself. Research using large, well-documented cohorts and considering sexes separately, is needed to improve prevention and treatment of exocrine and endocrine pancreas abnormalities in LMIC with a high burden of malnutrition and diabetes.

Prior undernutrition and insulin production several years later in Tanzanian adults

BACKGROUND

The prevalence, pathology, and existence of malnutrition-associated diabetes remain uncertain, especially with respect to adult-acquired undernutrition.

OBJECTIVE

The aim was to investigate the association of prior undernutrition (low BMI, in kg/m2), acquired in adulthood and insulin during an oral glucose tolerance test (OGTT).

METHODS

We followed up 630 adults recruited 7-14 y previously for other studies. Plasma insulin was measured fasting and at 30 and 120 min during an OGTT. The main exposure was BMI measured 7-14 y prior. The main outcome of interest was plasma insulin, controlling for time during the OGTT using generalized estimating equations, and exploratory outcomes were early insulin response (relative change in insulin and glucose from 0-30 min) and relative insulin and glucose AUCs from 0 to 120 min. Current confounding factors were age, sex, BMI, HIV, socioeconomic status, and physical activity.

RESULTS

In unadjusted analyses, increasing severity of prior malnutrition was associated with lower insulin concentration. In multivariate adjusted analyses, only current BMI was a strong predictor of overall insulin concentration. Associations with prior BMI of insulin responses accounting for glucose were also seen in unadjusted but not adjusted analyses. For insulin concentration but not the outcomes accounting for glucose, there was a sex interaction with prior BMI such that only men had lower insulin if previously malnourished: insulin (pmol/L) at 120 min was 311 (95% CI: 272, 351) for prior BMI ≥18.5, 271 (95% CI: 221, 321) for prior BMI 17.0-18.5, and 237 (95% CI: 194, 297) for prior BMI <17.0; P = 0.03. HIV status showed limited and variable associations with insulin.

CONCLUSIONS

Insulin concentration, fasting and during an OGTT, was normalized in women more than in men several years after adult malnutrition. Chronic malnutrition, as indicated by low prior and current BMI, may contribute to diabetes through low insulin secretion.

Timing of Nutrient Ingestion after Mild to Moderate Cycling Exercise Does Not Affect Gastric Emptying Rate in Humans

This study examined the effect of carbohydrate drink ingestion timing on gastrointestinal tract blood flow and motility after mild cycling exercise. Eight healthy participants were randomly assigned to ingest a liquid solution with 75 g glucose at either 5 min (PE-5) or 30 min (PE-30) after a single bout of leg cycling exercise according to target heart rate (approximately 120 beats/min). As the control trial (Con), participants ingested the same liquid solution without exercise. Celiac artery blood flow (BF), superior mesenteric artery BF, and gastric emptying rate were assessed by ultrasonography before and for 60 min after ingesting the glucose solution. Blood lactate, glucose, and plasma insulin were also measured at baseline and for 60 min after ingesting the glucose solution. Celiac artery BF significantly decreased from resting baseline immediately after exercise in both the PE-5 and PE-30 trials, and then returned to resting baseline just before the ingestion of glucose solution in the PE-30 trial. After ingesting the glucose solution, changes in celiac artery BF, superior mesenteric artery BF, % gastric emptying rate, blood lactate, blood glucose, and plasma insulin were not significantly different among the three trials. The timing of nutrient ingestion after mild exercise does not seem to impact the subsequent gastrointestinal motility, blood flow, and glycemic responses.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trait-level and momentary correlates of bulimia nervosa with a history of anorexia nervosa

OBJECTIVE

Some investigators have suggested subtyping bulimia nervosa (BN) by anorexia nervosa (AN) history. We examined trait-level and momentary eating-related and psychosocial factors in BN with and without an AN history.

METHOD

Interview, questionnaire, and ecological momentary assessment data of eating-related and psychological symptoms were collected from 122 women with BN, including 43 with (BN+) and 79 without an AN history (BN-).

RESULTS

Body mass index (kg/m(2) ) was lower in BN+ than BN- (p = 0.001). Groups did not differ on trait-level anxiety, shape/weight concerns, psychiatric comorbidity, or dietary restraint; or on momentary anxiety, dietary restriction, binge eating, purging, or exercise frequency, or affective patterns surrounding binge/purge behaviors. Negative affect increased prior to exercise and decreased thereafter in BN+ but not BN-, although groups did not statistically differ.

DISCUSSION

Results do not support formally subtyping BN by AN history. Exercise in BN+ may modulate negative affect, which could have important treatment implications.

Effect of premeal consumption of whey protein and its hydrolysate on food intake and postmeal glycemia and insulin responses in young adults

BACKGROUND

Dairy protein ingestion before a meal reduces food intake and, when consumed with carbohydrate, reduces blood glucose.

OBJECTIVE

The objective was to describe the effect of whey protein (WP) or its hydrolysate (WPH) when consumed before a meal on food intake, pre- and postmeal satiety, and concentrations of blood glucose and insulin in healthy young adults.

DESIGN

Two randomized crossover studies were conducted. WP (10-40 g) in 300 mL water was provided in experiment 1, and WP (5-40 g) and WPH (10 g) in 300 mL water were provided in experiment 2. At 30 min after consumption, the subjects were fed an ad libitum pizza meal (experiment 1) or a preset pizza meal (12 kcal/kg, experiment 2). Satiety, blood glucose, and insulin were measured at baseline and at intervals both before and after the meals.

RESULTS

In experiment 1, 20-40 g WP suppressed food intake (P < 0.0001) and 10-40 g WP reduced postmeal blood glucose concentrations and the area under the curve (AUC) (P < 0.05). In experiment 2, 10-40 g WP, but not WPH, reduced postmeal blood glucose AUC and insulin AUC in a dose-dependent manner (P < 0.05). The ratio of cumulative blood glucose to insulin AUCs (0-170 min) was reduced by > or =10 g WP but not by 10 g WPH.

CONCLUSIONS

WP consumed before a meal reduces food intake, postmeal blood glucose and insulin, and the ratio of cumulative blood glucose to insulin AUCs in a dose-dependent manner. Intact WP, but not WPH, contributes to blood glucose control by both insulin-dependent and insulin-independent mechanisms. This trial was registered at clinicaltrials.gov as NCT00988377 and NCT00988182.

The endocrinopathies of anorexia nervosa

OBJECTIVE

To describe the hormonal adaptations and alterations in anorexia nervosa.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Immunological disturbance and infectious disease in anorexia nervosa: a review

OBJECTIVE

Severely malnourished patients with anorexia nervosa (AN) are reported to show fewer symptomatic viral infections and a poorer response to bacterial infection than controls. They are also reported to show mild immune system changes, although the relevance of these to altered infection disease presentation in AN and AN pathophysiology is unknown. Thus, in this paper, we suggest a range of immune system changes that might underpin these altered responses to common pathogens, and review a number of recent infectious disease findings for their utility in explaining the pathophysiology of AN.

METHODS

A systematic review of the literature pertaining to immunity and infectious disease in AN was performed.

RESULTS

AN is associated with leucopenia, and the increased spontaneous and stimulated levels of proinflammatory cytokines [i.e. interleukin (IL)-1β, IL-6 and tumour necrosis factor α). A range of less consistent findings are also reviewed. Most of these data were not controlled for length of illness, degree of malnutrition, micronutrient or vitamin deficiencies or recent refeeding and starvation.

CONCLUSION

Cytokine disturbances have been suggested to be causally related to AN symptomatology and pathophysiology of AN, although the evidence supporting this assertion is lacking. Immune and cytokine changes in AN do, however, occur in association with a decreased incidence of symptomatic viral infection, decreased clinical response to bacterial infection leading to delayed diagnosis and increased morbidity and mortality associated with the infections.

Insulin, glucose, and pancreatic polypeptide responses to a test meal in restricting type anorexia nervosa before and after weight restoration

Prolonged malnutrition in individuals with anorexia nervosa (AN) has been associated with alterations in endocrine function that may play a sustaining role in the disorder. We hypothesized that abnormalities in endocrine responses to ingestion of a meal in AN are reversible and depend on weight restoration. We measured meal-induced endocrine responses in AN subjects at three time points during hospitalization: before refeeding (n = 13, mean BMI 16.7 kg/m(2)), after 2 wk of refeeding (mean BMI 18.0 kg/m(2)), and in the weight-restored state (mean BMI 20.3 kg/m(2)). Control subjects (n = 13, BMI 19-24.9 kg/m(2)) were tested once. Tests were 2.5-h sessions in which blood was drawn every 15 min before, during, and after a approximately 650-kcal test breakfast. Relative to controls, peak levels of glucose were depressed and peak levels of insulin in response to ingestion of the test meal were delayed, with response patterns in the third trial most similar to controls. Pancreatic polypeptide (PP) levels were increased in AN relative to controls regardless of weight status. The delay in insulin release and elevated PP levels did not correct with short-term refeeding and may contribute to the high relapse rates and maintenance of AN.

An examination of cognitive versus behavioral components of recovery from anorexia nervosa

Definitions of "full recovery" from anorexia nervosa (AN) vary, and rarely include the cognitive criteria of lack of body image distortion and fear of weight gain. We investigated the implications of including or excluding cognitive criteria of AN in the definition of "full recovery". Current symptomatology and personality characteristics associated with AN were assessed and compared in 42 behaviorally but not cognitively recovered women, 32 both behaviorally and cognitively recovered women, and 253 controls. On all measures included, the scores of the behaviorally recovered women were significantly more anorexic-like than those of the women recovered cognitively as well, who were indistinguishable from controls. Criteria for recovery from AN need to be refined and standardized, and cognitive criteria incorporated, to characterize a minority who recover to the extent that their eating attitudes and personality profiles are indistinguishable from those of women with no history of an eating disorder.

The psychopharmacotherapy of anorexia nervosa: clinical, neuroendocrine and metabolic aspects

Anorexia nervosa (AN) is a complex mental disorder presenting psychiatric and physical symptoms. Literature recognizes the role of several factors in the pathogenesis of this disorder, according to the biopsychosocial model. Many mechanisms are still partly unclear. Endocrine and metabolic alterations usually occur in AN, probably having a role in its pathogenesis and in the disorder perseverance. In consideration of the multifactorial pathogenesis, a multidisciplinary approach is needed in the treatment of anorexic patients. Up-to-date psychotherapy, psychopharmacological, endocrine and nutritional treatments are considered effective in improving AN. Literature does not however provide evidence of a single validated psychopharmacotherapy for anorexic patients. It is known that psychopharmacotherapy can influence hormonal and metabolic states in some conditions, but for the moment few data are present about these effects in AN. This article aims to review the data about the psychopharmacotherapy role in AN, focusing on the endocrine and metabolic effects of anti-depressants (AD) and novel antipsychotic drugs which seem to be the most effective in AN. Scant data are however available and further research should provide more evidence about these effects and also assess whether the severity of the neuroendocrine, hormonal and metabolic impairments can predict the lack of response to the psychopharmacological treatment with AD and neuroleptics.