Metabolic state and value-based decision-making in acute and recovered female patients with anorexia nervosa

The role of dysregulated ghrelin/LEAP-2 balance in anorexia nervosa

LEAP-2 is a ghrelin antagonist with an anorexigenic drive. This study investigates the evolution of plasma ghrelin and LEAP-2 concentrations in 29 patients with anorexia nervosa (AN) before and after refeeding and compares it to physiological adaptations during fasting in healthy controls or to mouse model of chronic food restriction and refeeding. Acute and chronic food restriction decrease LEAP-2 and increase ghrelin concentrations in both humans and mice, while patients with AN displayed higher ghrelin and LEAP-2 concentrations before than after refeeding (p = 0.043). After 6 months follow-up, patients with unstable weight gain (n = 17) had significantly decreased LEAP-2 concentrations after refeeding (p = 0.044), in contrast to patients with stable weight gain (n = 12). We provide evidence that the ghrelin/LEAP-2 system is not regulated according to the nutritional status in AN, in contrast to what is physiologically expected when coping with food restriction.

Cocaine intake correlates with risk-taking behavior and affects estrous cycling in female Sprague-Dawley rats

Navigating complex decisions and considering their relative risks and rewards is an important cognitive ability necessary for survival. However, use of and dependence on illicit drugs can result in long-lasting changes to this risk/reward calculus in individuals with substance use disorder. Recent work has shown that chronic exposure to cocaine causes long-lasting increases in risk taking in male and female rats, but there are still significant gaps in our understanding of the relationship between cocaine use and changes in risk taking. For example, it is unclear whether the magnitude of cocaine intake dictates the extent to which risk taking is altered. To address this, male and female Sprague-Dawley rats underwent cocaine (or sucrose) self-administration and, following a period of abstinence, were trained and tested in a rodent model of risky decision making. In this behavioral task, rats made discrete-trial choices between a lever associated with a small food reward (i.e., "safe" option) and a lever associated with a larger food reward accompanied by a variable risk of footshock delivery (i.e., "risky" option). Surprisingly, and in contrast to prior work in Long-Evans rats, there were no effects of cocaine self-administration on choice of the large, risky reward (i.e., risk taking) during abstinence in males or females. There was, however, a significant relationship between cocaine intake and risk taking in female rats, with greater intake associated with greater preference for the large, risky reward. Relative to their sucrose counterparts, female rats in the cocaine group also exhibited irregular estrous cycles, characterized by prolonged estrus and/or diestrus phases. Collectively, these data suggest that there may be strain differences in the effects of cocaine on risk taking and highlight the impact that chronic cocaine exposure has on hormonal cyclicity in females. Future work will focus on understanding the neural mechanisms underlying cocaine's intake-dependent effects on risk taking in females, and whether this is directly related to cocaine-induced alterations in neuroendocrine function.

Mouse-cursor trajectories reveal reduced contextual influence on decision conflict during delay discounting in anorexia nervosa

OBJECTIVE

The capacity of individuals with anorexia nervosa (AN) to forgo immediate food rewards in their long-term pursuit of thinness is thought to reflect elevated self-control and/or abnormal reward sensitivity. Prior research attempted to capture an increased tendency to delay gratification in AN using delay-discounting tasks that assess how rapidly the subjective value of rewards decreases as a function of time until receipt. However, significant effects were mostly subtle or absent. Here, we tested whether the process leading to such decisions might be altered in AN.

METHOD

We recorded mouse-cursor movement trajectories leading to the final choice in a computerized delay-discounting task (238 trials) in 55 acutely underweight females with AN and pairwise age-matched female healthy controls (HC). We tested for group differences in deviations from a direct choice path, a measure of conflict strength in decision making, and whether group moderated the effect of several predictors of conflict strength (e.g., choice difficulty, consistency). We also explored reaction times and changes in trajectory directions (X-flips).

RESULTS

No group differences in delay-discounting parameters or movement trajectories were detected. However, the effect of the aforementioned predictors on deviations (and to a lesser extent reaction times) was reduced in AN.

DISCUSSION

These findings suggest that while delay discounting and conflict strength in decision making are generally unaltered in AN, conflict strength was more stable across different decisions in the disorder. This might enable individuals with AN to pursue (maladaptive) long-term body-weight goals, because particularly conflicting choices may not be experienced as such.

PUBLIC SIGNIFICANCE

The deviations from a direct path of mouse-cursor movements during a computerized delay-discounting task varied less in people with anorexia nervosa. Assuming such deviations measure decision conflict, we speculate that this increased stability might help people with anorexia nervosa achieve their long-term weight goals, as for them the struggle with the decision to eat high-calorie meals when hungry will be milder, so they would be more likely to skip them.

Sex-dependent clinical presentation, body image, and endocrine status in long-term remitted anorexia nervosa

OBJECTIVE

Although anorexia nervosa (AN) in males has recently gained attention, knowledge of its psychological and physiological outcomes is still scarce. We explore sex-specific characteristics of long-term remitted AN with respect to residual eating disorder (ED) psychopathology, body image, and endocrinology.

METHOD

We recruited 33 patients with AN in remission for at least 18 months (24 women, 9 men) and 36 matched healthy controls (HCs). Eating disorder psychopathology and body image ideals were assessed via clinical interviews, questionnaires, and an interactive 3D body morphing tool. Plasma levels of leptin, free triiodothyronine, cortisol, and sex hormones were quantified. Univariate models controlled for age and weight were used to test for the effects of diagnosis and sex.

RESULTS

Both patient groups showed residual ED psychopathology but normal weight and hormone levels relative to HCs. Male remitted patients demonstrated significantly stronger muscularity-focused body image ideals, evident in interviews, self-reports, and behavioural data, than both female patients and HCs.

CONCLUSIONS

Sex-specific body image characteristics in patients with remitted AN point towards the need to adjust test instruments and diagnostic criteria to male-specific psychopathology. In the future, sufficiently powered studies should evaluate the risk of men with AN developing muscle dysmorphia in the long term.

Aberrant reward-related neural activation: Dimensional correlate of binge-eating severity or categorical marker of binge eating?

Binge eating (BE) is characterized by consuming an objectively large amount of food in a short period of time and experiencing loss of control over one's eating. The neural underpinnings of monetary reward anticipation and their association with BE severity remain poorly understood. Fifty-nine women aged 18 to 35 (M = 25.67, SD = 5.11) with a range of average weekly BE frequency (M = 1.96, SD = 1.89, range = 0-7) completed the Monetary Incentive Delay Task during fMRI scanning. Mean percent signal change within the left and right nucleus accumbens (NAc) during anticipation of monetary gain (versus non-gain) was extracted from a priori-defined functional 5 mm spheres and correlated with average weekly BE frequency. Exploratory voxel-wise whole-brain analyses examined the association between neural activation during anticipation of monetary reward and average weekly BE frequency. Body mass index and depression severity were covariates of non-interest in analyses. Mean percent signal change in the left and right NAc inversely correlated with average weekly BE frequency. Whole-brain analysis revealed no significant associations between neural activation during reward anticipation and average weekly BE frequency. In exploratory case-control analyses, mean percent signal change in the right NAc was significantly lower in women with BE (n = 41) versus women without BE (n = 18), but whole-brain analyses revealed no significant group differences in neural activation during reward anticipation. Decreased right NAc activity during monetary reward anticipation may distinguish women with and without BE.

Cognitive mechanisms underlying decision making involving risk of explicit punishment in male and female rats

Individuals engage in the process of risk-based decision making on a daily basis to navigate various aspects of life. There are, however, individual differences in this form of decision making, with some individuals exhibiting preference for riskier choices (risk taking) and others exhibiting preference for safer choices (risk aversion). Recent work has shown that extremes in risk taking (e.g., excessive risk taking or risk aversion) are not only cognitive features of neuropsychiatric diseases, but may in fact predispose individuals to the development of such diseases. To better understand individual differences in risk taking, and thus the mechanisms by which they confer disease vulnerability, the current study investigated the cognitive contributions to risk taking in both males and females. Rats were first behaviorally characterized in a decision-making task involving risk of footshock punishment and then tested on a battery of cognitive behavioral assays. Individual variability in risk taking was compared with performance on these tasks. Consistent with prior work, females were more risk averse than males. With the exception of the Set-shifting Task, there were no sex differences in performance on other cognitive assays. There were, however, sex-dependent associations between risk taking and specific cognitive measures. Greater risk taking was associated with better cognitive flexibility in males whereas greater risk aversion was associated with better working memory in females. Collectively, these findings reveal that distinct cognitive mechanisms are associated with risk taking in males and females, which may account for sex differences in this form of decision making.

Brain reward response in adolescents and young adults with anorexia nervosa is moderated by changes in body weight and sweetness perception

OBJECTIVE

Anorexia nervosa (AN) is a severe psychiatric illness with complex etiology. Recently, we found elevated striatal brain response to sweet taste stimuli in adolescents and young adults with AN. Here, we tested the hypothesis that nutritional rehabilitation normalizes prediction error activation, a measure for dopamine-related reward circuit response, to salient caloric taste stimuli in AN.

METHODS

A total of 28 individuals with AN (age = 16 ± 2 years; body mass index [BMI] = 16 ± 1) who previously underwent brain imaging while performing a taste prediction error task using sucrose as salient caloric stimulus, participated in a second brain imaging scan (BMI = 18 ± 1) after intensive specialized eating disorder treatment (41 ± 15 days). A total of 31 healthy controls (age = 16 ± 3 years; BMI = 21 ± 2) were also studied on two occasions.

RESULTS

At baseline, individuals with AN demonstrated an elevated salience response in bilateral caudate head and nucleus accumbens, and right ventral striatum. At the second scan, elevated response was only found in the right nucleus accumbens. A moderator analysis indicated that greater increase in BMI and greater decrease in sweetness perception predicted lesser prediction error response at the second scan in AN.

CONCLUSION

Consistent with the previously reported monetary stimulus-response, elevated taste prediction error response in AN was largely absent after weight restoration. This study indicates that changes in BMI and sweet taste perception are independent moderators of change of brain salience response in adolescents and young adults with AN. The study points toward dynamic changes in the brain reward circuitry in AN and highlights the importance of nutrition and weight restoration in that process.

PUBLIC SIGNIFICANCE STATEMENT

AN is a severe psychiatric illness. Biological factors that integrate neurobiology and behavior could become important targets to improve treatment outcome. This study highlights the importance of weight normalization and taste perception the normalization of brain function, and food type or taste-specific interventions could help in the recovery process. Furthermore, the study suggests that food-related and nonfood-related reward processing adapts to illness state in AN.

Methodological considerations for ghrelin isoforms assay in clinical evaluation in anorexia nervosa

The growing interest concerning the role of metabolic sensors in various eating disorders requires the implementation of a strict methodology to collect, store and process blood samples in clinical studies. In particular, measurement of isoforms of the appetite-stimulating hormone, ghrelin, has been challenging in clinical settings. Indeed the acyl ghrelin (AG) isoform is rapidly degraded into desacyl ghrelin (DAG) by blood esterases, thus optimal conditions for the conservation of AG and accurate determination of AG/DAG ratio should be used. Here, we compared different protease inhibitors (Aprotinin, PHMB, AEBSF) during blood collection, increasing delays (0–180 min) before centrifugation, plasma supplementation with various HCl concentrations, storage durations of frozen plasma (8 and 447 days) and immunoenzyme-assay procedures (one-step versus sequential) in healthy subjects. Optimal conditions were obtained by collecting blood with aprotinin and supplementation of plasma with 0.1 N HCl with subsequent freezing for at least 8 days and using one-step assay. Under such conditions, different patterns of secretion of ghrelin isoforms were characterized in patients with restrictive-type anorexia nervosa (AN-R) before and after nutritional recovery. We illustrate the pulsatile variations of ghrelin isoforms according to the time around a meal and hunger rates in 3 patients with AN-R. This study offers a comprehensive comparison of various conditions using selective and specific immunoassays for both ghrelin isoforms in order to optimize assay sensitivity and consistency among procedures. These assay conditions could therefore be widely used to elucidate precisely the role of ghrelin isoforms on eating behavior in physiological and pathological situations.

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Treatment conditions and assay procedures are critical for ghrelin isoforms level determination in plasma.

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Specific treatment conditions allow long term stability of ghrelin isoforms.

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HCl supplementation of plasma before freezing improves AG/DAG ratio on the short and long term.

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Variations of ghrelin isoforms occur with meal timing and chronic nutritional status in patients with anorexia nervosa.

Increased self-reported delay of gratification in acutely underweight, but not remitted anorexia nervosa

OBJECTIVE

Laboratory experiments using delay discounting tasks have delivered some evidence of an increased capacity to delay reward in anorexia nervosa (AN). Overall, however, findings have been inconclusive and no comprehensive studies of self-reported tendency to forgo immediate gratification in favor of long-term rewards exist in AN.

METHOD

A total of 71 acutely underweight female inpatients with AN (acAN); 52 women long-term weight-recovered from AN (recAN); and 120 healthy control women completed the Delaying Gratification Inventory (DGI). Fifty-two acAN were reassessed after short-term weight rehabilitation. Separate cross-sectional and longitudinal group comparisons tested for differences in DGI subscales (food, physical pleasure, social interaction, money, and achievement) and total scores.

RESULTS

DGI scores were elevated in acAN even after removing food-related items and accounting for comorbid symptoms. DGI scores remained relatively elevated following short-term weight rehabilitation, but no differences were evident between recAN and HC.

DISCUSSION

This study delivers self-report evidence supporting the notion of an increased propensity to delay gratification in individuals acutely ill with AN which does not appear to change with partial weight restoration alone. A reduction in the tendency to delay reward may thus be an important cognitive correlate of long-term recovery in AN.

A review of effort-based decision-making in eating and weight disorders

Effort-based decision-making provides a framework to understand the mental computations estimating the amount of work ("effort") required to obtain a reward. The aim of the current review is to systematically synthesize the available literature on effort-based decision-making across the spectrum of eating and weight disorders. More specifically, the current review summarises the literature examining whether 1) individuals with eating disorders and overweight/obesity are willing to expend more effort for rewards compared to healthy controls, 2) if particular components of effort-based decision-making (i.e. risk, discounting) relate to specific binge eating conditions, and 3) how individual differences in effort and reward -processing measures relate to eating pathology and treatment measures. A total of 96 studies were included in our review, following PRISMA guidelines. The review suggests that individuals with binge eating behaviours 1) are more likely to expend greater effort for food rewards, but not monetary rewards, 2) demonstrate greater decision-making impairments under risk and uncertainty, 3) prefer sooner rather than delayed rewards for both food and money, and 4) demonstrate increased implicit 'wanting' for high fat sweet foods. Finally, individual differences in effort and reward -processing measures relating to eating pathology and treatment measures are also discussed.

From Desire to Dread-A Neurocircuitry Based Model for Food Avoidance in Anorexia Nervosa

Anorexia nervosa is a severe psychiatric illness associated with food avoidance. Animal models from Berridge et al. over the past decade showed that environmental ambience, pleasant or fear inducing, can trigger either appetitive (desire) or avoidance (dread) behaviors in animals via frontal cortex, nucleus accumbens dopamine D1 and D2 receptors, and hypothalamus. Those mechanisms could be relevant for understanding anorexia nervosa. However, models that translate animal research to explain the psychopathology of anorexia nervosa are sparse. This article reviews animal and human research to find evidence for whether this model can explain food avoidance behaviors in anorexia nervosa. Research on anorexia nervosa suggests fear conditioning to food, activation of the corticostriatal brain circuitry, sensitization of ventral striatal dopamine response, and alterations in hypothalamic function. The results support the applicability of the animal neurocircuitry derived model and provide directions to further study the pathophysiology that underlies anorexia nervosa.

A Systematic Review and Meta-Analysis Finds Increased Blood Levels of All Forms of Ghrelin in Both Restricting and Binge-Eating/Purging Subtypes of Anorexia Nervosa

Anorexia nervosa (AN) is a severe psychiatric condition associated with high mortality and chronicity. The hunt for state, trait, subtyping, and prognostic biomarkers is ongoing and the orexigenic hormone ghrelin and its different forms, acyl ghrelin and desacyl ghrelin, have been proposed to be increased in AN, especially in the restrictive subtype. A systematic literature search was performed using established databases up to 30 November 2020. Forty-nine studies met inclusion criteria for cross-sectional and longitudinal meta-analyses on total ghrelin, acyl ghrelin, and desacyl ghrelin. All forms of ghrelin were increased in the acute stage of anorexia nervosa during fasting compared to healthy controls. Previous notions on differences in ghrelin levels between AN subtypes were not supported by current data. In addition, a significant decrease in total ghrelin was observed pre-treatment to follow-up. However, total ghrelin levels at follow-up were still marginally elevated compared to healthy controls, whereas for acyl ghrelin, no overall effect of treatment was observed. Due to heterogeneity in follow-up designs and only few data on long-term recovered patients, longitudinal results should be interpreted with caution. While the first steps towards a biomarker in acute AN have been completed, the value of ghrelin as a potential indicator of treatment success or recovery status or its use in subtype differentiation are yet to be established.

DNA methylation of ghrelin and leptin receptors in underweight and recovered patients with anorexia nervosa

Epigenetic mechanisms, which modulate gene expression, are becoming increasingly important in the research on anorexia nervosa (AN). Patients with AN have difficulties with the perception of hunger even though hormones like high ghrelin and low leptin signal the need for energy intake. Given the prominent role of the growth hormone secretagogue receptor (GHS-R1a) and the leptin receptor (LEPR) in appetite regulation, a dysregulation of the receptors' expression levels, possibly resulting from altered DNA promoter methylation, may contribute to the pathophysiology of AN. Such alterations could be secondary effects of undernutrition (state markers) or biological processes that may play an antecedent, possibly causal, role in the pathophysiology (trait markers). Therefore, the objective of this study was to examine DNA promoter methylation of the GHS-R1a and LEPR gene promoter regions and investigate whether methylation levels are associated with AN symptoms. We studied medication-free underweight patients with acute AN as well as weight-recovered patients and normal-weight, healthy female control subjects. While DNA methylation of the LEPR gene was similar across groups, GHS-R1a promoter methylation was increased in underweight AN compared to healthy controls - a finding which can be interpreted within the framework of the "ghrelin-resistance" hypothesis in AN. The results of the current study suggest for the first time a potential epigenetic mechanism underlying altered GHS-R1a sensitivity or altered ghrelin signaling in acutely underweight AN. If a ghrelin-centered model of AN can be verified, a next step could be the search for a dietary or psychopharmacological modulation at the ghrelin receptor, potentially via epigenetic mechanisms.

Study protocol of comprehensive risk evaluation for anorexia nervosa in twins (CREAT): a study of discordant monozygotic twins with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a severe disorder, for which genetic evidence suggests psychiatric as well as metabolic origins. AN has high somatic and psychiatric comorbidities, broad impact on quality of life, and elevated mortality. Risk factor studies of AN have focused on differences between acutely ill and recovered individuals. Such comparisons often yield ambiguous conclusions, as alterations could reflect different effects depending on the comparison. Whereas differences found in acutely ill patients could reflect state effects that are due to acute starvation or acute disease-specific factors, they could also reflect underlying traits. Observations in recovered individuals could reflect either an underlying trait or a "scar" due to lasting effects of sustained undernutrition and illness. The co-twin control design (i.e., monozygotic [MZ] twins who are discordant for AN and MZ concordant control twin pairs) affords at least partial disambiguation of these effects.

METHODS

Comprehensive Risk Evaluation for Anorexia nervosa in Twins (CREAT) will be the largest and most comprehensive investigation of twins who are discordant for AN to date. CREAT utilizes a co-twin control design that includes endocrinological, neurocognitive, neuroimaging, genomic, and multi-omic approaches coupled with an experimental component that explores the impact of an overnight fast on most measured parameters.

DISCUSSION

The multimodal longitudinal twin assessment of the CREAT study will help to disambiguate state, trait, and "scar" effects, and thereby enable a deeper understanding of the contribution of genetics, epigenetics, cognitive functions, brain structure and function, metabolism, endocrinology, microbiology, and immunology to the etiology and maintenance of AN.