Hormonal profile heterogeneity and short-term physical risk in restrictive anorexia nervosa

A scoping review of circulating peptides assessments in anorexia nervosa: Uncovering diversity and nuanced findings

Understanding biological mechanisms underlying anorexia nervosa (AN) is necessary to develop care strategies. Despite many articles dedicated to peptides assessment in AN, there is no systematic review. A scoping review of circulating peptides published in relation to AN, comparing their results with those of controls, was conducted. Embase and PubMed databases were search from 1966 to 2022 (PROSPERO CRD42022323716). All original English articles, assessing peptides in AN (except classical markers) were analyzed. 1151 studies for 207 peptides, in 486 published articles were selected, and evidences/trends in AN were compared to controls. Fifteen clusters of function gathering peptides covering physiopathological aspects of AN were identified. This scoping review revealed a large variety of circulating peptides explored in AN. Some peptides presented with convincing results and helped understanding pathophysiologic aspects. Other peptides presented with nuanced results, partly due to insufficient number of studies, multiple assay techniques, inadequate sampling time, and lack of phenotyping. Conversion from bench-to-bed remains difficult and may explain why peptides evaluations did not currently lead to specific international recommendations or tailored therapeutic/preventive strategies. Peptide evaluation in anorexia nervosa could explore secretion profiles, and test it in well-phenotyped patients with AN, to conclude for potential clinical use, and finally design therapeutic tests.

The influence of anorexia nervosa on oral health and related parameters potentially relevant to orthodontic treatment: a systematic review and meta-analysis

OBJECTIVES

Information on the oral health of patients with anorexia nervosa remains not satisfactory. The aim of this systematic review is to evaluate oral health parameters in anorexic patients compared to healthy individuals. Furthermore, potential clinical implications for orthodontic treatment are discussed from an orthodontic perspective.

MATERIALS AND METHODS

Electronic databases were searched for case-control and controlled clinical trial studies on dentofacial manifestations in anorexic patients up to 2/2024. Study selection, data extraction and risk of bias assessment was done independently by two authors. Random-effects meta-analyses of mean differences (MDs) or relative risks (RRs) with their 95% confidence intervals (CIs) were conducted, followed by sensitivity analyses.

RESULTS

Eleven out of 573 initially identified studies were included. They involved oral health analyses of general anorexic patients ≥ 12 years (mean age 18.4). The meta-analysis showed that anorexia nervosa was associated with a significantly increased caries experience (DMFT), plaque accumulation and gingival inflammation (BOP). PH and salivary flow rate were significantly altered in patients with anorexia nervosa, although no significant relationship between α-amylase levels and anorexia nervosa was demonstrated.

CONCLUSIONS

These data enabled us to formulate modalities for anorexia-specific orthodontic treatments. Based on the results, patients with anorexia nervosa exhibit an increased risk of caries and gingival inflammatory signs.

CLINICAL RELEVANCE

The systematic information on dentofacial manifestations obtained in this study should be considered to better manage the oral health of anorexia patients.

Older adult women with chronic anorexia nervosa: heterogeneous adaptation to undernutrition over time

INTRODUCTION

Anorexia nervosa (AN) in older adult women is primarily described through reviews or case reports focusing on psychiatric traits, with no comprehensive studies evaluating their complete nutritional and hormonal profiles. This study aimed to describe a group of women with anorexia nervosa aged above 35 years old (AN35), and compare them with young women with anorexia nervosa (ANY) and normal-weight control participants.

METHOD

Anthropometric, metabolic, nutritional, and psychiatric parameters were collected and compared among three groups of women: 50 AN35, 37 ANY, and 38 controls.

RESULTS

AN35 exhibited a mean disease duration of 271 ± 19 months, with 94% chronic forms and 58% restrictive types. Despite having similar BMI as ANY, AN35 displayed more altered parameters, including higher liver enzymes (p = 0.007), free T3 (p = 0.0046) and leptin (p < 0.0001); and lower albumin (p = 0.0029), and white cells (p < 0.0001). AN35 showed significant heterogeneity in hormonal adaptation, such as free T3. Half of the patients aged above 51 years revealed high gonadotropin levels despite being undernourished. Additionally, AN35 groups presented with 50% of bones fractures, decreased T-scores under -2.5 (p < 0.0001 for femoral), and altered micro architectural HRPQT parameters compared to ANY.

CONCLUSION

Anorexia nervosa in older adult women is predominantly chronic. Nutritional parameters changes with age suggests a significant heterogeneity and possible adaptation of energy balance and bodyweight set point for others. Complications may be severe, altering the quality of life, and sometimes potentially lethal. These findings highlight the potential adaptation of energy balance with age, and should assist clinicians in clinical practice.

Reduction in Pappalysin-2 Levels and Lower IGF-I Bioavailability in Female Adolescents With Anorexia Nervosa

CONTEXT

Anorexia nervosa (AN) can cause severe undernutrition associated with alterations in the IGF axis. Pappalysins (PAPP-A, PAPP-A2) and stanniocalcins (STC-1, STC-2) modulate IGF binding-protein (IGFBP) cleavage and IGF bioavailability, but their implications in AN are unknown.

OBJECTIVE

We determined serum levels of PAPP-As and STCs in relationship with classical IGF axis parameters in female adolescents with AN and their association with nutritional status and secondary amenorrhea.

METHODS

Parameters of the IGF axis were determined in fasting serum samples of 68 female adolescents with AN at diagnosis and 62 sex- and age-matched controls. Standardized body mass index (BMI) and bone mineral density (BMD) were calculated.

RESULTS

Patients with AN had lower concentrations of total and free IGF-I, total IGFBP-3, acid-labile subunit (ALS), insulin, PAPP-A2, STC-1, and STC-2 and higher levels of IGF-II and IGFBP-2. Their free/total IGF-I ratio was decreased and the intact/total IGFBP-3 and -4 ratios increased. BMI was directly related to total IGF-I and intact IGFBP-3 and inversely with IGFBP-2 and intact IGFBP-4. Weight loss was directly correlated with intact IGFBP-4 and negatively with intact IGFBP-3, ALS, STC-2, and PAPP-A2 concentrations. BMD was directly related to intact IGFBP-3 and inversely with intact IGFBP-4 and PAPP-A2 levels. Patients with amenorrhea had lower levels of total IGF-I and IGFBP-3 than those with menses.

CONCLUSION

The reduction of PAPP-A2 in patients with AN may be involved in a decline in IGFBP cleavage, which could underlie the decrease in IGF-I bioavailability that is influenced by nutritional status and amenorrhea.

[Medical complications in anorexia and bulimia nervosa]

Anorexia nervosa and bulimia nervosa are eating disorders associated with life-threatening multisystemic medical complications. This narrative review aimed to present the medical complications most related to these disorders. In anorexia nervosa, many of them are linked to malnutrition and underweight, usually reversible with renutrition and weight restoration, although refeeding can also be linked to some medical complications. Purging behaviors observed in the anorexia nervosa binge-purging subtype and bulimia nervosa have been mainly related to hydrolectrolyte and acid-base disturbances, in addition to local complications. Thus, an early identification and therapeutic intervention of these disorders is considered crucial. Integral medical monitoring should be ensured to prevent potential serious complications from the early stages, with the involvement of physicians, psychologists, nutritionists, and other specialists in a multidisciplinary approach according to the patient's needs.

Structure-function relationship of the pituitary gland in anorexia nervosa and intense physical activity

Patients with Anorexia Nervosa (AN) and athletes share intense physical activity and pituitary hormonal disturbances related to absolute (AN) or relative (athletes) undernutrition. Pituitary gland (PG) structure evaluations in those conditions are scarce, and did not differentiate anterior from posterior lobe. We evaluated the structure-function relationship of anterior and posterior PG in AN and athletes, and potential reversibility of this alteration in a group of weight-recovered patients (AN_Rec). Manual delineation of anterior (AP) and posterior (PP) PG was performed on T1-weighted MR images in 17 women with AN, 15 women with AN_Rec, 18 athletes women and 25 female controls. Anthropometric, hormonal, and psychometric parameters were explored and correlated with PG volumes. AP volume (APV) was lower in AN (448 ± 82 mm3), AN_Rec (505 ± 59 mm3), and athletes (540 ± 101 mm3) vs. Controls (615 ± 61 mm3, p < 0.00001, p < 0.00001 and p = 0.02, respectively); and smaller in AN vs. AN_Rec (p = 0.007). PP volume did not show any differences between the groups. APV was positively correlated with weight (R = 0.36, p = 0.011) in AN, and luteinizing hormone (R = 0.35, p = 0.014) in total group. In AN, mean growth hormone (GH) was negatively correlated with global pituitary volume (R = 0.31, p = 0.031) and APV (R = 0.29, p = 0.037). Absolute and relative undernutrition led to a decreased anterior pituitary gland volume, which was reversible with weight gain, correlated with low bodyweight, and blockade of gonadal hypothalamic-pituitary axis. Intriguing inverse correlation between anterior pituitary gland volume and GH plasma level could suggests a low storage capacity of anterior pituitary gland and increased reactivity to low insulin-like growth factor type 1.

Mechanisms and predictors of menses resumption once normal weight is reached in anorexia nervosa

BACKGROUND

In cases of Anorexia Nervosa (AN), achieving weight gain recovery beyond the lower limits set by the World Health Organization and normalizing classical nutritional markers appears to be essential for most patients. However, this is not always adequate to restore menstrual cycles. This discrepancy can cause concern for both patients and healthcare providers, and can impact the medical management of these individuals. Thus, the purpose of this study was to assess the ability of anthropometric and hormonal factors to predict the resumption of menstrual cycles in individuals with anorexia nervosa upon reaching a normal body weight.

METHOD

Patients with AN who had achieved a normal Body Mass Index but had not yet resumed their menstrual cycles (referred to as ANRec) were evaluated on two occasions: first at visit 1 and then again 6 months later, provided their body weight remained stable over this period (visit 2). Among the 46 ANRec patients who reached visit 2, they were categorized into two groups: 20 with persistent amenorrhea (PA-ANRec) and 26 who had regained their menstrual cycles (RM-ANRec). Anthropometric measurements, several hormone levels, Luteinizing Hormone (LH) pulsatility over a 4-h period, and LH response to gonadotropin-releasing hormone injection (LH/GnRH) were then compared between the two groups at visit 1.

RESULTS

Patients in the RM-ANRec group exhibited higher levels of follicular stimulating hormone, estradiol, inhibin B, LH/GnRH, and lower levels of ghrelin compared to those in the PA-ANRec group. Analysis of Receiver Operating Characteristic curves indicated that having ≥ 2 LH pulses over a 4-h period, LH/GnRH levels ≥ 33 IU/l, and inhibin B levels > 63 pg/ml predicted the resumption of menstrual cycles with a high degree of specificity (87%, 100%, and 100%, respectively) and sensitivity (82%, 80%, and 79%, respectively).

CONCLUSIONS

These three hormonal tests, of which two are straightforward to perform, demonstrated a high predictive accuracy for the resumption of menstrual cycles. They could offer valuable support for the management of individuals with AN upon achieving normalized weight. Negative results from these tests could assist clinicians and patients in maintaining their efforts to attain individualized metabolic targets.

TRIAL REGISTRATION

IORG0004981.

Endocrinology of Underweight and Anorexia Nervosa

More than any other mental illness, the course, prognosis, and therapy of anorexia nervosa are shaped by the physical changes associated with being underweight. This article provides an overview of the endocrine changes associated with malnutrition and underweight. This overview serves as a basis for understanding the other articles in this special issue, which deal with the health risks associated with being underweight. In this context, the differences between underweight in anorexia nervosa and in constitutional thinness are of particular importance in assessing the impact of intentional weight loss. In this context, the regulation of hunger and satiety deserves special interest, as this is the area in which the intentional influence on body weight comes into play. Clinical consequences on, for example, fertility, bone metabolism, the homeostasis of, for example, serum glucose levels, or body temperature have been observed for a long time; nonetheless, the medical responses, apart from vitamin supplementations and advice to gain weight, are still limited. Therefore, emphasis was placed on the potential improvement of outcomes through the administration of central or peripheral hormones. Studies were identified on PubMed via a selection of relevant keywords; original texts that were cited in reviews were studied where it was advantageous. This review found some promising data on bone health and the administration of transdermal oestrogen, which is not yet widely used, as well as distinct hormonal markers to differentiate between CT and AN. We concluded that the continuous efforts to investigate the role of endocrinology in underweight and/or anorexia nervosa lead to outcome benefits and that more and higher-powered studies are needed.

Bone, fat, and muscle interactions in health and disease

Energy metabolism is a point of integration among the various organs and tissues of the human body, not only in terms of consumption of energy substrates but also because it concentrates a wide interconnected network controlled by endocrine factors. Thus, not only do tissues consume substrates, but they also participate in modulating energy metabolism. Soft mesenchymal tissues, in particular, play a key role in this process. The recognition that high energy consumption is involved in bone remodeling has been accompanied by evidence showing that osteoblasts and osteocytes produce factors that influence, for example, insulin sensitivity and appetite. Additionally, there are significant interactions between muscle, adipose, and bone tissues to control mutual tissue trophism. Not by chance, trophic and functional changes in these tissues go hand in hand from the beginning of an individual's development until aging. Likewise, metabolic and nutritional diseases deeply affect the musculoskeletal system and adipose tissue. The present narrative review highlights the importance of the interaction of the mesenchymal tissues for bone development and maintenance and the impact on bone from diseases marked by functional and trophic disorders of adipose and muscle tissues.

Bone Perspectives in Functional Hypothalamic Amenorrhoea: An Update and Future Avenues

One of the most important and potentially long-lasting detrimental consequences of Functional Hypothalamic Amenorrhoea (FHA) is on skeletal homeostasis. Beyond oestrogen deficiency, FHA is associated with a cascade of additional neuro-endocrine and metabolic alterations, some adaptive, but which combine to disrupt skeletal homeostasis. Ultimately, this leads to a two-fold increased risk of fractures in women with FHA compared to healthy eumenorrhoeic women. Although the cornerstone of management of FHA-related bone loss remains recovery of menses via restoration of metabolic/psychological balance, there is rapidly developing evidence for hormonal manipulations (with a particular emphasis on route of administration) and other pharmacological treatments that can protect or improve skeletal homeostasis in FHA. In this mini-review, we provide an update on the pathophysiology, clinical management and future avenues in the field from a bone perspective.

Dehydroepiandrosterone status and efficacy of dehydroepiandrosterone supplementation for bone health in anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

This study was designed to determine the status of dehydroepiandrosterone (DHEA) in women with anorexia nervosa (AN) and to assess the efficacy of DHEA supplementation as a treatment for bone health in women with AN.

METHOD

Studies were retrieved from the PubMed, Embase, Cochrane Library, MEDLINE, and Scopus databases from inception to February 14, 2022. Observational studies that compared serum DHEA levels between women with AN and healthy controls were included for meta-analysis, and randomized controlled trials (RCTs) that evaluated the effects of DHEA supplementation on bone mass were reviewed.

RESULTS

Meta-analysis of 15 cross-sectional studies revealed that patients with AN had significantly elevated serum DHEA levels (mean difference (MD) = 311.63 ng/dl; 95% confidence interval (CI), 78.01-545.25) and reduced DHEAS levels (MD = -24.90 μg/dl; 95% CI, -41.72 to -8.07) compared with healthy controls. A systematic review of seven RCTs found that DHEA monotherapy does not improve bone mineral density (BMD) compared with placebo after adjusting for weight gain. While the combination of DHEA and conjugated oral contraceptives has led to increased bone strength and decreased bone loss, the beneficial effect appears to be limited to older adolescents and adults with closed physes. Potential detrimental effects on BMD were identified in younger adolescents with open physes in one study.

DISCUSSION

Due to the lack of apparent benefit of DHEA in women with AN and its potential detrimental effect on BMD in young patients with AN, current evidence does not support the use of DHEA.

PUBLIC SIGNIFICANCE

This study demonstrates that women with anorexia nervosa have abnormal levels of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS), which have been suggested by previous studies to play a role in the development of low bone density in this condition. However, current evidence does not support the use of DHEA as a treatment to preserve bone health in patients with anorexia nervosa given the lack of clear benefit following its use and also because of a potential detrimental effect on bone mineral density in young patients with anorexia nervosa.

Time course and reaction types of serum IGF-1 and its relationship to BMI and leptin regarding inpatients with anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a severe mental disorder that is characterized by restriction of energy intake, low weight, and endocrine abnormalities. One of the known endocrine changes in relation to underweight is in the GH/IGF-I axis. The aim of the study was (a) to investigate longitudinal characteristics of the IGF-I-change during therapy and weight gain in adult AN, (b) to determine relationships between IGF-I and leptin, (c) to characterize patients with weak and pronounced hormonal reactions to underweight.

DESIGN

Data was assessed from 19 AN patients. Over the first two months, serum IGF-I concentrations were assessed on a weekly basis; thereafter on a monthly basis. The trend of IGF-I values over time was analyzed using individual growth models.

RESULTS

In total, n = 177 IGF-I measurements were analyzed. IGF-I increased significantly dependent on BMI (slope = 20.81, p < 0.001), not modulated by duration of disease. The increase in IGF-I was significantly related to the increase in leptin concentrations over time (slope = 15.57, p < 0.001). Patients with a weaker hormonal reaction to underweight were significantly older compared to patients with a pronounced hormonal reaction (t(17) = 3.07, p = 0.007).

CONCLUSIONS

During treatment, IGF-I change is clearly related to BMI as well as to leptin. Age appears to be associated with the IGF-I response to underweight.

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.

Incidence of Impaired Kidney Function Among Adolescent Patients Hospitalized With Anorexia Nervosa

IMPORTANCE

Anorexia nervosa (AN) is a common psychiatric disorder associated with electrolyte imbalances and impaired kidney function, but their incidence and association with disease severity are unknown.

OBJECTIVE

To analyze kidney function in patients with AN and its association with body mass index (BMI) and physiologic parameters of disease severity.

DESIGN, SETTING, AND PARTICIPANTS

Single-center retrospective case-control study of recently hospitalized patients with a diagnosis of AN according to International Classification of Diseases, Ninth Revision. All patients were aged 9 to 18 years and hospitalized in the general pediatric ward between 2010 and 2019. BMI and estimated glomerular filtration rate (eGFR) were compared with age- and sex-matched controls hospitalized with other diagnoses.

MAIN OUTCOMES AND MEASURES

Impaired kidney function was defined as eGFR less than 90 mL/min/1.73 m2. Association between eGFR, BMI, minimal heart rate, and free triiodothyronine (T3) levels were determined using logistic regression.

RESULTS

A total of 395 patients were included in the study group (81.6% were female; mean [SD] age, 14.6 [2.2] years; median BMI percentile, 12.3 [IQR, 0.9-42.0]). Impaired kidney function was found in 36.8% (146 of 395). Mean (SD) eGFR decreased during hospitalization in the group with kidney function impairment (admission: 83 [10.9] mL/min/1.73 m2; nadir: 79.1 [8.5] mL/min/1.73 m2; latest: 97.7 [15.7] mL/min/1.73 m2; P < .001). Mean (SD) serum creatinine (SCr) to BMI ratio was higher in both anorexia groups compared with controls in impaired kidney function (4.9% [1.0%]), non-impaired kidney function (3.55% [0.84%]); and control groups (2.8 [1.1%]) (P < .001). There was no difference in admission BMI between anorexia groups with and without kidney function impairment. Mean (SD) free T3 levels (3.5 [0.2] pmol/L vs 4.08 [1.2] pmol/L; P < .001) and mean (SD) minimal heart rate (44 [11] beats per min vs 56 [16] beats per min; P < .001) were lower and hospital stay was longer (median, 13 [IQR, 6-21] days vs 8 [IQR, 4-19] days; P = .03) in the impaired kidney function group. The highest correlation was found between minimal heart rate and minimal eGFR (R = 0.53; P < .001).

CONCLUSIONS AND RELEVANCE

Impaired kidney function in patients with AN is common and transiently worsens during hospitalization. SCr values probably underestimate the degree of kidney function impairment in AN. Results of this study found that patients with impaired kidney function had worse anorexia severity parameters unrelated to admission BMI. Therefore, kidney function impairment may be a better marker of anorexia severity.

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.

The Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S)

In a healthy athlete, the caloric intake is sufficient for sports energy needs and body physiological functions, allowing a balance between energy availability, bone metabolism, and menstrual cycle. On the other hand, an imbalance caused by low energy availability due to a restrictive diet, eating disorders or long periods of energy expenditure leads to multisystemic deregulation favoring the essential functions of the body. This phenomenon, described as the female athlete triad, occurs in a considerable percentage of high-performance athletes, with harmful consequences for their future. The present review was carried out based on a critical analysis of the most recent publications available and aims to provide a global perception of the topic relative energy deficit in sport (RED-S). The objective is to promote the acquisition of more consolidated knowledge on an undervalued theme, enabling the acquisition of preventive strategies, early diagnosis and/or appropriate treatment.

Role of Neuroendocrine, Immune, and Autonomic Nervous System in Anorexia Nervosa-Linked Cardiovascular Diseases

Anorexia nervosa represents a severe mental disorder associated with food avoidance and malnutrition. In patients suffering from anorexia nervosa, cardiovascular complications are the main reason leading to morbidity and mortality. However, the origin and pathological mechanisms leading to higher cardiovascular risk in anorexia nervosa are still unclear. In this aspect, the issue of exact pathological mechanisms as well as sensitive biomarkers for detection of anorexia nervosa-linked cardiovascular risk are discussed. Therefore, this review synthesised recent evidence of dysfunction in multiple neuroendocrine axes and alterations in the immune system that may represent anorexia nervosa-linked pathological mechanisms contributing to complex cardiovascular dysregulation. Further, this review is focused on identification of non-invasive biomarkers for the assessment of increased cardiovascular risk in anorexia nervosa that can be linked to a clinical application. Complex non-invasive assessment of cardiovascular autonomic regulation—cardiac vagal control (heart rate variability), sympathetic vascular activity (blood pressure variability), and cardiovascular reflex control (baroreflex sensitivity)—could represent a promising tool for early diagnosis, personalized therapy, and monitoring of therapeutic interventions in anorexia nervosa particularly at a vulnerable adolescent age.

Decreased cerebral opioid receptors availability related to hormonal and psychometric profile in restrictive-type anorexia nervosa

PURPOSE

The opioid system role in anorexia nervosa (AN) pathophysiology is still unclear since conflicting results were reported on peripheral and cerebrospinal fluid opioids levels. The study main aim was to evaluate cerebral AN opiate receptor availability by using [¹¹C] diprenorphine, a ligand with non-selective binding.

METHODS

In vivo [¹¹C]diprenorphine cerebral non-displaceable binding potential (BP_ND) evaluated by PET imaging was compared between three groups : 17 undernourished restrictive-type AN patients (LeanAN), 15 AN patients having regained normal weight (RecAN) and 15 controls. A lower BP_ND may account for an increased opioid tone and vice versa. Serum hormones and endogenous opioids levels, eating-related and unspecific psychological traits were also evaluated.

RESULTS

Compared to controls, LeanAN and RecAN patients had decreased [¹¹C]diprenorphine BP_ND in middle frontal gyrus, temporo-parietal cortices, anterior cingulate cortex and in left accumbens nucleus. Hypothalamo-pituitary (H-P), left amygdala and insula BP_ND was found decreased only in LeanAN and that of putamen only in RecAN. LeanAN presented higher dynorphin A and enkephalin serum levels than in controls or RecAN. Inverse correlations were found in total group between : 24 h mean serum cortisol levels and anterior cingulate gyrus or insula BP_ND; eating concern score and left amygdala BP_ND. Positive correlation were found between leptin and hypothamus BP_ND; LH and pituitary BP_ND.

CONCLUSIONS

Low opiate receptor availability may be interpreted as an increased opioid tone in areas associated with both reward/aversive system in both AN groups. The relationship between the opioid receptors activity and hypercorticism or specific psychometric scores in some of these regions suggests adaptive mechanisms facing anxiety but also may play a role in the disease perpetuation.

Caffeine Upregulates Hepatic Sex Hormone-Binding Globulin Production by Increasing Adiponectin Through AKT/FOXO1 Pathway in White Adipose Tissue

SCOPE

Epidemiological studies have shown that caffeine increases serum sex hormone-binding globulin (SHBG) levels. The relationship between caffeine and SHBG production has never been studied before at molecular level. The aim of this study is to examine whether caffeine regulates SHBG production and to determine the associated molecular mechanisms.

METHODS AND RESULTS

Two different studies are performed; in vitro studies using human HepG2 cells treated with caffeine (100 and 500 µm) and in vivo studies using a humanized SHBG transgenic mice drinking caffeine in the water (0.1 mg mL^-1 ) for 12 days. The results show that caffeine does not change SHBG production in HepG2 cells. By contrast, caffeine treatment increases significantly hepatic SHBG production in human SHBG transgenic mice when compared with control mice. Caffeine increases adiponectin levels in epididymal adipose tissue of human SHBG transgenic mice. Moreover, caffeine increases adiponectin production by reducing protein kinase B (AKT) phosphorylation which increases forkhead box protein O1 (FOXO1) protein levels in 3T3-L1 mature adipocytes and human SHBG transgenic mice. Finally, caffeine-induced increase in adiponectin in turn upregulates hepatic hepatocyte nuclear receptor 4-alpha (HNF-4α) levels in human SHBG transgenic mice.

CONCLUSIONS

The results show that caffeine upregulates hepatic SHBG expression by increasing adiponectin production through AKT/FOXO1 pathway in the adipose tissue.

Identifying psychosocial and familial correlates and the impact of the stressful life events in the onset of anorexia nervosa: Control-case study (ANOBAS): Psychosocial and familial correlates and stressful life events in AN

Anorexia nervosa (AN) is a multifactorial illness. Although several studies have determined which factors could predispose AN, few studies have determined which factors could precipitate it. What is more, it has been suggested that having experienced stressful life events (SLE) could be related to the onset of AN. The aim of this study was to explore specific psychosocial and familial correlates and the impact of SLE in the onset of AN. Following a case-control design, 40 adolescents diagnosed with AN were matched to three control groups, 40 healthy adolescents, 40 adolescents with affective disorders, 40 adolescents with asthma and their families by sex, age and socioeconomic status. Diagnostic interviews K-DSADS and questionnaires were used. The results empathised that no specific predisposing correlates were found for AN. Similarly, the increase of the amount of SLE prior to the onset is an overall characteristic for psychiatric disorders, which in AN it is only specifically related to psychological correlates, but no to cortisol. In terms of specific SLE, those related to interpersonal problems were frequent at the onset of AN. The results highlight the consequences of SLEs in the emotional well-being of the AN adolescents, that could be specific for this psychopathology.

Hypothalamic Structural and Functional Imbalances in Anorexia Nervosa

The hypothalamus contains integrative systems that support life, including physiological processes such as food intake, energy expenditure, and reproduction. Here, we show that anorexia nervosa (AN) patients, contrary to normal weight and constitutionally lean individuals, respond with a paradoxical reduction in hypothalamic levels of glutamate/glutamine (Glx) upon feeding. This reversal of the Glx response is associated with decreased wiring in the arcuate nucleus and increased connectivity in the lateral hypothalamic area, which are involved in the regulation on a variety of physiological and behavioral functions including the control of food intake and energy balance. The identification of distinct hypothalamic neurochemical dysfunctions and associated structural variations in AN paves the way for the development of new diagnostic and treatment strategies in conditions associated with abnormal body mass index and a maladaptive response to negative energy balance.

Associations between neuropsychological performance and appetite-regulating hormones in anorexia nervosa and healthy controls: Ghrelin's putative role as a mediator of decision-making

Anorexia nervosa (AN) is a severe eating disorder accompanied by alterations in endocrinological circuits and deficits in neuropsychological performance. In this study, a series of appetite-regulating hormones (ghrelin, leptin, cholecystokinin, PYY, adiponectin, and visfatin) were measured under fasting conditions in female patients with AN and female healthy controls. All of the participants also underwent a battery of neuropsychological assessment [namely the Iowa Gambling Task (IGT), the Wisconsin Card Sorting Test (WCST), and the Stroop Color and Word Test (SCWT)]. As the main finding, we found that higher ghrelin levels predict better performance in the IGT. Ghrelin may be a putative mediator of decision-making, a finding that has not been described so far. The role of ghrelin in decision-making can only be described as speculative, as there are hardly any additional evidence-based data published up to date. Further studies are warranted.

Periodontal condition, changes in salivary biochemical parameters, and oral health-related quality of life in patients with anorexia and bulimia nervosa

BACKGROUND

Anorexia and bulimia nervosa can have significant effects on oral health. Assessment of enzyme concentrations in saliva can be useful for obtaining information on molecular biomarkers for the prevention, monitoring, and diagnosis of oral diseases. This study investigated the periodontal condition, changes in salivary biochemical parameters, and oral health-related quality of life (OHRQoL) in patients with anorexia and bulimia nervosa.

METHODS

The study comprised 60 women patients who attended a Brazilian medical school. Participants were divided into two groups: patients with anorexia and bulimia nervosa (ABN; n = 30) and control patients (CN; n = 30). Oral clinical examinations were carried out to evaluate the periodontal condition by Community Periodontal Index, and interviews using the Oral Health Impact Profile (OHIP-14) were conducted to assess OHRQoL. Saliva samples were collected for the evaluation of salivary concentrations of total protein, alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and thiobarbituric acid reactive substance (TBARS), and salivary flow rate.

RESULTS

Periodontal condition in the ABN group was significantly worse than that in the CN group. The ABN group showed significantly higher salivary concentrations of total protein, AST, ALT, and LDH than the CN group. There was no significant difference in the salivary concentrations of TBARS among the groups. The OHIP-14 score was higher in the ABN group than in the CN group.

CONCLUSION

Anorexia and bulimia nervosa are associated with poor periodontal condition, elevated salivary concentrations of total protein, AST, ALT, and LDH, decreased salivary flow rate and a significant adverse impact on OHRQoL.

Differences in cortisol concentrations in adolescents with eating disorders: a systematic review

OBJECTIVE

To perform a systematic review of the literature for scientific evidence of possible differences in cortisol concentrations in adolescents with eating disorders.

SOURCE OF DATA

Electronic searches were conducting in the PubMed, Scientific Electronic Library Online, Virtual Health Library, and Science Direct databases for articles published between 2007 and 2017 using the keywords, cortisol, hydrocortisone; eating disorders, bulimia, bulimia nervosa, anorexia, anorexia nervosa; adolescence, adolescent, adolescents.

SYNTHESIS OF DATA

A total of 192 articles were found. After the analysis of the eligibility criteria using the PRISMA method, 19 articles were selected for the present review. Most studies were conducted in Europe. Adolescents diagnosed with anorexia nervosa were evaluated in all studies, except one, when other eating disorders were investigated. Blood was the means used for the determination of cortisol. In ten studies, cortisol levels were higher in the group with anorexia than the control group and a reduction in cortisol levels occurred in the adolescents after being submitted to nutritional recovery.

CONCLUSIONS

Patients with eating disorders may have several clinical consequences, such as changes in body fat distribution, changes in bone mineral density, worsening of neurocognitive ability, and endocrine changes (e.g., hypercortisolemia), which in turn can lead to hyperglycemia, insulin resistance, hypertension, and increased risk of infections. The findings demonstrate that adolescents with eating disorders, especially anorexia nervosa, have increased cortisol levels, which are reduced after the treatment period. Further studies on differences in cortisol concentrations in adolescents with other eating disorders are needed, using different methods.

Endocrine Effects of Relative Energy Deficiency in Sport

The term Relative Energy Deficiency in Sport was introduced by the International Olympic Committee in 2014. It refers to the potential health and performance consequences of inadequate energy for sport, emphasizing that there are consequences of low energy availability (EA; typically defined as <30 kcal·kg^-1 fat-free mass·day^-1) beyond the important and well-established female athlete triad, and that low EA affects populations other than women. As the prevalence and consequences of Relative Energy Deficiency in Sport become more apparent, it is important to understand the current knowledge of the hormonal changes that occur with decreased EA. This paper highlights endocrine changes that have been observed in female and male athletes with low EA. Where studies are not available in athletes, results of studies in low EA states, such as anorexia nervosa, are included. Dietary intake/appetite-regulating hormones, insulin and other glucose-regulating hormones, growth hormone and insulin-like growth factor 1, thyroid hormones, cortisol, and gonadal hormones are all discussed. The effects of low EA on body composition, metabolic rate, and bone in female and male athletes are presented, and we identify future directions to address knowledge gaps specific to athletes.

Prospective, randomized, double-blind, placebo-controlled phase IIa clinical trial on the effects of an estrogen-progestin combination as add-on to inpatient psychotherapy in adult female patients suffering from anorexia nervosa

BACKGROUND

There is a need for novel treatment approaches in anorexia nervosa (AN). While there is broad knowledge with regard to altered appetite regulation and neuropsychological deficits in AN patients on the one hand, and the effects of estrogen replacement upon neuropsychological performance in healthy subjects on the other, up to now, no study has implemented estrogen replacement in AN patients, in order to examine its effects upon AN-associated and general psychopathology, neuropsychological performance and concentrations of peptide components of the hypothalamus-pituitary-adrenal (HPA) axis and within appetite-regulating circuits.

METHODS

This is a randomized placebo-controlled clinical trial on the effects of a 10-week oral estrogen replacement (combination of ethinyl estradiol 0.03 mg and dienogest 2 mg) in adult female AN patients. The primary target is the assessment of the impact of sex hormone replacement upon neuropsychological performance by means of a neuropsychological test battery consisting of a test for verbal intelligence, the Trail making test A and B, a Go/No-go paradigm with food cues and the Wisconsin Card Sorting Test. Secondary targets include a) the examination of safety and tolerability (as mirrored by the number of adverse events), b) assessments of the impact upon eating disorder-specific psychopathology by means of the Eating Disorder Examination Questionnaire (EDE-Q) and the Eating Disorder Inventory-2 (EDI-2), c) the influence upon anxiety using the State-Trait-Anxiety Inventory (STAI), d) assessments of plasma cortisol levels during a dexamethasone-suppression test and appetite-regulating plasma peptides (ghrelin, leptin, insulin, glucose) during an oral glucose tolerance test and, e) a possible impact upon the prescription of antidepressants.

DISCUSSION

This is the first study of its kind. There are no evidence-based psychopharmacological options for the treatment of AN. Thus, the results of this clinical trial may have a relevant impact on future treatment regimens. Novel approaches are necessary to improve rates of AN symptom remission and increase the rapidity of treatment response. Identifying the underlying biological (e.g. neuroendocrinological) factors that maintain AN or may predict patient treatment response represent critical future research directions. Continued efforts to incorporate novel pharmacological aspects into treatments will increase access to evidence-based care and help reduce the burden of AN.

TRIAL REGISTRATION

European Clinical Trials Database, EudraCT number 2015-004184-36, registered November 2015; ClinicalTrials.gov Identifier: NCT03172533 , retrospectively registered May 2017.

Metabolic and neuroendocrine adaptations to undernutrition in anorexia nervosa: from a clinical to a basic research point of view

The exact mechanisms linking metabolic and neuroendocrine adaptations to undernutrition and the pathophysiology of anorexia nervosa (AN) are not fully understood. AN is a psychiatric disorder of complex etiology characterized by extreme starvation while the disease is progressing into a chronic state. Metabolic and endocrine alterations associated to this disorder are part of a powerful response to maintain whole body energy homeostasis. But these modifications may also contribute to associated neuropsychiatric symptoms (reward abnormalities, anxiety, depression) and thus participate to sustain the disease. The current review presents data with both a clinical and basic research point of view on the role of nutritional and energy sensors with neuroendocrine actions in the pathophysiology of the disease, as they modulate metabolic responses, reproductive functions, stress responses as well as physical activity. While clinical data present a full description of changes occurring in AN, animal models that integrate either spontaneous genetic mutations or experimentally-induced food restriction with hyperactivity and/or social stress recapitulate the main metabolic and endocrine alterations of AN and provide mechanistic information between undernutrition state and symptoms of the disease. Further progress on the central and peripheral mechanism involved in the pathophysiology of eating disorders partly relies on the development and/or refinement of existing animal models to include recently identified genetic traits and better mimic the complex and multifactorial dimensions of the disease.

Bone metabolism in anorexia nervosa and hypothalamic amenorrhea

Anorexia nervosa (AN) and hypothalamic amenorrhea (HA) are states of chronic energy deprivation associated with severely compromised bone health. Poor bone accrual during adolescence followed by increased bone loss results in lifelong low bone density, degraded bone architecture, and higher risk of fractures, despite recovery from AN/HA. Amenorrhea is only one of several compensatory responses to the negative energy balance. Other hypothalamic-pituitary hormones are affected and contribute to bone deficits, including activation of hypothalamic-pituitary-adrenal axis and growth hormone resistance. Adipokines, particularly leptin, provide information on fat/energy stores, and gut hormones play a role in the regulation of appetite and food intake. Alterations in all these hormones influence bone metabolism. Restricted in scope, current pharmacologic approaches to improve bone health have had overall limited success.

Cortisol and DHEA in development and psychopathology

Dehydroepiandrosterone (DHEA) and cortisol are the most abundant hormones of the human fetal and adult adrenals released as end products of a tightly coordinated endocrine response to stress. Together, they mediate short- and long-term stress responses and enable physiological and behavioral adjustments necessary for maintaining homeostasis. Detrimental effects of chronic or repeated elevations in cortisol on behavioral and emotional health are well documented. Evidence for actions of DHEA that offset or oppose those of cortisol has stimulated interest in examining their levels as a ratio, as an alternate index of adrenocortical activity and the net effects of cortisol. Such research necessitates a thorough understanding of the co-actions of these hormones on physiological functioning and in association with developmental outcomes. This review addresses the state of the science in understanding the role of DHEA, cortisol, and their ratio in typical development and developmental psychopathology. A rationale for studying DHEA and cortisol in concert is supported by physiological data on the coordinated synthesis and release of these hormones in the adrenal and by their opposing physiological actions. We then present evidence that researching cortisol and DHEA necessitates a developmental perspective. Age-related changes in DHEA and cortisol are described from the perinatal period through adolescence, along with observed associations of these hormones with developmental psychopathology. Along the way, we identify several major knowledge gaps in the role of DHEA in modulating cortisol in typical development and developmental psychopathology with implications for future research.

The endocrine manifestations of anorexia nervosa: mechanisms and management

Anorexia nervosa is a psychiatric disorder characterized by altered body image, persistent food restriction and low body weight, and is associated with global endocrine dysregulation in both adolescent girls and women. Dysfunction of the hypothalamic-pituitary axis includes hypogonadotropic hypogonadism with relative oestrogen and androgen deficiency, growth hormone resistance, hypercortisolaemia, non-thyroidal illness syndrome, hyponatraemia and hypooxytocinaemia. Serum levels of leptin, an anorexigenic adipokine, are suppressed and levels of ghrelin, an orexigenic gut peptide, are elevated in women with anorexia nervosa; however, levels of peptide YY, an anorexigenic gut peptide, are paradoxically elevated. Although most, but not all, of these endocrine disturbances are adaptive to the low energy state of chronic starvation and reverse with treatment of the eating disorder, many contribute to impaired skeletal integrity, as well as neuropsychiatric comorbidities, in individuals with anorexia nervosa. Although 5-15% of patients with anorexia nervosa are men, only limited data exist regarding the endocrine impact of the disease in adolescent boys and men. Further research is needed to understand the endocrine determinants of bone loss and neuropsychiatric comorbidities in anorexia nervosa in both women and men, as well as to formulate optimal treatment strategies.

Thyroid Allostasis-Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming

The hypothalamus-pituitary-thyroid feedback control is a dynamic, adaptive system. In situations of illness and deprivation of energy representing type 1 allostasis, the stress response operates to alter both its set point and peripheral transfer parameters. In contrast, type 2 allostatic load, typically effective in psychosocial stress, pregnancy, metabolic syndrome, and adaptation to cold, produces a nearly opposite phenotype of predictive plasticity. The non-thyroidal illness syndrome (NTIS) or thyroid allostasis in critical illness, tumors, uremia, and starvation (TACITUS), commonly observed in hospitalized patients, displays a historically well-studied pattern of allostatic thyroid response. This is characterized by decreased total and free thyroid hormone concentrations and varying levels of thyroid-stimulating hormone (TSH) ranging from decreased (in severe cases) to normal or even elevated (mainly in the recovery phase) TSH concentrations. An acute versus chronic stage (wasting syndrome) of TACITUS can be discerned. The two types differ in molecular mechanisms and prognosis. The acute adaptation of thyroid hormone metabolism to critical illness may prove beneficial to the organism, whereas the far more complex molecular alterations associated with chronic illness frequently lead to allostatic overload. The latter is associated with poor outcome, independently of the underlying disease. Adaptive responses of thyroid homeostasis extend to alterations in thyroid hormone concentrations during fetal life, periods of weight gain or loss, thermoregulation, physical exercise, and psychiatric diseases. The various forms of thyroid allostasis pose serious problems in differential diagnosis of thyroid disease. This review article provides an overview of physiological mechanisms as well as major diagnostic and therapeutic implications of thyroid allostasis under a variety of developmental and straining conditions.

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.

Pulsatile gonadotropin-releasing hormone therapy in persistent amenorrheic weight-recovered anorexia nervosa patients

OBJECTIVE

To compare hormonal and clinical responses to GnRH pulsatile treatment in weight-recovered anorexia nervosa patients (Rec-AN) with persistent functional hypothalamic amenorrhea (HA) vs. in patients with secondary and primary HA.

DESIGN

Retrospective, observational, ambulatory study.

SETTING

University hospital.

PATIENT(S)

Forty-one women: 19 Rec-AN (body mass index >18.5 kg/m² without menses recovery), 15 secondary HA without any eating disorders patients (SHA), and 7 primary HA patients (PHA).

INTERVENTION(S)

Gonadotropin-releasing hormone pulsatile therapy.

MAIN OUTCOME MEASURE(S)

Baseline E₂, LH, and P plasma levels and their changes during induction cycles; ovulation, follicular recruitment, and pregnancies.

RESULTS

The Rec-AN group displayed higher basal E₂ and LH plasma levels after GnRH injection compared with SHA and PHA. Higher E₂ and LH levels were observed during induction cycles in Rec-AN compared with SHA and PHA. Follicular recruitment was higher in Rec-AN. The ovulation rate was higher in Rec-AN compared with PHA but similar to SHA.

CONCLUSION(S)

This study showed increased gonadal status and higher E₂ response to pulsatile GnRH therapy in persistent amenorrheic weight-recovered AN compared with HA from other causes. It suggests that their individual set-point of body weight allowing a fully functional gonadal axis is not reached yet. Specific factors of gonadal inertia in Rec-AN still remain unclear.

Gender and age differences in cardiovascular complications in anorexia nervosa patients

BACKGROUND

Anorexia nervosa (AN) is characterized by severe malnutrition and electrolyte imbalances. Differences in cardiovascular complications between males and females with AN have not been studied. Additionally, coronary artery disease (CAD) prevalence and cardiovascular complications in patients with AN >65years have not been reported.

METHODS

AN patients>18years were identified in the Nationwide Inpatient Sample 2009-2010 database using the Ninth Revision of International Classification of Disease code 307.1. Demographics, risk factors, and cardiovascular event rates were compared to general population data.

RESULTS

CAD incidence was lower in all AN patients compared to the general population (4.4% vs 18.4%, p<0.001). Despite AN males having higher prevalences of hypertension and diabetes than AN females, there was no difference in CAD. AN males had higher rates of cardiac arrests, arrhythmias, and heart failure. Interestingly, 4.3% of patients with AN were >65years old. When compared to the general population>65years, older AN patients had lower rates of CAD (35% vs 16%; p<0.001). Older AN patients still had higher CAD rates compared to the general population under 65 (8.6%) and AN patients under 65 (4%; p<0.001). Older AN patients had a lower incidence of heart failure (24% vs 16%; p=0.04), and a trend towards less arrhythmias (30% vs 21%; p=0.08).

CONCLUSIONS

Our data suggests that male AN patients experienced more cardiac arrests, arrhythmias, and heart failure than female AN patients. Additionally, older AN patients have a decreased incidence of CAD and heart failure compared to the general population>65years old.

Interleukin-7 Plasma Levels in Human Differentiate Anorexia Nervosa, Constitutional Thinness and Healthy Obesity

Introduction

Interleukin-7 (IL-7) is a cytokine involved in energy homeostasis as demonstrated in rodents. Anorexia nervosa is characterized by restrained eating behavior despite adaptive orexigenic regulation profile including high ghrelin plasma levels. Constitutional thinness is a physiological condition of resistance to weight gain with physiological anorexigenic profile including high Peptide YY plasma level. Healthy obesity can be considered as a physiological state of resistance to weight loss with opposite appetite regulating profile to constitutional thinness including low Peptide YY plasma level. No studies in IL-7 are yet available in those populations. Therefore we evaluated circadian plasma levels of IL-7 in anorexia nervosa compared to constitutional thinness, healthy obese and control females.

Materials and Methods

10 restrictive-type anorexia nervosa women, 5 bingeing/purging anorexia nervosa woman, 5 recovered restrictive anorexia nervosa women, 4 bulimic females, 10 constitutional thinness women, 7 healthy obese females, and 10 normal weight women controls were enrolled in this cross-sectional study, performed in endocrinology unit and academic laboratory. Twelve-point circadian profiles of plasma IL-7 levels were measured in each subject.

Results

24h mean IL-7 plasma levels (pg/ml, mean±SEM) were decreased in restrictive-type anorexia nervosa (123.4±14.4, p<0.0037), bingeing/purging anorexia nervosa (24.2±5.6, p<0.001), recovered restrictive anorexia nervosa (64.2±16.1, p = 0.01) and healthy obese patients (51±3.2, p<0.001) compared to controls (187.7±28.6). Bulimic patients (197.4±42.7) and constitutional thinness patients (264.3±35.8) were similar to controls.

Conclusions

Low IL-7 is part of the adaptive profile in restrictive-type anorexia nervosa, confirming its difference with constitutional thinness. Healthy obesity, with low IL-7, is once again in mirror image of constitutional thinness with normal high IL-7.

Salivary alpha-amylase, secretory IgA and free cortisol as neurobiological components of the stress response in the acute phase of anorexia nervosa

Objectives One novel hypothesis of the pathogenesis of anorexia nervosa (AN) is the possible role of mental stress in hyperactivity of the autonomic nervous system (ANS) and of the hypothalamic-pituitary-adrenal (HPA) axis. Two components of stress response - salivary alpha-amylase (sAA) and free cortisol - have been proposed. They can be determined in saliva, which closely reflects their concentrations in plasma. The purpose of this study was to measure salivary free cortisol, sAA and their correlation to secretory IgA (sIgA) of patients with AN in comparison to the average population. Methods A controlled clinical trial was designed for a matched group of 47 AN patients and 54 healthy individuals. After clinical examination, unstimulated salivary samples were taken during the acute stage of AN (BMI < 15 kg/m(2)) in the first week of hospitalisation. An enzyme-linked immunosorbent assay (ELISA) suitable for measuring sAA, sIgA and free cortisol were used. Results Anorexic patients exhibited disturbances in sAA secretion, and significantly increased cortisol and sIgA levels with a distinct correlation between these two parameters. Conclusions The behaviour of cortisol, sAA and sIgA levels can be assessed as an effect of stress reaction among AN patients with hyperactivity of the HPA axis and ANS dysregulation. The effect of stress response can be assessed reliably in saliva.

Cardiac changes in anorexia nervosa

Introduction Anorexia nervosa is an eating disorder, which is associated with many different medical complications as a result of the weight loss and malnutrition that characterise this illness. It has the highest mortality rate of any psychiatric disorder. A large portion of deaths are attributable to the cardiac abnormalities that ensue as a result of the malnutrition associated with anorexia nervosa. In this review, the cardiac complications of anorexia nervosa will be discussed.

METHODS

A comprehensive literature review on cardiac changes in anorexia nervosa was carried out.

RESULTS

There are structural, functional, and rhythm-type changes that occur in patients with anorexia nervosa. These become progressively significant as ongoing weight loss occurs.

CONCLUSION

Cardiac changes are inherent to anorexia nervosa and they become more life-threatening and serious as the anorexia nervosa becomes increasingly severe. Weight restoration and attention to these cardiac changes are crucial for a successful treatment outcome.

Influence of premorbid BMI on clinical characteristics at presentation of adolescent girls with eating disorders

BACKGROUND

Considering the prevalence of obesity in society it can be expected that some adolescents with an eating disorder (ED) start weight loss from an overweight and present at a near-normal weight. Presently, the influence of premorbid BMI on clinical characteristics of adolescent girls presenting with an ED has ben studied.

METHOD

Premorbid growth charts were available for 275 postmenarcheal adolescent girls presenting with an ED (anorexia nervosa = 27, (subthreshold) bulimia nervosa = 9, restrictive EDNOS = 239). Initial assessment included measurement of weight and length, physical examination, blood sampling and administration of the Eating Disorder Examination-Questionnaire youth version (EDE-Q).

RESULTS

Despite greater weight loss girls with a high premorbid body mass index (BMI) had a higher BMI at presentation compared to those with a lower premorbid BMI. Although not underweight some presented with clinical and laboratory signs of starvation. These signs were related to not only low BMI but also to rapid and large weight loss. Their EDE-Q scores did not differ from those of girls who presented with an underweight.

CONCLUSION

Girls with a restrictive ED and premorbid overweight may present with a near-normal BMI. They can nevertheless be medically compromised and have eating disturbed cognitions at the level of underweight girls. They should not be regarded as having a less severe ED but merit full assessment and a start of treatment.

Plasma cholesterol is related to menstrual status in adolescent girls with eating disorders and weight loss

AIM

This study examined the relationship between plasma cholesterol and circulating triiodothyronine and oestradiol in 561 adolescent girls aged 11-17 with eating disorders.

METHODS

Plasma total cholesterol, high-density lipoprotein cholesterol, serum triodothyronine and oestradiol were measured at assessment, and historical weight data were obtained from growth charts provided by the school health services. Cholesterol levels were related to weight change, menstrual status and serum hormones.

RESULTS

Plasma total cholesterol levels of >5.0 mmol/L were found in 38% of the 77 girls who were premenarcheal, 32% of the 199 with secondary amenorrhoea and 17% of those who were still menstruating. These cholesterol levels were inversely related to serum oestradiol and triiodothyronine concentrations, but not weight change, in amenorrhoic girls and were positively related to body mass index and inversely related to weight loss and serum triiodothyronine in girls who were still menstruating.

CONCLUSION

Increased plasma total cholesterol was related to amenorrhoea in adolescent girls with eating disorders and weight loss. Oestrogens appeared to mediate the effect of starvation on cholesterol, most effectively in premenarcheal girls. Re-establishing menstruation is an important goal in the treatment of eating disorders, to avoid dyslipidaemia and the risk of future cardiovascular disease.

Increased Bone Marrow Adiposity in a Context of Energy Deficit: The Tip of the Iceberg?

Elevated bone marrow adiposity (BMA) is defined as an increase in the proportion of the bone marrow (BM) cavity volume occupied by adipocytes. This can be caused by an increase in the size and/or number of adipocytes. BMA increases with age in a bone-site-specific manner. This increase may be linked to certain pathophysiological situations. Osteoporosis or compromised bone quality is frequently associated with high BMA. The involvement of BM adipocytes in bone loss may be due to commitment of mesenchymal stem cells to the adipogenic pathway rather than the osteogenic pathway. However, adipocytes may also act on their microenvironment by secreting factors with harmful effects for the bone health. Here, we review evidence that in a context of energy deficit (such as anorexia nervosa (AN) and restriction rodent models) bone alterations can occur in the absence of an increase in BMA. In severe cases, bone alterations are even associated with gelatinous BM transformation. The relationship between BMA and energy deficit and the potential regulators of this adiposity in this context are also discussed. On the basis of clinical studies and preliminary results on animal model, we propose that competition between differentiation into osteoblasts and differentiation into adipocytes might trigger bone loss at least in moderate-to-severe AN and in some calorie restriction models. Finally, some of the main questions resulting from this hypothesis are discussed.

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.

Neuropeptide Y and α-MSH circadian levels in two populations with low body weight: anorexia nervosa and constitutional thinness

Context

Anorexia nervosa (AN) presents an adaptive appetite regulating profile including high levels of ghrelin and 26RFa (orexigenic) and low levels of leptin and PYY (anorexigenic). However, this adaptive mechanism is not effective in promoting food intake. The NPY/proopiomelanocortin (POMC) system plays a crucial role in the regulation of feeding behavior as NPY is the most potent orexigenic neuropeptide identified so far and as the POMC-derived peptide α-MSH drastically reduces food intake, and this peptidergic system has not been thoroughly studied in AN.

Objective

The aim of the present study was thus to investigate whether a dysfunction of the NPY/POMC occurs in two populations with low body weight, AN and constitutional thinness (CT).

Design and Settings

This was a cross-sectional study performed in an endocrinological unit and in an academic laboratory.

Investigated Subjects

Three groups of age-matched young women were studied: 23 with AN (AN), 22 CT and 14 normal weight controls.

Main Outcome Measures

Twelve-point circadian profiles of plasma NPY and α-MSH levels were measured in the three groups of investigated subjects.

Results

No significant circadian variation of NPY was detected between the three groups. Plasma α-MSH levels were significantly lower in AN (vs controls) all over the day. The CT group, compared to controls, presented lower levels of α-MSH in the morning and the evening, and an important rise during lunchtime.

Conclusion

In AN patients, the NPY system is not up-regulated under chronic undernutrition suggesting that this may play a role in the inability of anorectic women to adapt food intake to their energy demand. In contrast, low circadian α-MSH levels integrate the adaptive profile of appetite regulation of this disease. Finally, in CT women, the important α-MSH peak detected during lunchtime could explain why these patients are rapidly food satisfied.

Bone metabolism in adolescent girls with eating disorders and weight loss: independent effects of weight change, insulin-like growth factor-1 and oestradiol

Adolescents with eating disorders (ED) are at risk of developing osteoporosis if weight is not recovered. Previous investigations do not separate the effects of weight change per se from those of concomitant hormonal changes. In this investigation serum osteocalcin (OC), C-terminal telopeptide of collagen (CTX), insulin-like growth factor-1 (IGF-1) and oestradiol were measured at assessment of 498 girls with ED and during weight gain of 59 girls. At assessment, OC concentrations were associated independently with weight (change), IGF-1 and oestradiol. Low weight, a high rate of weight loss and the hormone concentrations were associated with low OC. Low weight and high rate of weight loss were associated with high CTX concentrations but there were no associations independent of weight (change) with the hormones. During weight recovery, OC and CTX were independently and positively associated with weight, weight gain, IGF-1 and oestradiol. Bone metabolism markers are related to weight change independently of IGF-1 and oestradiol during both weight loss and weight gain. During weight gain, when pubertal development and growth are resumed there is an additional independent positive association between the markers and IGF-1 and oestradiol. These relationships are strongest in premenarcheal girls.

Physical activity: benefit or weakness in metabolic adaptations in a mouse model of chronic food restriction?

In restrictive-type anorexia nervosa (AN) patients, physical activity is usually associated with food restriction, but its physiological consequences remain poorly characterized. In female mice, we evaluated the impact of voluntary physical activity with/without chronic food restriction on metabolic and endocrine parameters that might contribute to AN. In this protocol, FRW mice (i.e., food restriction with running wheel) reached a crucial point of body weight loss (especially fat mass) faster than FR mice (i.e., food restriction only). However, in contrast to FR mice, their body weight stabilized, demonstrating a protective effect of a moderate, regular physical activity. Exercise delayed meal initiation and duration. FRW mice displayed food anticipatory activity compared with FR mice, which was strongly diminished with the prolongation of the protocol. The long-term nature of the protocol enabled assessment of bone parameters similar to those observed in AN patients. Both restricted groups adapted their energy metabolism differentially in the short and long term, with less fat oxidation in FRW mice and a preferential use of glucose to compensate for the chronic energy imbalance. Finally, like restrictive AN patients, FRW mice exhibited low leptin levels, high plasma concentrations of corticosterone and ghrelin, and a disruption of the estrous cycle. In conclusion, our model suggests that physical activity has beneficial effects on the adaptation to the severe condition of food restriction despite the absence of any protective effect on lean and bone mass.

Anorexia nervosa - medical complications

In contrast to other mental health disorders, eating disorders have a high prevalence of concomitant medical complications. Specifically, patients suffering from anorexia nervosa (AN) have a litany of medical complications which are commonly present as part of their eating disorders. Almost every body system can be adversely, affected by this state of progressive malnutrition. Moreover, some of the complications can have permanent adverse effects even after there is a successful program of nutritional rehabilitation and weight restoration. Within this article we will review all body systems affected by AN. There is also salient information about both, how to diagnose these medical complications and which are the likely ones to result in permanent sequelae if not diagnosed and addressed early in the course of AN. In a subsequent article, the definitive medical treatment for these complications will be presented in a clinically practical manner.