Changes of body composition in bulimia nervosa: increased visceral fat and adrenal gland size

Continuous glucose monitoring for detection of glycemic variability, hypoglycemia, and hyperglycemia in women with eating disorders

Background

The aim of this study was to investigate the relationships between hypoglycemia, hyperglycemia, glycemic variability (GV), and eating behavior by measuring daily glucose levels through an intermittently scanned continuous glucose monitoring (isCGM) system in outpatients classified according to eating disorder subtypes.

Methods

We analyzed data for 18 patients (four ANR, nine ANBP, and five BN cases). A FreeStyle Libre Pro® device was attached to the posterior aspect of the upper arm for glucose monitoring. This device conducted measurements every 15 min for five consecutive days. We estimated the mean amplitude of glycemic excursions (MAGE), hypoglycemia, and hyperglycemia.

Results

The mean glucose levels were 91.1 ± 2.2 mg/dL in the ANR group, 94.8 ± 7.5 mg/dL in the ANBP group, and 87.1 ± 8.0 mg/dL in the BN group (P = 0.174). The overall mean MAGE index was 52.8 ± 20.5 mg/dL. The mean MAGE values according to the subtypes were 42.2 ± 5.6 mg/dL in the ANR group, 57.4 ± 23.7 mg/dL in the ANBP group, and 53.0 ± 21.8 mg/dL in the BN group (P = 0.496). Over the course of five days, the frequency of hypoglycemia was as follows: three occurrences in the ANBP group, five occurrences in the BN group, and no occurrences in the ANR group (P = 0.016). Moreover, the occurrence of hypoglycemia was statistically significantly higher in the BN group than in the ANR group (P = 0.013). In the BN group, the frequency of hypoglycemia was highest between 2 and 6 AM, while hypoglycemia was observed throughout the day in the ANBP group. The frequency of hyperglycemia was one occurrence in the ANR group, one occurrence in the BN group, and zero occurrences in the ANBP group (P = 0.641).

Conclusions

Varying GV, hypoglycemia, and hyperglycemia were observed in all subtypes of eating disorders. Our findings suggest that eating behaviors such as binge eating and purging are associated with GV and hypoglycemia. We showed the importance of developing different nutritional approaches tailored to the subtype of eating disorder to prevent hypoglycemia. Additional studies are needed to explore the relationship between glucose levels and eating behaviors in patients with eating disorders.

Risk of eating disorders, changes in salivary cortisol concentrations and nutritional status of adolescents

PURPOSE

The imposition of the thin body as an ideal of beauty and the changes that occur in adolescence lead to a constant concern with adolescents' body weight, putting them at risk for eating disorders. Thus, the study sought to investigate associations between eating disorders and salivary cortisol concentrations, nutritional status and depressive symptoms in female adolescents with bulimia.

METHODS

A cross-sectional study was carried out with 1435 adolescents aged 10-19 years. The Bulimic Investigatory Test of Edinburgh (BITE) and Body Shape Questionnaire (BSQ) questionnaires were used. A follow-up study was conducted from a random selection of female adolescents diagnosed with Bulimia Development and Well-Being Assessment-(DAWBA) to assess associations with salivary cortisol concentrations and nutritional status.

RESULTS

The prevalence of body dissatisfaction among adolescents with symptoms of bulimia was 37%. There was a significant difference between salivary cortisol and bulimia (Risk Group = 0.33 ± 0.20 μg/100 ml, Diagnostic Group = 0.44 ± 0.21 μg/100 ml p = 0.040), and correlation positive between the risk of bulimia with symptoms of depression (0.355 p = 0.002) and with Body Mass Index (0.259 p = 0.028). High concentrations of salivary cortisol in bulimic adolescents may be associated with hyperactivity of the hypothalamic-pituitary-adrenal axis and depressive symptoms.

CONCLUSIONS

Nutritional status indicators cannot be used alone for the diagnosis of bulimia, since cortisol levels seem to be a reliable parameter in the identification of bulimia, provided they are used with other diagnostic criteria.

LEVEL III

Evidence obtained from cross-sectional study.

Body composition and physical fitness in women with bulimia nervosa or binge-eating disorder

OBJECTIVE

Knowledge about physical fitness in women with bulimia nervosa (BN) or binge-eating disorder (BED) is sparse. Previous studies have measured physical activity largely through self-report, and physical fitness variables are mainly restricted to body mass index (BMI) and bone mineral density. We expanded the current knowledge in these groups by including a wider range of physical fitness indicators and objective measures of physical activity, assessed the influence of a history of anorexia nervosa (AN), and evaluated predictive variables for physical fitness.

METHOD

Physical activity, blood pressure, cardiorespiratory fitness (CRF), muscle strength, body composition, and bone mineral density were measured in 156 women with BN or BED, with mean (SD) age 28.4 years (5.7) and BMI 25.3 (4.8) kg m-2 .

RESULTS

Level of physical activity was higher than normative levels, still <50% met the official physical activity recommendation. Fitness in women with BN were on an average comparable with recommendations or normative levels, while women with BED had lower CRF and higher BMI, VAT, and body fat percentage. We found 10-12% with masked obesity. A history of AN did not predict current physical fitness, still values for current body composition were lower when comparing those with history of AN to those with no such history.

DISCUSSION

Overall, participants with BN or BED displayed adequate physical fitness; however, a high number had unfavorable CRF and body composition. This finding calls for inclusion of physical fitness in routine clinical examinations and guided physical activity and dietary recommendations in the treatment of BN and BED.

MDCT Linear and Volumetric Analysis of Adrenal Glands: Normative Data and Multiparametric Assessment

OBJECTIVES

To study linear and volumetric adrenal measurements, their reproducibility, and correlations between total adrenal volume (TAV) and adrenal micronodularity, age, gender, body mass index (BMI), visceral (VAAT) and subcutaneous adipose tissue volume (SAAT), presence of diabetes, chronic alcoholic abuse and chronic inflammatory disease (CID).

METHODS

We included 154 patients (M/F, 65/89; mean age, 57 years) undergoing abdominal multidetector row computed tomography (MDCT). Two radiologists prospectively independently performed adrenal linear and volumetric measurements with semi-automatic software. Inter-observer reliability was studied using inter-observer correlation coefficient (ICC). Relationships between TAV and associated factors were studied using bivariate and multivariable analysis.

RESULTS

Mean TAV was 8.4 ± 2.7 cm(3) (3.3-18.7 cm(3)). ICC was excellent for TAV (0.97; 95 % CI: 0.96-0.98) and moderate to good for linear measurements. TAV was significantly greater in men (p < 0.0001), alcoholics (p = 0.04), diabetics (p = 0.0003) and those with micronodular glands (p = 0.001). TAV was lower in CID patients (p = 0.0001). TAV correlated positively with VAAT (r = 0.53, p < 0.0001), BMI (r = 0.42, p < 0.0001), SAAT (r = 0.29, p = 0.0003) and age (r = 0.23, p = 0.005). Multivariable analysis revealed gender, micronodularity, diabetes, age and BMI as independent factors influencing TAV.

CONCLUSIONS

Adrenal gland MDCT-based volumetric measurements are more reproducible than linear measurements. Gender, micronodularity, age, BMI and diabetes independently influence TAV.

KEY POINTS

• Volumetric measurements are more reproducible than linear measurements for adrenal glands. • Inter-observer reproducibility of adrenal gland volume is excellent using semiautomatic software. • Gender, age, BMI, and diabetes independently influence total adrenal gland volume. • Adrenal micronodularity is associated with increased total adrenal gland volume.

Examination of central body fat deposition as a risk factor for loss-of-control eating

BACKGROUND

Elevated body mass index (BMI), higher waist-to-hip ratio, and body dissatisfaction have been investigated as risk factors for the development of bulimic symptoms. Central fat deposition may be particularly relevant to eating disorders. To our knowledge, the longitudinal relations between fat distribution, body dissatisfaction, and loss-of-control (LOC) eating development and maintenance have not been studied.

OBJECTIVE

We examined body fat distribution, independent of BMI and depressive symptoms, as a unique correlate and predictor of body dissatisfaction and LOC eating cross-sectionally and over a 2-y follow-up.

DESIGN

Body composition was measured by using dual-energy X-ray absorptiometry in 294 adult women at risk of weight gain at baseline, 6 mo, and 24 mo. We assessed LOC eating, body dissatisfaction, and depressive symptoms at baseline, 6 wk, 6 mo, 12 mo, and 24 mo by using the Eating Disorder Diagnostic Interview, the Multidimensional Body-Self Relations Questionnaire-Appearance Scales Body Areas Satisfaction subscale, and the Center for Epidemiologic Studies-Depression Scale, respectively.

RESULTS

Independent of BMI, baseline total percentage body fat, percentage trunk fat, and percentage abdominal fat were related to greater body dissatisfaction. Total percentage body fat and trunk fat tended to be associated with greater body dissatisfaction at all subsequent time points. Women with a greater percentage trunk fat, specifically abdominal fat, were at highest risk of developing LOC eating. In the full sample, women with higher baseline percentage trunk and abdominal fat showed increases in LOC eating episode frequency over time, whereas LOC eating frequency remained stable among women with smaller percentages of fat in trunk and abdominal regions.

CONCLUSION

These findings lend further support to the premise that increased central body fat deposition is associated with body image dissatisfaction and suggest that it may represent a risk and maintenance factor for LOC eating. This trial was registered at clinicaltrials.gov as NCT00456131.

Reassessing the reliability of the salivary cortisol assay for the diagnosis of Cushing syndrome

Objective

The cortisol concentration in saliva is 10-fold lower than total serum cortisol and accurately reflects the serum concentration, both levels being lowest around midnight. The salivary cortisol assay measures free cortisol and is unaffected by confounding factors. This study analysed published data on the sensitivity and specificity of salivary cortisol levels in the diagnosis of Cushing syndrome.

Methods

Data from studies on the use of different salivary cortisol assay techniques in the diagnosis of Cushing syndrome, published between 1998 and 2012 and retrieved using Ovid MEDLINE®, were analysed for variance and correlation.

Results

For the 11 studies analysed, mean sensitivity and specificity of the salivary cortisol assay were both >90%. Repeated measurements were easily made with this assay, enabling improved diagnostic accuracy in comparison with total serum cortisol measurements.

Conclusions

This analysis confirms the reliability of the saliva cortisol assay as pragmatic tool for the accurate diagnosis of Cushing syndrome. With many countries reporting a rising prevalence of metabolic syndrome, diabetes and obesity – in which there is often a high circulating cortisol level – salivary cortisol measurement will help distinguish these states from Cushing syndrome.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Active depression is associated with regional adiposity in the upper abdomen and the neck

OBJECTIVE

In major depression, the incidence of overweight, the risk of type 2 diabetes, as well as cardiovascular disease is increased. Aim was to determine body fat distribution in depressive and healthy females using whole body Magnetic Resonance Imaging (MRI). Measurements of total adipose tissue (TAT), visceral (VAT), and subcutaneous adipose tissue (SCAT) at the trunk and the whole body fat distribution along the body axis were performed and compared. Differences in body fat distribution between depressive and healthy females and their location were evaluated.

METHODS

In total, 11 women with a depressive syndrome (major depression, MD) and 45 healthy female volunteers (HC) matched for age and body mass index were compared. Total tissue (TT), TAT, VAT, and SCAT were quantified using T1-weighted whole body MRI. Adipose tissue distribution was compared along the body axis.

RESULTS

MD patients showed higher adipose tissue volumes than the HC group. Especially in the upper abdomen, at the upper extremities and the neck, MD patients are characterized by a significantly higher adipose tissue mass compared to the HC group.

CONCLUSIONS

The results of this study confirm the hypothesis of a high stress level with a disturbed hypothalamic-pituitary-adrenal (HPA) axis leading to a Cushing-like habitus and high visceral fat levels. The increased fat levels at the arms, as well as the whole body fat may be well-founded by a lack of activity in depression. These effects should be evaluated in further longitudinal studies investigating patients with a depressive syndrome and after remission.

Repetitive transcranial magnetic stimulation reduces cortisol concentrations in bulimic disorders

BACKGROUND

In people with bulimic eating disorders, exposure to high-calorie foods can result in increases in food craving, raised subjective stress and salivary cortisol concentrations. This cue-induced food craving can be reduced by repetitive transcranial magnetic stimulation (rTMS). We investigated whether rTMS has a similar effect on salivary cortisol concentrations, a measure of hypothalamic-pituitary-adrenal axis (HPAA) activity.

METHOD

We enrolled twenty-two female participants who took part in a double-blind randomized sham-controlled trial on the effects of rTMS on food craving. Per group, eleven participants were randomized to the real or sham rTMS condition. The intervention consisted of one session of high-frequency rTMS delivered to the left dorsolateral prefrontal cortex (DLPFC). Salivary cortisol concentrations were assessed at four time points throughout the 90-min trial. To investigate differences in post-rTMS concentrations between the real and sham rTMS groups, a random-effects model including the pre-rTMS cortisol concentrations as covariates was used.

RESULTS

Salivary cortisol concentrations following real rTMS were significantly lower compared with those following sham rTMS. In this sample, there was also a trend for real rTMS to reduce food craving more than sham rTMS.

CONCLUSIONS

These results suggest that rTMS applied to the left DLPFC alters HPAA activity in people with a bulimic disorder.

Endocrine manifestations of eating disorders

CONTEXT

The endocrinopathies associated with eating disorders involve multiple systems and mechanisms designed to preserve energy and protect essential organs. Those systems that are most affected are in need of significant energy, such as the reproductive and skeletal systems. The changes in neuropeptides and in the hypothalamic axis that mediate these changes also receive input from neuroendocrine signals sensitive to satiety and food intake and in turn may be poised to provide significant energy conservation. These adaptive changes are described, including the thyroid, GH, and cortisol axes, as well as the gastrointestinal tract.

EVIDENCE ACQUISITION

Articles were found via PubMed search for both original articles and reviews summarizing current understanding of the endocrine changes of eating disorders based on peer review publications on the topic between 1974 and 2009.

CONCLUSION

The signals that control weight and food intake are complex and probably involve multiple pathways that appear to have as a central control the hypothalamus, in particular the medial central area. The hypothalamic dysfunction of eating disorders provides a reversible experiment of nature that gives insight into understanding the role of various neuropeptides signaling nutritional status, feeding behavior, skeletal repair, and reproductive function.

Anorexia, bulimia, and the female athlete triad: evaluation and management

The female athlete triad is an increasingly prevalent condition involving disordered eating, amenorrhea, and osteoporosis. An athlete can suffer from all 3 components of the triad, or just 1 or 2 of the individual conditions. The main element underlying all the aspects of the triad is an adaptation to a negative caloric balance. Screening for these disorders should be an important component of an athlete's care. Prevention and treatment should involve a team approach, including a physician, a nutritionist, and a mental health provider.

Correlation of fat distribution in whole body MRI with generally used anthropometric data

OBJECTIVES

: Obesity is a commonly known risk for many diseases such as metabolic syndrome and cardiovascular disease. Especially important is the discrimination of the adipose tissue inside the abdomen and the subcutaneous adipose tissue. Aim of this study was to compare the whole body fat distribution, and the volume of different adipose tissue compartments respectively, with anthropometric data.

MATERIALS AND METHODS

: Sixty-eight volunteers (20 males, 48 females, 42.3 +/- 15.4 years) were investigated in the context of 2 whole body magnetic resonance imaging (MRI) studies which compared the body fat distribution of depressive and bulimic patients with healthy controls. Unpublished data acquired in these studies were analyzed retrospectively.The sample consisted of 38 healthy volunteers, 17 patients with a depressive syndrome and 13 women suffering from bulimia nervosa. Individual body volume, total adipose tissue (TAT) volume, subcutaneous adipose tissue (SCAT) volume at the trunk, and visceral adipose tissue (VAT) volume were determined, using whole body MRI. Additionally, body fat profiles were standardized and a mean body distribution was calculated. Other modalities to acquire body fat content were: skin fold caliper, body impedance (3 different devices) and simple anthropometric data (Waist to Hip Ratio [WHR], Body Mass Index [BMI], distance of the aponeurosis of the rectus abdominis muscle to the ventral rim of the abdominal aorta (measured in MRI images on umbilical level) (AD) and subcutaneous adipose tissue thickness at the same level). The different modalities were correlated with the MRI data.

RESULTS

: There were highly significant correlations between the skin fold data and TAT (Spearman coefficient 0.668, P >/= 0.0004) and SCAT (0.662, P >/= 0.0004). But there was no correlation with VAT. Impedance data revealed significant correlations of TAT and SCAT (Spearman 0.7, P >/= 0.0004).Simple anthropometric data like waist and hip circumference, WHR, and BMI revealed significant correlations (Spearman coefficient around 0.7-0.4, P < 0.05) with the fat compartments TAT, VAT, and SCAT.The standardized body fat slices and the VAT slices were correlated with the anthropometric data and impedance data to explore specific areas along the body axis where the correlations were higher or weaker. Skinfold data, BMI, and body impedance data yielded significant correlations with TAT along the whole body axis, as well as with VAT in almost the whole analyzed area. However, there was no special body region with locally higher correlations. WHR depicted high correlations with whole VAT, and regional TAT at the abdomen (and not with the other body regions) especially in women. Therefore, it seems to be the best marker for abdominal fat and VAT in this study.

CONCLUSIONS

: We compared different body measures and body fat devices with the whole body fat distribution acquired by MRI. Generally, there were significant correlations of all modalities with body fat content (TAT) and mainly with SCAT. Correlations with VAT compartment were much weaker and an adequate estimation of VAT is, therefore, not possible. Only WHR revealed significant correlations with the fat in the body center, but only in women. If it is important to investigate especially the VAT which is responsible for a higher cardiovascular risk, risk for a metabolic syndrome and that is correlated with the course of different psychiatric diseases, cross sectional techniques such as MRI can not be substituted by simpler methods.