Somatic comorbidity in anorexia nervosa: First results of a 21-year follow-up study on female inpatients

[Anorexia nervosa, a familiar and complex pathology]

Anorexia nervosa affects people of all ages, and has the highest mortality rate of all psychiatric disorders, following medical complications inherent in the disease or suicide. Early and appropriate treatment is crucial to prevent the risk of chronic disease, which may affect one in two anorexics. Severe undernutrition linked to a complex psychopathology calls for the necessary theoretical and clinical knowledge on the part of the caregiver, applied to the dynamics of care, ideally conceived in a transdisciplinary way and involving nursing teams.

Increased risk of somatic diseases following anorexia nervosa in a controlled nationwide cohort study

OBJECTIVE

To assess the risk of somatic diseases in connection with anorexia nervosa (AN).

METHOD

This matched cohort study was based on Danish registries of all patients born 1961-2008 with a first-time diagnosis of AN in 1994-2018 at age 8-32 and matched controls without an eating disorder. For 13 somatic disease categories, time from inclusion date to time of first somatic diagnosis, accounting for censoring, was studied by use of time-stratified Cox models.

RESULTS

A total of 9985 AN patients born 1961-2008 and 49,351 controls were followed for a median (interquartile range) of 9.0 (4.4-15.7) years. During the first 2 years after entry there was a 60% higher hazard for any somatic disease among patients with AN than among controls, while the ratio from three to 11 years was reduced to 1.18. Regardless of age at diagnosis, the hazard among patients and controls were no different at approximately a decade after diagnosis of AN and the cumulative risk for patients for 12 of 13 disease categories was always higher or no less that for controls. For all disease categories, the hazard ratio (HR) was higher when close to entry. For most disease categories, age at diagnosis of AN did not modify the effect.

DISCUSSION

While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls. Large HRs were seen in the early years after diagnosis during which patients require extensive medical interventions.

PUBLIC SIGNIFICANCE

Based on Danish registries, a large sample of almost 10,000 patients with AN born 1961-2008 and almost 50,000 matched controls were followed for a median of 9 years. While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls.

Emerging Comorbidities in Inflammatory Bowel Disease: Eating Disorders, Alcohol and Narcotics Misuse

Inflammatory bowel disease (IBD) is a chronic and potentially devastating condition of the digestive tract which is exemplified by increasing prevalence worldwide, byzantine pathogenesis with a poorly defined role of the environmental factors, and complex clinical demonstration. As a systemic disease, IBD may progress with a wide spectrum of extraintestinal manifestations (EMs) and comorbidities affecting different organs and systems, from anaemia, undernutrition, and cancer to those which are often neglected like anxiety and depression. Evolving IBD epidemiology and changing environment are reflected by an expanding list of IBD-related comorbidities. In contrast to the well-established role of smoking the connection between alcohol and IBD is still debatable on many levels, from pathogenesis to complications. Furthermore, little is known about narcotics use in IBD patients, even if there are obvious factors that may predispose them to narcotics as well as alcohol misuse. Last but not least, the question arises what is the prevalence of eating disorders in IBD. In our paper, we aimed to discuss the current knowledge on alcohol and drugs misuse and eating disorders as emerging extraintestinal comorbidities in IBD.

Health in adulthood after severe anorexia nervosa in adolescence: a study of exposed and unexposed women

OBJECTIVE

To compare the global health status, frequency of somatic and psychological problems, and alcohol use in adulthood among women hospitalized in adolescence for severe anorexia nervosa (AN), with a matched control sample from the general population.

METHOD

Women (n = 86) who had been hospitalized for AN 9.31 ± 1.82 years previously were compared with 258 controls matched for gender, age, and socio-professional category. Data were retrieved from a French survey on health and social insurance coverage, and was mainly collected by self-report, except for the assessment of current eating disorders for those previously hospitalized for AN (assessed with the MINI).

RESULTS

The women who had been hospitalized for AN reported significantly poorer current health status compared to controls (OR 2.9, 95% CI 1.5-5.79). According to the MINI, 13 women previously hospitalized with severe AN still presented an eating disorder (ED). Women with past AN reported more frequent acute throat infections (OR 4.9, 95% CI 1.81-13.51), gastralgia (OR 3.6, 95% CI 1.9-6.83), gastro-oesophageal reflux (OR 5.279, 95%CI 2.11-13.22), excess blood cholesterol or triglyceride levels (OR 2.55, 95% CI 1.03-6.33), anxiety (OR 8.7, 95% CI 3.48-21.8) and depression (OR 5.02 (2.8-9.01). These differences remained significant and of the same order of magnitude in sensitivity analyses among subjects with previous AN but without current ED, except for perceived health status and excess cholesterol and triglyceride levels.

DISCUSSION

Women who had been hospitalized for severe AN reported more symptoms 10 years after treatment, implies psychological and somatic follow-up in the long term.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Length of stay for anorexia nervosa: Systematic review and meta-analysis

OBJECTIVE

Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance.

METHOD

Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies.

RESULTS

Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index.

CONCLUSIONS

This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.

Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit

OBJECTIVE

Anorexia nervosa (AN) is associated with one of the highest mortality rates of any psychiatric disorder but limited mortality data were reported for those with extremely severe malnutrition. This study aimed to estimate standardized mortality ratio (SMR), investigate predictive factors of mortality and causes of death among a sample of patients with AN admitted to a specialized clinical nutrition unit (CNU) because of extremely severe malnutrition.

METHODS

Between 11/27/1997 and 01/15/2014, vital status was determined for 384 patients admitted for AN at the first time in the CNU. Sociodemographic, anamnestic, and clinical data were collected. We calculated the SMR. Univariate and multivariate Cox regression analyses were performed to identify mortality predictors.

RESULTS

Crude mortality rate was 11.5%. (44 deaths) and SMR 15.9 [CI 95% (11.6-21.4)], 5.2 years post inpatient treatment. Mortality predictors at the time of hospitalization were as follows: older age, occurrence of an in-hospital suicide attempt, transfer to medical intensive care unit and the following somatic complications: frank anemia, dysnatremia, infectious and cardiac complications. Other predictors of mortality were: past or present history of discharge against medical advice, hematological comorbidities (not related to AN). A longer inpatient length of stay was a protective factor.

CONCLUSION

Very severely malnourished patients with AN hospitalized in a medical unit because of extremely severe somatic issues have a medium-term mortality rate higher than the general population and even higher than patients in tertiary specialized ED units. This study highlights predictive factors of mortality that will help clinicians in recognizing and managing patients at risk of death.

The Ghrelin-AgRP Neuron Nexus in Anorexia Nervosa: Implications for Metabolic and Behavioral Adaptations

Anorexia Nervosa (AN) is viewed as primarily a psychiatric disorder owing to the considerable behavioral and genetic overlap with mood disorders and other psychiatric traits. However, the recent reconceptualization of AN as one of both psychiatric and metabolic etiology suggests that metabolic circuits conveying hunger, or sensitive to signals of hunger, may be a critical nexus linking metabolic dysfunction to mood disturbances. Within the brain, hunger is primarily percieved by Agouti-related (AgRP) neurons and hunger increases plasma concentrations of the hormone ghrelin, which targets ghrelin receptors on AgRP neurons to facilitate metabolic adaptations to low energy availability. However, beyond the fundamental role in maintaining hunger signaling, AgRP neurons regulate a diverse range of behaviors such as motivation, locomotor activity, negative reinforcement, anxiety, and obsession and a key factor involved in the manifestation of these behavioral changes in response to activation is the presence or absence of food availability. These changes can be considered adaptive in that they promote affective food-seeking strategies in environments with limited food availability. However, it also suggests that these neurons, so well-studied for their metabolic control, shape mood-related behaviors in a context-dependent manner and dysfunctional control leads not only to metabolic problems but also potentially mood-related problems. The purpose of this review is to underline the potential role of AgRP neurons and ghrelin signaling in both the metabolic and behavioral changes observed in anorexia nervosa. We aim to highlight the most recent studies on AgRP neurons and ghrelin signaling and integrate their metabolic and behavioral roles in normal function and highlight how dysfunction may contribute to the development of AN.

Feeding and eating disorders

Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence-a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.

Clinical Characteristics of Inpatients with Childhood vs. Adolescent Anorexia Nervosa

We aimed to compare the clinical data at first presentation to inpatient treatment of children (<14 years) vs. adolescents (≥14 years) with anorexia nervosa (AN), focusing on duration of illness before hospital admission and body mass index (BMI) at admission and discharge, proven predictors of the outcomes of adolescent AN. Clinical data at first admission and at discharge in 289 inpatients with AN (children: n = 72; adolescents: n = 217) from a German multicenter, web-based registry for consecutively enrolled patients with childhood and adolescent AN were analyzed. Inclusion criteria were a maximum age of 18 years, first inpatient treatment due to AN, and a BMI <10th BMI percentile at admission. Compared to adolescents, children with AN had a shorter duration of illness before admission (median: 6.0 months vs. 8.0 months, p = 0.004) and higher BMI percentiles at admission (median: 0.7 vs. 0.2, p = 0.004) as well as at discharge (median: 19.3 vs. 15.1, p = 0.011). Thus, in our study, children with AN exhibited clinical characteristics that have been associated with better outcomes, including higher admission and discharge BMI percentile. Future studies should examine whether these factors are actually associated with positive long-term outcomes in children.

Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: A systematic review and meta-analysis

BACKGROUND

Hospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed.

OBJECTIVE

The objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population.

METHOD

A systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded.

RESULTS

From electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%).

CONCLUSIONS

Medical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population.

Inflammatory Bowel Disease and Eating Disorders: A systematized review of comorbidity

OBJECTIVE

Research has shown that there is an association between Inflammatory Bowel Disease, anxiety and mood disorders, however little is known about their association with Eating Disorders. In this paper we will present a case of a young female with a comorbid diagnosis of Inflammatory Bowel Disease and Eating Disorder, and then discuss the results from a systematic review of the literature, describing published cases of patients with the same condition.

METHODS

A systematized review of the literature was conducted according to MOOSE guidelines. A computerized literature search of MEDLINE, PsycINFO and EMBASE, and a manual search through reference lists of selected original articles were performed to identify all published case-reports, case series and studies of Inflammatory Bowel Disease and Eating Disorders.

RESULTS

Fourteen articles were included, encompassing 219 cases, including ours. The vast majority were females ranging from 10 to 44years old. Anorexia Nervosa (n=156) and Crohn's Disease (n=129) was the most frequent combination (n=90) reported in the literature. These cases present a poor prognosis because of corticoid refusal, medication abandon and/or deliberate exacerbation of IBD symptoms, in the context of trying to lose weight.

CONCLUSION

Recent evidence suggests there is a possible association between Inflammatory Bowel Disease and Eating Disorders, although the mechanisms involved in its ethiopathogenesis are still unknown. To be aware of this association is important because a delayed diagnosis of this comorbidity may lead to worse prognosis. Further research and a multidisciplinary approach could facilitate earlier diagnosis and provide therapeutic interventions.

Difficulty eating and significant weight loss in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type

Joint Hypermobility Syndrome, also known as Ehlers-Danlos Syndrome Hypermobility Type (JHS/EDS-HT), is a heritable disorder of connective tissue, common but poorly known by the medical community. Although generalized joint hypermobility and fragility of tissues have been described as core features, recent research highlights the multisystemic nature of JHS/EDS-HT, which presents with a wide range of articular and extra-articular symptoms. Among these, gastrointestinal problems, temporomandibular disorders, and smell and taste abnormalities are common among those affected, having significant implications for eating. The present work reviews the literature linking JHS/EDS-HT and eating problems. Two illustrative case reports, in which JHS/EDS-HT manifestations contribute to developing and maintaining disturbed eating behaviors and significant weight loss, are presented.

Does specialization of treatment influence mortality in eating disorders?--A comparison of two retrospective cohorts

Eating disorders (EDs) are psychiatric disorders associated with high morbidity and mortality. It is well established that patients with anorexia nervosa (AN) have an increased risk of premature death, whereas mortality data are lacking for the other EDs. This study aimed to establish mortality rates in a sample of ED patients (n=998) with a mean follow-up of 12 years. This was compared to previous data from the same catchment area before a multidisciplinary centre was established. The standardized mortality ratio (SMR) was calculated. To compare the two cohorts, adjusted crude ratios were calculated with the confounding variables: body mass index (BMI), age at referral and diagnosis. In the latest cohort the SMR for AN was 2.89 vs 11.16 in the time before our specialization. SMR for bulimia nervosa (BN) and for eating disorder not otherwise specified (EDNOS) in the latest cohort were 2.37 and 1.14 respectively. When comparing two retrospective cohorts it is not possible to draw a definite conclusion, however the present study supports that integrating a somatic unit in a multidisciplinary centre may have a favourable influence on mortality in AN.

The use of animal models to decipher physiological and neurobiological alterations of anorexia nervosa patients

Extensive studies were performed to decipher the mechanisms regulating feeding due to the worldwide obesity pandemy and its complications. The data obtained might be adapted to another disorder related to alteration of food intake, the restrictive anorexia nervosa. This multifactorial disease with a complex and unknown etiology is considered as an awful eating disorder since the chronic refusal to eat leads to severe, and sometimes, irreversible complications for the whole organism, until death. There is an urgent need to better understand the different aspects of the disease to develop novel approaches complementary to the usual psychological therapies. For this purpose, the use of pertinent animal models becomes a necessity. We present here the various rodent models described in the literature that might be used to dissect central and peripheral mechanisms involved in the adaptation to deficient energy supplies and/or the maintenance of physiological alterations on the long term. Data obtained from the spontaneous or engineered genetic models permit to better apprehend the implication of one signaling system (hormone, neuropeptide, neurotransmitter) in the development of several symptoms observed in anorexia nervosa. As example, mutations in the ghrelin, serotonin, dopamine pathways lead to alterations that mimic the phenotype, but compensatory mechanisms often occur rendering necessary the use of more selective gene strategies. Until now, environmental animal models based on one or several inducing factors like diet restriction, stress, or physical activity mimicked more extensively central and peripheral alterations decribed in anorexia nervosa. They bring significant data on feeding behavior, energy expenditure, and central circuit alterations. Animal models are described and criticized on the basis of the criteria of validity for anorexia nervosa.

A comparison of clinical characteristics between adolescent males and females with eating disorders

BACKGROUND

Eating disorders (ED) are serious disorders that have a negative impact on both the psychological and the physiological well-being of the afflicted. Despite the fact that ED affect both genders, males are often underrepresented in research and when included the sample sizes are often too small for separate analyses. Consequently we have an unclear and sometimes contradictory picture of the clinical characteristics of males with ED. The aim of the present study was to improve our understanding of the clinical features of adolescent males with eating disorders.

METHODS

We compared age at presentation, weight at presentation, history of significantly different premorbid weight and psychiatric (Attention Deficit Hyperactivity Disorder (ADHD)) and somatic comorbidity (celiac disease and diabetes) of 58 males to 606 females seeking medical care for eating disorders at the Children's Hospital in Uppsala, Sweden during the years 1999-2012. As all boys were diagnosed with either AN or Other Specified Feeding or Eating Disorder (OSFED) atypical AN, the age and weight comparisons were limited to those girls fulfilling the diagnostic criteria for AN or OSFED atypical AN.

RESULTS

There was no significant difference in age at presentation. Differences in weight at presentation and premorbid weight history were mixed. A significantly higher percentage of males had a history of a BMI greater than two standard deviations above the mean for their corresponding age group. As well, there was a higher prevalence of ADHD among the males whereas celiac disease and diabetes only was found among the females.

CONCLUSIONS

A better understanding of the clinical characteristics of males with ED at presentation should improve our ability to identify males with ED and thereby aid in tailoring the best treatment alternatives.

Quality of life in eating disorders: a meta-analysis

Eating disorders (EDs) comprise a variety of symptoms and have a profound impact on everyday life. They are associated with high morbidity and mortality. The objective of this study was to analyse published data on health-related quality of life (HRQoL) in EDs so as to compare the results to general population norm data and to investigate potential differences between ED diagnostic groups. A systematic review of the current literature was conducted using a keyword-based search in PubMed and PsychInfo. The search covered anorexia nervosa (AN), bulimia nervosa (BN), eating disorders not otherwise specified (EDNOS) and binge eating disorder (BED) and used the Medical Outcomes Study Short Form-36 Health Survey (SF-36) as a measure of HRQoL. Of the 102 citations identified, 85 abstracts were reviewed and seven studies were included in the meta-analysis. AN patients were included in five studies (n=227), BN in four studies (n=216), EDNOS in two studies (n=166) and BED in four studies (n=148). We tested for between-study variation and significant differences between the diagnostic groups. The results confirmed a significantly lower level of HRQoL in all EDs compared to a population mean. It was not possible to establish any differences between the diagnostic groups.

The current status of suicide and self-injury in eating disorders: a narrative review

The aim of this paper is to review recent literature on suicide and self-injury in eating disorders (ED) including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Among psychiatric diagnoses, EDs are associated with increased mortality rates, even when specialized treatment is available. Of the mortalities that are reported in individuals with EDs, suicide is among the most commonly reported causes of death. Additionally, suicidal and non-suicidal self-injurious behaviors occur frequently in this clinical population. A literature search was undertaken using the databases of Medline/PubMed and PsycInfo to identify papers describing suicidality in individuals with ED diagnoses. The authors identified studies and review articles published between 2005-2013 (inclusive) that describe the relationship between EDs and suicide, and associated behaviors including self-injurious behaviors, or non-suicidal self-injury (NSSI). The initial search resulted in 1095 papers that met the a priori search criteria. After careful review, 66 papers were included. The majority of papers described clinical cohorts that were studied longitudinally. The diagnosis described most frequently in selected studies was AN. There are limited current data about the prevalence of suicide and NSSI among individuals with EDs. Among the published studies that focus specifically on the relationship between EDs and suicidality, most describe AN in more detail than other EDs. Nonetheless, rates of mortality, and specifically rates of suicide, are undeniably high in ED populations, as are the rates of self-harm. Therefore, it is critical for clinicians and caretakers to carefully evaluate these patients for suicide risk and to refer promptly for appropriate treatment.

Personality Assessment Inventory profiles of university students with eating disorders

BACKGROUND

Eating disorders are complex disorders that involve medical and psychological symptoms. Understanding the psychological factors associated with different eating disorders is important for assessment, diagnosis, and treatment.

METHODS

This study sought to determine on which of the 22 Personality Assessment Inventory (PAI) scales patients with anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS) differed, and whether the PAI can be used to classify eating disorder subtypes. Because we were interested in both whether the PAI could be used to differentiate eating disorder subtypes from each other, as well as from other disorders, we also included a group of patients with major depression.

RESULTS

The three eating disorder groups did differ significantly from each other, and from the patients with depression, on a number of the PAI scales. Only two PAI scales (Anxiety and Depression), however, exceeded a T-score of 70 for the patients with anorexia nervosa, no scales exceeded a T-score of 70 for the patients with bulimia nervosa or EDNOS, and only two exceeded a T-score of 70 for the patients with depression (Depression and Suicide). A discriminant function analysis revealed an overall correct classification between the groups of 81.6%.

CONCLUSIONS

The PAI helps to understand the psychological factors associated with eating disorders and can be used to assist with assessment. Continued investigation using the PAI in an eating disordered population is supported.

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.