Anorexia nervosa: some observations on "dieters" and "vomiters", cholesterol and carotene

Eating disorders in the female patient: pathophysiology and treatment strategies

Eating disorders are common in girls and women. Two common eating disorders--anorexia nervosa and bulimia nervosa--have significant medical complications. Oral and maxillofacial surgeons must be cognizant of the signs, symptoms, and medical consequences of these disorders. The increased incidence of these diseases has implications in the surgical management the oral and maxillofacial surgery patient. A review of the literature and guidelines in the perioperative management of these surgical patients are presented in this article.

Serum beta-carotene in anorexia nervosa patients: a case-control study

OBJECTIVE

To study the prevalence of hypercarotenemia in a large cohort of patients with anorexia nervosa (AN), to compare serum beta-carotene (betaC) values among restricting and purging AN subjects, and to investigate whether hypercarotenemia is related to an increase in low-density lipoprotein (LDL) cholesterol.

METHOD

Retrospective case-control study including 101 female patients and 95 age-matched normal controls in whom fasting serum betaC and lipid profiles were determined.

RESULTS

The prevalence of hypercarotenemia (>200 microg/dl) in the AN population was 62%. Mean serum betaC level was significantly higher in AN patients than in controls (237 +/- 103 vs. 160 +/- 45 microg/dl, p <.0001). Among AN patients, the level was higher in restricters than in purgers (271 +/- 110 vs. 186 +/- 78 microg/dl, p <.005). Fasting serum total and LDL cholesterol levels were also significantly higher in patients with AN than in controls, but no correlation was found between serum betaC and LDL cholesterol values.

DISCUSSION

Hypercarotenemia is a common finding in AN patients, especially in the restricter subgroup. The high prevalence of elevated serum betaC in AN patients supports its diagnostic value in atypical forms of eating disorders.

Detection, evaluation, and treatment of eating disorders the role of the primary care physician

OBJECTIVE

To describe how primary care clinicians can detect an eating disorder and identify and manage the associated medical complications.

DESIGN

A review of literature from 1994 to 1999 identified by a MEDLINE search on epidemiology, diagnosis, and therapy of eating disorders, including anorexia nervosa and bulimia nervosa.

MEASUREMENTS AND MAIN RESULTS

Detection requires awareness of risk factors for, and symptoms and signs of, anorexia nervosa (e.g., participation in activities valuing thinness, family history of an eating disorder, amenorrhea, lanugo hair) and bulimia nervosa (e.g., unsuccessful attempts at weight loss, history of childhood sexual abuse, family history of depression, erosion of tooth enamel from vomiting, partoid gland swelling, and gastroesophageal reflux). Providers must also remain alert for disordered eating in female athletes (the female athlete triad) and disordered eating in diabetics. Treatment requires a multidisciplinary team including a primary care practitioner, nutritionist, and mental health professional. The role of the primary care practitioner is to help determine the need for hospitalization and to manage medical complications (e.g., arrhythmias, refeeding syndrome, osteoporosis, and electrolyte abnormalities such as hypokalemia).

CONCLUSION

Primary care providers have an important role in detecting and managing eating disorders.

Plasma cholesterol and endogenous cholesterol synthesis during refeeding in anorexia nervosa

Normal or high levels of cholesterol have been measured in patients with anorexia nervosa (AN). Given that cholesterol intake in AN is usually very low, the reasons for this anomaly are not clearly understood. We studied lipid and lipoprotein profiles and endogenous cholesterol synthesis, estimated by serum lathosterol, in a population of 14 girls with AN, before and during a period of 30 days refeeding. The initial body mass index (BMI) of the patients was 13.41+/-1.62 kg/m(2). No changes were observed during refeeding in endocrine parameters (ACTH, cortisol and estradiol). At Day 0 the lipids data measured here showed normal levels of triglycerides, and total cholesterol at the upper limits of the normal range (5.44+/-1 mmol/l). At this time, total and LDL cholesterol were negatively correlated with transthyretin and BMI. Serum lathosterol (a precursor in cholesterol synthesis pathway) increased significantly (5.99+/-1.75 (Day 0) vs. 8.39+/-2.96 (Day 30); P=0.02) while there was a significant decrease in apo B (0.79+/-0.33 (Day 0) vs. 0. 60+/-0.17 g/l (Day 30), P=0.02) with refeeding. Thus, patients with initial high cholesterol levels have the worst nutritional status and high cholesterol levels are not related to a de novo synthesis. This profile returns to normal with refeeding. An increase of cellular cholesterol uptake may be responsible for this apparently paradoxical evolution with increase of cholesterol synthesis and decrease of apo B during renutrition.

Eating disorders. Guide to medical evaluation and complications

Eating disorders lead to numerous physical complaints with signs and symptoms affecting nearly every organ system of the body. We review the presentation of a patient with eating disorder to the primary care giver or general psychiatrist, focusing on the physical manifestations of the underlying illness. Specific complications related to laboratory findings, the gastrointestinal tract, and the endocrine system are reviewed. Algorithms for medical evaluation of these patients are also presented.

Nutritional disorder of anorexia nervosa: a review

In the treatment of anorexia nervosa, the importance of weight restoration has been well documented. Resting energy expenditure, which is initially reduced, often increases markedly in association with refeeding. Previous studies that have examined micronutrient status in anorexia nervosa have reported inconsistent and sometimes contradictory conclusions, due to the heterogeneity of the population, the cross-sectional nature of these investigations, and, at times, the use of inappropriate methods to determine nutrient status. Abnormal nutritional findings in patients with anorexia nervosa are primarily a consequence of semistarvation. Neuroendocrine abnormalities, degree of recovery, and phase of treatment affect interpretation of data. Despite the importance of nutritional rehabilitation, few controlled studies that address the clinical efficacy of various dietary treatment regimens have been conducted.

Anorexia nervosa "restricters" who purge: implications for subtyping anorexia nervosa

It has not been clear from earlier studies whether it is binge eating per se or the compensatory behaviors frequently associated with binge eating (i.e., self-induced vomiting and/or laxative abuse) that provide the most relevant marker for subclassifying anorexia nervosa. The current study addressed this question by comparing the clinical and psychological features of three groups of anorexia nervosa patients: "pure restricting" patients who do not binge (by definition) and who also do not purge (AN-R, N = 116); "restricting-purging" patients who engage in purging behavior (AN-RP, N = 74); and anorexia nervosa "bulimics" who binge eat as defined in earlier studies (AN-B, N = 190). While all three groups displayed similar levels of psychological disturbance on many variables, the overall pattern of findings indicates that the AN-RP group displays significantly more psychopathology than the AN-R group and their profile of disturbance is very similar to that observed with the AN-B group. Thus, anorexia nervosa patients who purge, regardless of whether or not they report objective binge episodes, may be meaningfully distinguished from nonpurging patients. These results, combined with the medical risks associated with purging behaviors and the formidable problems associated with the definition of binge eating, support a sub-typing system for anorexia nervosa based on the presence or absence of purging rather than binge eating.

Anorexia and bulimia in anorexia nervosa: a study of psychosocial functioning and associated psychiatric symptomatology

Seventeen fasting patients with anorexia nervosa and 15 who also binged were compared in terms of their psychosocial functioning and associated psychiatric symptomatology, using the Delusions Symptoms and States Inventory (Foulds & Bedford, 1975). Both groups scored very highly on the state of anxiety, depression, and elation sets of the DSSI, but less highly on the compulsive and ruminative symptoms sets and on the phobic dissociative and conversion symptom sets. The bingeing anorexic group was significantly older and heavier than the fasting group and experienced more feelings of self-harm and guilt. The bingeing group reported sexual interference during childhood, and currently experienced a desire to vomit during sexual activity to a significantly greater degree than the fasting group.

Autonomic arousal in eating disorders: further evidence for the clinical subdivision of anorexia nervosa

Autonomic arousal, measured by skin conductance level and response, was examined in 36 female patients with eating disorders (anorexia nervosa and bulimia nervosa) and 32 control subjects. No differences were found between the control group and anorexics who lost weight solely through dieting (restricting anorexics). Patients with a diagnosis of bulimia nervosa and anorexics with bulimic features, however, showed fewer spontaneous skin conductance responses and were faster to habituate to 85 dB tones than either controls or restricting anorexic patients. The pattern of findings supports recent views concerning the clinical subdivision of anorexia nervosa.

Anorexia nervosa occurring in patients with diabetes mellitus

Three patients with insulin dependent diabetes mellitus who developed anorexia nervosa are described. Unlike the few cases already reported the patients' diabetes proved very difficult to control with dire consequences in each case.