Association between resting energy expenditure, psychopathology and HPA-axis in eating disorders

International study of the Complex Stress Reaction Syndrome: Implications for transdiagnostic clinical practice

BACKGROUND

The debate regarding diagnostic classification systems in psychiatry (categorial vs dimensional systems) has essential implications for the diagnosis, prevention and treatment of stress reactions. We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries, and termed it the Complex Stress Reaction Syndrome (CSRS).

AIM

To investigate CSRS, Type A (psychiatric symptoms, spanning anxiety, depression, stress symptoms, and post-traumatic stress disorder (PTSD)), with or without long-coronavirus disease (COVID) residuals (CSRS, Type B, neuropsychiatric symptoms spanning cognitive deficits and fatigue, excluding systemic symptoms). Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population (Type A) or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals (Type B).

METHODS

977 individuals in four continents (North America, Europe, Australia and the Middle East) completed the online study questionnaire in six languages using the Qualtrics platform. The study was managed by six teams in six countries that promoted the study on social media. The questionnaire assessed anxiety, depression, stress symptoms and PTSD (CSRS, Type A), cognitive deficits and fatigue (CSRS, Type B). The data were analyzed using Proportion Analyses, Multivariate Analysis of Co-Variance (MANCOVA), linear regression analyses and validated clinical cutoff points.

RESULTS

The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety, depression, stress symptoms, and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents, age groups, and gender. This supports the transdiagnostic argument embedded in the CSRS (Type A). The same pattern of results was found in infected/recovered individuals. The prevalence of the 4 psychiatric symptoms combination was significantly greater than that of 5 and 6 symptoms, when adding cognitive deficits and fatigue, respectively. MANCOVA showed a significant three-way interaction (age × gender × continent). Further analyses showed that the sources of this three-way interaction were threefold relating to two sub-populations at-risk: (1) Individuals that self-identified as non-binary gender scored significantly higher on all 4 psychiatric symptoms of the CSRS, Type A at young age groups (< 50 years old) in North America compared to (self-identified) women and men located in the 4 continents studied, and to other ages across the adult life span; and (2) This pattern of results (CSRS, Type A) was found also in women at young ages (< 40 years old) in North America who scored higher compared to men and women in other continents and other ages. Linear regression analyses confirmed the MANCOVA results.

CONCLUSION

These results show a combined mental health risk factor related to stress reactivity, suggesting that the CSRS is sensitive to populations at risk and may be applied to future identification of other vulnerable sub-populations. It also supports the transdiagnostic approach for more accurate prevention and treatment. Time will tell if such transdiagnostic syndromes will be part of the discussions on the next revisions of the traditional classification systems or whether the crisis in psychiatry further evolves.

Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome

The evaluation of suspected hypercortisolism is one of the most challenging problems in medicine. The signs and symptoms described by Dr Harvey Cushing are common and often create diagnostic confusion to even experienced endocrinologists. Cushing syndrome is classically defined as neoplastic hypercortisolism resulting from an ACTH-secreting tumor or from autonomous secretion of excess cortisol associated with benign or malignant adrenal neoplasia. The increasing recognition of the negative cardiometabolic effects of mild cortisol excess without overt physical signs of Cushing syndrome has led to more screening for endogenous hypercortisolism in patients with adrenal nodular disease, osteoporosis, and the metabolic syndrome. However, sustained or intermittent activation of the dynamic hypothalamic-pituitary-adrenal axis caused by chemical (alcohol), inflammatory (chronic kidney disease), psychologic (major depression), and physical (starvation/chronic intense exercise) stimuli can result in clinical and/or biochemical features indistinguishable from neoplastic hypercortisolism. Nonneoplastic hypercortisolism (formerly known as pseudo-Cushing syndrome) has been recognized for more than 50 years and often causes diagnostic uncertainty. This expert consultation describes two patients with features of Cushing syndrome who were referred for inferior petrosal sinus sampling for the differential diagnosis of ACTH-dependent hypercortisolism. Both patients were discovered to have nonneoplastic hypercortisolism: one from a covert alcohol use disorder and the other to chronic kidney disease. This consultation emphasizes the value of a good history and physical examination, appropriate laboratory testing, and the desmopressin acetate stimulation test to aid in distinguishing neoplastic from nonneoplastic hypercortisolism.

Clinical Correlates of Measured and Predicted Resting Energy Expenditure in Patients with Anorexia Nervosa: A Retrospective Cohort Study

Resting energy expenditure (REE; i.e., the calorie amount required for 24 h during a non-active period) is an important parameter in nutritional rehabilitation of patients with anorexia nervosa (AN). This study determined whether age, body mass index, AN duration/subtype/specific symptoms/clinical severity, cognitive function alterations, and psychiatric comorbidities influenced REE or the difference between the calculated and estimated REE. Patients with AN who were followed at a daycare treatment facility between May 2017 and January 2020 (n = 138) underwent a complete assessment that included the MINI, Eating Disorder Examination Questionnaire, d2 test of attention, body fat composition by bioelectrical impedance analysis (BIA) and REE measurement by indirect calorimetry (REEIC). AN subtype (N = 66 for restrictive subtype and N = 69 for non-restrictive subtype; p = 0.005), free-fat mass (<0.001), and fat mass (<0.001) were associated with REEIC. Age (p < 0.001), height (p = 0.003), and AN duration (N = 46 for <3 years and N = 82 for ≥3 years; p = 0.012) were associated with the difference between estimated REE (using the Schebendach equation) and measured REEIC. Therefore, the Schebendach equation was adjusted differently in the two patients’ subgroups (AN duration ≤ or >3 years). Overall, REE was higher in patients with restrictive than non-restrictive AN. In the absence of BIA measures, REE-estimating equations should take into account AN duration.

A novel integrated approach to estimate the mitochondrial content of neuronal cells and brain tissues

BACKGROUND

Mitochondria and their dynamics fuel most cellular processes both in physiological and pathological conditions. In the central nervous system, mitochondria sustain synaptic transmission and plasticity via multiple mechanisms which include their redistribution and/or expansion to higher energy demanding sites, sustaining activity changes and promoting morphological circuit adaptations.

NEW METHOD

To be able to evaluate changes in mitochondrial number and protein phenotype, we propose a novel methodological approach where the simultaneous analysis of both mitochondrial DNA and protein content is performed on each individual microsample, avoiding non-homogeneous loss of material.

RESULTS

We validated this method on neuronal-like cells and tissue samples and obtained estimates for the mitochondrial/genomic DNA ratio as well as for the abundance of protein counterparts. When the mitochondrial content per cell was evaluated in different brain areas, our results matched the known regional variation in aerobic-anaerobic metabolism. When long-term potentiation (LTP) was induced on hippocampal neurons, we detected increases in the abundance of mitochondria that correlated with the degree of synaptic enhancement.

CONCLUSIONS

Our approach can be effectively used to study the mitochondrial content andits changes in different brain cells and tissues.

Resting energy expenditure in acutely ill and stabilized patients with anorexia nervosa and bulimia nervosa

OBJECTIVE

Determining resting energy expenditure (REE) may be important in the nutritional assessment of adolescents with eating disorders (EDs). Calculated equations assessing REE, developed according to data from healthy people, may under- or overestimate REE in EDs. We have sought to compare the REE measured in clinical settings to that calculated using equations in actively ill adolescents with anorexia nervosa (AN) and bulimia nervosa (BN), and following stabilization of weight and disordered eating.

METHODS

Thirty-five female adolescents with AN and 25 with BN were assessed at admission to inpatient treatment and at discharge. REE was measured using indirect calorimetry (DELTATRAC Metabolic Monitor). Expected REE was calculated using the Harris-Benedict equation.

RESULTS

An overestimation of expected versus measured REE was found for both patients with AN and BN, both at admission and discharge. Second, the differences between expected and measured REE were significantly less robust in BN versus AN. Third, REE before renourishing was lower in inpatients with AN versus BN. Fourth, the REE of patients with AN (both measured and expected) increased from admission to discharge, to a greater extent than expected solely from the increase in weight. The difference between admission and discharge expected and measured REE was significant also in patients with BN.

DISCUSSION

Our findings suggest that predicted and measured REE are different in both AN and BN, and that both expected and measured REE are not useful in the planning of renourishing programs in patients with AN.

Cortisol reactivity in patients with anorexia nervosa after stress induction

There is a need of experimental studies on biomarkers in patients with anorexia nervosa (P_AN), especially in the context of stress, in order to foster understanding in illness maintenance. To this end, the cortisol response to an acute stressor was investigated in n = 26 P_AN (BMI: 19.3 ± 3.4 kg/m²), age, and gender matched to n = 26 healthy controls (HC; BMI: 23.08 ± 3.3 kg/m²). For this purpose, salivary cortisol parameters were assessed in two experimental conditions: (1) rest/no intervention and (2) stress intervention (TSST; Trier Social Stress Test). In addition, psychological indicators of stress were assessed (Primary Appraisal Secondary Appraisal, Visual Analogue Scale, and Trier Inventory for the assessment of Chronic Stress), as well as psychological distress, depression, and eating disorder (ED) symptoms. A 2 × 2 × 8 ANOVA demonstrated elevated cortisol levels in P_AN in the resting condition. In the stress intervention no significant group effect in terms of cortisol (F (1, 50) = 0.69; p = 0.410; [Formula: see text]). A significant condition (F (1, 50) = 20.50; p = 0.000; [Formula: see text]) and time effect (F(2.71, 135.44) = 11.27; p = 0.000; [Formula: see text]) were revealed, as well as two significant interaction effects. First: Condition × group (F (1, 50) = 4.17, p = 0.046; [Formula: see text]) and second: Condition × time (F (2.71, 135.44) = 16.07, p = 0.000, [Formula: see text]). In terms of AUC_G, no significant differences between both groups were exhibited. Regardless, significant results were evinced in terms of an increase (AUC_i: F(1, 50) = 20.66, p = 0.015, [Formula: see text]), baseline to peak (+20 min post-TSST: t₅ = 16.51 (9.02), p = 0.029) and reactivity (M_PAN = 0.73 vs. M_HC = 4.25, p = 0.036). In addition, a significant correlation between AUC_G and BMI: r (24) = -0.42, p = 0.027 was demonstrated, but not between AUC_i and BMI (r (24) = -0.26, p = 0.20). Psychological indices suggested higher levels of chronic and perceived stress in P_AN relative to HC. However, stress perception in the stress condition (VAS) was comparable. Additional analyses demonstrated that ED-symptoms are highly correlated with psychological distress and depression, but not with BMI. In addition, it could be demonstrated that reactivity is rather related to ED-symptoms and psychological burden than to BMI. In conclusion, P_AN showed elevated basal cortisol levels at rest and exhibited a blunted cortisol reactivity to the TSST as evinced by salivary cortisol parameters. Further, it was shown that weight recovery influences reversibility of hypercortisolemia, i.e., cortisol levels normalize with weight gain. However, HPAA (hypothalamus-pituitary-adrenal axis) irregularities in terms of reactivity persist even at a BMI ≤ 19.3 (±3.4). Our data suggest that pronounced psychological burden in P_AN, have a greater impact on the HPAA functionality (secondary to the ED) than BMI itself.

Evaluation of a short protocol for indirect calorimetry in females with eating disorders and healthy controls

BACKGROUND AND AIMS

To enable clinicians to identify the clinical picture and treatment progress and to adjust eating plans according to personal energy needs, it is important to know the patient's correct resting metabolic rate (RMR). Indirect calorimetry (IC) is the preferred method for assessment of RMR, but long duration of measurement increases the load on the patients, and reduces the effectiveness in clinical and scientific settings. Further; not all patients reach a valid RMR according to the suggested best practice protocol, with 5 min of steady state (SS) where respiratory gas volume exchange varies less than 10%. The aim of this study was to evaluate the possibility for an abbreviated RMR protocol and SS criterion.

METHODS

Forty two women diagnosed with bulimia nervosa or binge eating disorder (eating disorder group, ED), originally recruited for an outpatient treatment study, and 26 age and gender matched healthy controls (HC) were studied during a single, prolonged IC measurement. Participants rested for 10 min in supine position wearing a two-way breathing facemask, before a continuous measurement period of 20 min. Results from a standard 5 min SS criterion was compared to an abbreviated 3 min SS criterion. Both SS-criteria were evaluated through three different SS protocols (<10% variation in respiratory gas exchange), being: 1) measurement during the first 3 or 5 min, 2) measurement after discarding the first 5 min, and 3) the lowest identified RMR during the 20 min of measurement.

RESULTS

About 50% of the participants reached an early SS in both the defined SS minute criteria. Participants reaching a valid SS throughout the 20 min of measurement increased from ∼90% to 100% with an abbreviated 3 min SS. With a 5 min SS criterion, the median (range) RMR for the 3 protocols were 1639.9 (1239.2), 1508.8 (1457.6) and 1500.6 (1328.8) respectively for the ED group, and 1702.2 (1239.4), 1608.4 (1076.4) and 1594.8 (1029.2) respectively for the HC group, (p > 0.05 for all between-group analysis). With a 3 min SS criterion, the median (range) RMR were 1533.6 (1298.2), 1461.2 (1406.1), and 1395.8 (1447.3) respectively for the ED group and 1681.7 (1332.4), 1613.7 (1266.0) and 1523.1 (1050.3), respectively for the HC group, (p > 0.05 for all between-group analysis). Lowest measured RMR was different compared to the other two SS protocols in both the ED- and the HC group, and for both the 5 min- and the 3 min SS criteria, respectively (p < 0.04). Furthermore, a SS of 3 min resulted in lower RMR compared to 5 min SS (p < 0.00) and an increased number of participants classified as hypo-metabolic (RMRmeasured/RMRcalculated < 0.9).

CONCLUSIONS

An abbreviated measurement protocol to identify the lowest RMR using IC was not successful. Abbreviating the SS criteria from 5 to 3 min, resulted in a lower RMR, hence encouraging further examination of the validity of shorter SS criterion than practiced today. Registered in Clinical Trials by id-number NCT02079935, and approved by the Norwegian Regional Committee for Medical and Health Research Ethics with id-number 2013/1871. The trial in which control persons were recruited, is approved by the Norwegian Regional Committees for Medical and Health Research Ethics with the id-number 2016/1718, and prospectively registered in Clinical Trials with the id-number NCT03007459.