Eating Disorders, Autoimmune, and Autoinflammatory Disease

Identification of State Markers in Anorexia Nervosa: Replication and Extension of Inflammation-Associated Biomarkers Using Multiplex Profiling

Background

Proteomics offers potential for detecting and monitoring anorexia nervosa (AN) and its variant, atypical AN (atyp-AN). However, research has been limited by small protein panels, a focus on adult AN, and lack of replication.

Methods

In this study, we performed Olink multiplex profiling of 92 inflammation-related proteins in females with AN/atyp-AN (n = 64), all of whom were ≤90% of expected body weight, and age-matched healthy control individuals (n = 44).

Results

Five proteins differed significantly between the primary AN/atyp-AN group and the healthy control group (lower levels: HGF, IL-18R1, TRANCE; higher levels: CCL23, LIF-R). The expression levels of 3 proteins (lower IL-18R1, TRANCE; higher LIF-R) were uniquely disrupted in participants with AN in our primary model. No unique expression levels emerged for atyp-AN. In the total sample, 12 proteins (ADA, CD5, CD6, CXCL1, FGF-21, HGF, IL-12B, IL18, IL-18R1, SIRT2, TNFSF14, TRANCE) were positively correlated with body mass index and 5 proteins (CCL11, FGF-19, IL8, LIF-R, OPG) were negatively correlated with body mass index in our primary models.

Conclusions

Our results replicate the results of a previous study that demonstrated a dysregulated inflammatory status in AN and extend those results to atyp-AN. Of the 17 proteins correlated with body mass index, 11 were replicated from a previous study that used similar methods, highlighting the promise of inflammatory protein expression levels as biomarkers of AN disease monitoring. Our findings underscore the complexity of AN and atyp-AN by highlighting the inability of the identified proteins to differentiate between these 2 subtypes, thereby emphasizing the heterogeneous nature of these disorders.

Cerebrospinal fluid characteristics of patients presenting for evaluation of pediatric acute-neuropsychiatric syndrome

Objectives

This study characterizes cerebral spinal fluid (CSF) indices including total protein, the albumin quotient, IgG index and oligoclonal bands in patients followed at a single center for pediatric acute-neuropsychiatric syndrome (PANS) and other psychiatric/behavioral deteriorations.

Methods

In a retrospective chart review of 471 consecutive subjects evaluated for PANS at a single center, navigational keyword search of the electronic medical record was used to identify patients who underwent lumbar puncture (LP) as part of the evaluation of a severe or atypical psychiatric deterioration. Psychiatric symptom data was ascertained from parent questionnaires and clinical psychiatric evaluations. Inclusion criteria required that subjects presented with psychiatric deterioration at the time of first clinical visit and had a lumbar puncture completed as part of their evaluation. Subjects were categorized into three subgroups based on diagnosis: PANS (acute-onset of severe obsessive compulsive disorder (OCD) and/or eating restriction plus two other neuropsychiatric symptoms), autoimmune encephalitis (AE), and "other neuropsychiatric deterioration" (subacute onset of severe OCD, eating restriction, behavioral regression, psychosis, etc; not meeting criteria for PANS or AE).

Results

71/471 (15.0 %) of patients underwent LP. At least one CSF abnormality was seen in 29% of patients with PANS, 45% of patients with "other neuropsychiatric deterioration", and 40% of patients who met criteria for autoimmune encephalitis. The most common findings included elevated CSF protein and/or albumin quotient. Elevated IgG index and IgG oligoclonal bands were rare in all three groups.

Conclusion

Elevation of CSF protein and albumin quotient were found in pediatric patients undergoing LP for evaluation of severe psychiatric deteriorations (PANS, AE, and other neuropsychiatric deteriorations). Further studies are warranted to investigate blood brain barrier integrity at the onset of the neuropsychiatric deterioration and explore inflammatory mechanisms.

Examining the Genetic Links between Clusters of Immune-mediated Diseases and Psychiatric Disorders

Importance

Autoimmune and autoinflammatory diseases have been linked to psychiatric disorders in the phenotypic and genetic literature. However, a comprehensive model that investigates the association between a broad range of psychiatric disorders and immune-mediated disease in a multivariate framework is lacking.

Objective

This study aims to establish a factor structure based on the genetic correlations of immune-mediated diseases and investigate their genetic relationships with clusters of psychiatric disorders.

Design Setting and Participants

We utilized Genomic Structural Equation Modeling (Genomic SEM) to establish a factor structure of 11 immune-mediated diseases. Genetic correlations between these immune factors were examined with five established factors across 13 psychiatric disorders representing compulsive, schizophrenia/bipolar, neurodevelopmental, internalizing, and substance use disorders. We included GWAS summary statistics of individuals of European ancestry with sample sizes from 1,223 cases for Addison's disease to 170,756 cases for major depressive disorder.

Main Outcomes and Measures

Genetic correlations between psychiatric and immune-mediated disease factors and traits to determine genetic overlap. We develop and validate a new heterogeneity metric, Q Factor , that quantifies the degree to which factor correlations are driven by more specific pairwise associations. We also estimate residual genetic correlations between pairs of psychiatric disorders and immune-mediated diseases.

Results

A four-factor model of immune-mediated diseases fit the data well and described a continuum from autoimmune to autoinflammatory diseases. The four factors reflected autoimmune, celiac, mixed pattern, and autoinflammatory diseases. Analyses revealed seven significant factor correlations between the immune and psychiatric factors, including autoimmune and mixed pattern diseases with the internalizing and substance use factors, and autoinflammatory diseases with the compulsive, schizophrenia/bipolar, and internalizing factors. Additionally, we find evidence of divergence in associations within factors as indicated by Q Factor . This is further supported by 14 significant residual genetic correlations between individual psychiatric disorders and immune-mediated diseases.

Conclusion and Relevance

Our results revealed genetic links between clusters of immune-mediated diseases and psychiatric disorders. Current analyses indicate that previously described relationships between specific psychiatric disorders and immune-mediated diseases often capture broader pathways of risk sharing indexed by our genomic factors, yet are more specific than a general association across all psychiatric disorders and immune-mediated diseases.

Clinical characterization of Co-morbid autoimmune disease and eating disorders: a retrospective chart review

Research suggests a link between autoimmune illnesses (AI) and eating disorders (ED). We retrospectively reviewed charts of adolescent patients presenting for eating disorder treatment. We compared the presentation and treatment course for those with an ED and comorbid AI [with (GI-AI, N = 59) or without (non-GI, N = 21) gastrointestinal inflammation] with matched ED-only cases. The sample was overwhelmingly female, with an average age of 15.40. Weight gain trajectories differed across groups, with similar rates of weight gain between controls and non GI-AI cases and with a lower rate of weight gain for individuals with comorbid GI-AI. Over half (56%) of patients reported an AI diagnosis prior to ED; 38% reported an AI diagnosis following ED, and 6% reported ED and AI simultaneous diagnosis. On presentation, ED-only controls had higher rates of comorbid anxiety than cases in either AI group, while those with non-GI AI were more likely to report depression. Mean total GI symptoms, % goal weight at presentation, vital sign instability, and markers of refeeding syndrome did not differ across groups. Health care professionals treating patients with either condition should have a low threshold for asking additional questions to identify the presence of the other condition.

Elevated interleukin-6 in women with binge-eating spectrum disorders

OBJECTIVE

Binge-eating spectrum disorders (BESD) involve large eating episodes accompanied by a sense of loss of control that occur in individuals with body weights spanning the full body mass index (BMI) spectrum. While research links BESD with peripheral inflammation, this literature is limited by underpowered studies and a failure to control for confounding variables that could promote inflammation independent of dysregulated eating, specifically elevated body adiposity and depression. Our study examined plasma interleukin-6 (IL-6), a marker of peripheral inflammation, in a sample of women with BESD and non-eating disorder controls, controlling for BMI, body adiposity, and depression.

METHOD

Participants (N = 94) included women with BESD (n = 73) or no eating disorder (n = 21) who completed structured clinical interviews in a larger study, selected to represent BMI categories ranging from underweight to obese in both groups. Fasting blood samples were processed for plasma IL-6 concentration via enzyme-linked immunosorbent assays. In addition to assessing group differences in plasma IL-6, exploratory analyses examined associations between IL-6 and biological and clinical markers of BESD.

RESULTS

Significantly elevated plasma IL-6 was found in women with BESD, relative to controls, that was not accounted for by BMI, adiposity, or depression. Plasma IL-6 was positively correlated with plasma leptin concentration, clinical assessments of eating disorder severity, and participants' largest self-reported eating episode.

DISCUSSION

Peripheral inflammation is specifically linked to presence of dysregulated eating independently from weight, adiposity, and depression in BESD. Future research should probe the potential role of neuroinflammation in altered eating behavior.

PUBLIC SIGNIFICANCE

This study provides the first demonstration that inflammation, characterized by elevated plasma IL-6 concentration, is uniquely associated with dysregulated eating in a transdiagnostic group of individuals with BESD. A better understanding of whether immune factors contribute to dysregulated eating could help identify novel biological targets for intervention.

Celiac Disease and Inflammatory Bowel Disease Are Associated With Increased Risk of Eating Disorders: An Ontario Health Administrative Database Study

INTRODUCTION

Previous national registry studies have reported an increased risk of eating disorders in immune-mediated conditions (inflammatory bowel disease and celiac disease). Our objective was to examine the association between immune-mediated gastrointestinal (GI) diseases and incident eating disorders in Ontario.

METHODS

This was a retrospective matched cohort study of individuals <50 years of age with a diagnosis of an immune-mediated GI disease between 2002 and 2020 ("cases"). Those with a pre-existing eating disorder were excluded. Cases (n = 83,920) were matched with controls (n = 167,776) based on birth year, sex, and region of residence. Incidence rate ratio and hazard ratio were estimated using Poisson regression model and adjusted Cox proportional models, respectively.

RESULTS

Over the follow-up period (up to January 31, 2022), 161 cases and 160 controls were identified with eating disorders. The overall incidence rate ratio (95% confidence interval, P -value) of eating disorders in immune-mediated GI disease was 1.99 (1.6-2.5, P < 0.001). The adjusted hazard ratio for eating disorder in cases with immune-mediated GI diseases was 1.98 (1.6-2.5, P < 0.001). In the pediatric group of incident cases (≤18 years of age), overall adjusted hazard ratio was 2.62 (1.9-3.7, P < 0.001) compared with 1.56 (1.02-2.4, P = 0.041) for adults (>18 years of age). The largest hazard ratio of 4.11 (1.6-10.3, P = 0.003) was observed for pediatric incident cases of ulcerative colitis.

DISCUSSION

Inflammatory bowel disease and celiac disease are associated with the development of eating disorders. The magnitude of the association was stronger in the pediatric age group, underscoring the need for early screening and detection.

Dissecting the biology of feeding and eating disorders

Feeding and eating disorders (FEDs) are heterogenous and characterized by varying patterns of dysregulated eating and weight. Genome-wide association studies (GWASs) are clarifying their underlying biology and their genetic relationship to other psychiatric and metabolic/anthropometric traits. Genetic research on anorexia nervosa (AN) has identified eight significant loci and uncovered genetic correlations implicating both psychiatric and metabolic/anthropometric risk factors. Careful explication of these metabolic contributors may be key to developing effective and enduring treatments for devastating, life-altering, and frequently lethal illnesses. We discuss clinical phenomenology, genomics, phenomics, intestinal microbiota, and functional genomics and propose a path that translates variants to genes, genes to pathways, and pathways to metabolic outcomes to advance the science and eventually treatment of FEDs.

Mental and physical health in children of women with a history of anorexia nervosa

Few studies have investigated the offspring of women with anorexia nervosa (AN). The aim of this study was to examine perinatal status, mental and physical health in the offspring of mothers with a history of AN. Fifty-one individuals with adolescent-onset AN and 51 matched controls (COMP) have been followed prospectively. Presently, 30 years after AN onset, at a mean age of 44 years, female participants who had given birth (nAN = 40, nCOMP = 40) were interviewed regarding psychiatric health in their offspring using the Developmental and Well-Being Assessment and the MINI International Neuropsychiatric Interview. In addition, information on the offspring's perinatal status, psychiatric- and physical health was obtained from the Swedish Medical Birth Register and The Swedish National Patient Register. Data regarding mental and physical health were available for 83 and 86 offspring in the AN and COMP groups, respectively. At birth, all of weight, length, head circumference and ponderal index were significantly reduced in the offspring of mothers with a history of AN. In adolescence, parental interviews indicated an overrepresentation of current psychiatric diagnoses in the offspring of mothers with AN. Compared with the offspring in the COMP group, endocrinological, immune and metabolic disorders were much more common in the offspring of the AN group. In conclusion, a history of AN increases the risk of worse perinatal outcome of the offspring. Later on, in childhood and adolescence, psychiatric and physical morbidity may be overrepresented in the offspring of women with AN.

The importance of factors early in life for development of eating disorders in young people, with some focus on type 1 diabetes

AIM

Eating disorders have a serious impact on quality of life, especially when combined with Type 1 diabetes. We investigated eating disorders in relation to factors early in life with some focus on Type 1 diabetes.

METHODS

Out of 21,700 children born 1st of Oct 1997-1st of Oct 1999 17,055 (78.6%) were included in ABIS (All Babies in southeast Sweden) and 16,415 had adequate questionnaires. ICD-10 diagnosis from The National Patient Register was merged with the ABIS data.

RESULTS

In total 247 individuals, 19 boys (7.7%) and 219 girls (92.3%) out of 16,415 (1.5%) developed eating disorders (EDs), 167 (1.0%) Type 1 diabetes of whom 7 (4.2%) also got eating disorders (ED) (OR 3.25 (1.47-7.28); p = 0.04), all of them years after diagnosis of Type 1 diabetes. EDs was associated with high parental education especially in fathers (OR 1.65 (1.09-2.50); p = 0.02) and to at birth anxiety, and depression among mothers. There was no association with the duration of breastfeeding.

CONCLUSIONS

Eating disorders are common in girls, with increased risk in high-educated but psychologically vulnerable families. Prevalence is increased in type 1 diabetes. Even modern diabetes treatment needs to be completed with psychological support.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Anorexia Nervosa in vivo cytokine production: a systematic review

INTRODUCTION

The underlying psychobiology that contributes to Anorexia Nervosa (AN) onset and disease progression remains unclear. New research is emerging suggesting a possible link between inflammation and a variety of mental illnesses. Alterations of cytokines may play a role in the pathogenesis of AN. Some studies have found differences in the cytokine profile of those with AN compared to healthy controls, but results are heterogeneous. The aim of this work was to systematically review existing studies investigating in-vivo cytokine production in those with AN before and after weight restoration compared to controls.

METHODS

A comprehensive literature search of four electronic databases (PubMed, PsychInfo, EMBASE and CINAH) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify human in-vivo studies investigating the relationship between AN and cytokine production. Data extracted from included studies related to population characteristics (e.g. age, gender, mean mBMI/%IBW), cytokine measurement and relevant findings. Confounding factors (e.g. smoking status, co-morbid mental illness, menstruation status) were also collected.

RESULTS

36 studies were eligible for this systematic review of which the majority were conducted in Europe (77.8%) and involved female subjects (97.2%). Those with AN ranged in age from 13 to 47 years and had an illness duration of 3 months to 24 years. 15 candidate cytokines and 3 receptors were identified (TNF-alpha, IL-6, IL-1B, CRP, IL-2, IL-7, IL-10, IFN-γ, TNF-R2, IL-1 α, IL-15, TNF-R1, IL-17, IL-18, TGF-B1, IL-12, IL-6R and TGF-B2) exploring in-vivo levels in patients with AN and comparing to controls. TNF-alpha and IL-6 were the most extensively studied with IL-6 being significantly elevated in 4 out of 8 (50%) of longitudinal studies when comparing AN patients at baseline compared to post weight restoration. Following weight restoration, there was no difference in IL-6 levels when comparing to HC in 7 of 8 (87.5%) longitudinal studies examined.

CONCLUSIONS

The most promising cytokine potentially involved in the pathogenesis of AN appears to be IL-6, and possibly TNF-alpha pathways. The heterogeneity of clinical and methodology factors impedes the generalizability of results. Future studies may wish to address these methodological shortcomings as alterations in cytokine levels in AN could act as therapeutic targets assisting with weight restoration and psychopathology and may offer diagnostic potential.

Exposures during pregnancy and at birth are associated with the risk of offspring eating disorders

BACKGROUND

Eating disorders (ED) are severe psychiatric disorders, commonly debuting early. Aberrances in the intrauterine environment and at birth have been associated with risk of ED. Here, we explore if, and at what effect size, a variety of such exposures associate with offspring ED, that is, anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS).

METHODS

This population-based cohort study, conducted from September 2021 to August 2023, used Finnish national registries of all live births in 1996-2014 (N = 1,097,753). Cox proportional hazards modeling was used to compare ED risk in exposed versus unexposed offspring, adjusting for potential confounders and performing sex-stratified analyses.

RESULTS

A total of 6614 offspring were diagnosed with an ED; 3668 AN, 666 BN, and 4248 EDNOS. Lower risk of offspring AN was seen with young mothers, continued smoking, and instrumental delivery, while higher risk was seen with older mothers, inflammatory disorders, prematurity, small for gestational age, and low Apgar. Offspring risk of BN was higher with continued smoking and prematurity, while lower with postmature birth. Offspring risk of EDNOS was lower with instrumental delivery, higher for older mothers, polycystic ovary syndrome, insulin-treated pregestational diabetes, antibacterial treatment, prematurity, and small for gestational age. Sex-specific associations were found.

CONCLUSIONS

Several prenatal and at birth exposures are associated with offspring ED; however, we cannot exclude confounding by maternal BMI. Nevertheless, several exposures selectively associate with risk of either AN, BN, or EDNOS, and some are sex-specific, emphasizing the importance of subtype- and sex-stratified analyses of ED.

PUBLIC SIGNIFICANCE

We define environmental factors involved in the development of different ED, of importance as preventive measure, but also in order to aid in defining the molecular pathways involved and thus in the longer perspective contribute to the development of pharmacological treatment of ED.

Ankylosing spondylitis and psychiatric disorders in European population: a Mendelian randomization study

Background

Epidemiologic evidence has demonstrated a correlation between ankylosing spondylitis and psychiatric disorders. However, little is known about the common genetics and causality of this association. This study aimed to investigate the common genetics and causality between ankylosing spondylitis (AS) and psychiatric disorders.

Methods

A two-sample Mendelian Randomization (MR) analysis was carried out to confirm causal relationships between ankylosing spondylitis and five mental health conditions including major depressive disorder (MDD), anxiety disorder (AXD), schizophrenia (SCZ), bipolar disorder (BIP), and anorexia nervosa (AN). Genetic instrumental variables associated with exposures and outcomes were derived from the largest available summary statistics of genome-wide association studies (GWAS). Bidirectional causal estimation of MR was primarily obtained using the inverse variance weighting (IVW) method. Other MR methods include MR-Egger regression, Weighted Median Estimator (WME), Weighted Mode, Simple Mode, and Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO). Sensitivity analyses are conducted to estimate the robustness of MR results.

Results

The findings suggest that AS may be causally responsible for the risk of developing SCZ (OR = 1.18, 95% confidence interval = (1.06, 1.31), P = 2.58 × 10-3) and AN (OR = 1.32, 95% confidence interval = (1.07, 1.64), P = 9.43 × 10-3). In addition, MDD, AXD, SCZ, AN, and BIP were not inversely causally related to AS (all p > 0.05).

Conclusion

Our study provides fresh insights into the relationship between AS and psychiatric disorders (SCZ and AN). Furthermore, it may provide new clues for risk management and preventive interventions for mental disorders in patients with AS.

Identification of State Markers in Anorexia Nervosa: Replication and Extension of Inflammation Associated Biomarkers Using Multiplex Profiling in Anorexia Nervosa and Atypical Anorexia Nervosa

Proteomics provides an opportunity for detection and monitoring of anorexia nervosa (AN) and its related variant, atypical-AN (atyp-AN). However, research to date has been limited by the small number of proteins explored, exclusive focus on adults with AN, and lack of replication across studies. This study performed Olink Proseek Multiplex profiling of 92 proteins involved in inflammation among females with AN and atyp-AN (N = 64), all < 90% of expected body weight, and age-matched healthy controls (HC; N=44). After correction for multiple testing, nine proteins differed significantly in the AN/atyp-AN group relative to HC group ( lower levels: CXCL1, HGF, IL-18R1, TNFSF14, TRANCE; higher levels: CCL23, Flt3L, LIF-R, MMP-1). The expression levels of three proteins ( lower IL-18R1, TRANCE; higher LIF-R) were uniquely disrupted in females with AN. No unique expression levels emerged for atyp-AN. Across the whole sample, twenty-one proteins correlated positively with BMI (ADA, AXIN1, CD5, CD244, CD40, CD6, CXCL1, FGF-21, HGF, IL-10RB, IL-12B, IL18, IL-18R1, IL6, LAP TGF-beta-1, SIRT2, STAMBP, TNFRSF9, TNFSF14, TRAIL, TRANCE) and six (CCL11, CCL23, FGF-19, IL8, LIF-R, OPG) were negatively correlated with BMI. Overall, our results replicate the prior study demonstrating a dysregulated inflammatory status in AN, and extend these results to atyp-AN (AN/atyp-AN all < 90% of expected body weight). Of the 27 proteins correlated with BMI, 18 were replicated from a prior study using similar methods, highlighting the promise of inflammatory protein expression levels as biomarkers of disease monitoring. Additional studies of individuals across the entire weight spectrum are needed to understand the role of inflammation in atyp-AN.

Dysfunction of Inflammatory Pathways and Their Relationship with Anti-Hypothalamic Autoantibodies in Patients with Anorexia Nervosa

Background: Despite several attempts, the etiopathogenesis of anorexia nervosa (AN) is still unknown. However, the activation of the immune response in neuropsychiatric diseases, including AN, is increasingly evident. We aimed to explore immune response parameters in patients with AN and identify the link between the presence of specific autoantibodies for hypothalamic antigens and the inflammatory response. The relationship between inflammatory markers and the duration of the disease has been also investigated. Methods: Twenty-two patients with AN were included, and none were under psychopharmacological treatment or suffering from autoimmune conditions. Serum concentrations of interleukin (IL)-6, IL-1β, tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β, and IL-21 were determined by ELISA kits. In addition, autoantibodies against hypothalamic antigens are quantitatively evaluated. Results: IL-6, IL-1 β, TNF-α, and TGF-β are significantly increased in patients with AN. A positive correlation with body mass index and with the amount of autoantibody specific for hypothalamic antigens exists. Notably, a progressive reduction of cytokines correlates with the progression of AN. In addition, IL-21 is increased in the blood of patients with AN and negatively correlates with autoantibody concentrations. Conclusions: This study shows that the increased pro-inflammatory phenotype in patients affected by AN correlates with the concentration of autoantibody specific for hypothalamic antigens. Of interest, the pro-inflammatory state seems to be reduced with duration of AN. In addition, IL-21 could work as a stimulant of the immune response, thus possibly increasing the autoreactivity.

Anorexia Nervosa in Juvenile Systemic Lupus Erythematosus (SLE): A Causality Dilemma

Juvenile-onset systemic lupus erythematosus (jSLE) is an autoimmune disorder with multifaceted clinical findings in different organ systems. Neuropsychiatric manifestations affect more than half of SLE patients, and there is increasing evidence that anorexia nervosa (AN), a feeding and eating disorder (FED) characterized by significantly reduced energy intake, is among them. Herein, a review of the literature on the potential association between jSLE and AN was performed. Reported clinical cases were identified, and putative pathophysiological mechanisms were sought that could potentially explain the observed relationship between these two pathological entities. Four reports of isolated cases and a case series including seven patients were identified. In this limited patient pool, the diagnosis of AN preceded that of SLE in the majority of cases, whereas in all cases both entities were diagnosed within a time span of two years. Many explanations for the observed relationships have been proposed. AN has been associated with the stress of chronic disease diagnosis; on the other hand, the chronic inflammation associated with AN may contribute to the development/appearance of SLE. Adverse childhood experiences, concentrations of leptin, shared autoantibodies, and genetic traits appear to be important factors in this well-established interplay. In essence, it seems important to increase clinician awareness of the concomitant development of AN and SLE and invite further research on the subject.

Mapping anorexia nervosa genes to clinical phenotypes

BACKGROUND

Anorexia nervosa (AN) is a psychiatric disorder with complex etiology, with a significant portion of disease risk imparted by genetics. Traditional genome-wide association studies (GWAS) produce principal evidence for the association of genetic variants with disease. Transcriptomic imputation (TI) allows for the translation of those variants into regulatory mechanisms, which can then be used to assess the functional outcome of genetically regulated gene expression (GReX) in a broader setting through the use of phenome-wide association studies (pheWASs) in large and diverse clinical biobank populations with electronic health record phenotypes.

METHODS

Here, we applied TI using S-PrediXcan to translate the most recent PGC-ED AN GWAS findings into AN-GReX. For significant genes, we imputed AN-GReX in the Mount Sinai BioMe™ Biobank and performed pheWASs on over 2000 outcomes to test the clinical consequences of aberrant expression of these genes. We performed a secondary analysis to assess the impact of body mass index (BMI) and sex on AN-GReX clinical associations.

RESULTS

Our S-PrediXcan analysis identified 53 genes associated with AN, including what is, to our knowledge, the first-genetic association of AN with the major histocompatibility complex. AN-GReX was associated with autoimmune, metabolic, and gastrointestinal diagnoses in our biobank cohort, as well as measures of cholesterol, medications, substance use, and pain. Additionally, our analyses showed moderation of AN-GReX associations with measures of cholesterol and substance use by BMI, and moderation of AN-GReX associations with celiac disease by sex.

CONCLUSIONS

Our BMI-stratified results provide potential avenues of functional mechanism for AN-genes to investigate further.

Low Self-Esteem and Life Satisfaction as a Significant Risk Factor for Eating Disorders among Adolescents

Background: Eating disorders are a problem that is becoming more and more common among younger and younger age groups. Many studies examine the risk factors for EDs, however, the treatment of these diseases is very complicated and requires dietary, psychological and medical intervention. Methods: 233 primary and secondary school students aged 12 to 19 were surveyed using the EAT-26 (Eating Attitudes Test-26) questionnaire, the self-esteem Scale SES and the Cantril scale for life satisfaction. Results: Women, when compared to men, showed lower self-esteem, satisfaction with their appearance, body weight and their lives and at the same time a higher risk of eating disorders in all three areas. Low life satisfaction is often correlated with weight loss greater than 10 kg. Low self-esteem correlated positively with significant weight loss (>10 kg) and more frequent uncontrollable binge eating and exercising (more than 60 min a day) to influence appearance. People with low self-esteem were more likely to be treated for EDs. Subjects dissatisfied with their lives binged, feeling that they could not stop. Conclusion: The younger the person, the more likely they are to develop eating disorders. This is closely correlated with low self-esteem and negative life satisfaction. Men were more likely to be satisfied with their weight, appearance, and life, and were less likely to show ED symptoms.

Epidemiology of eating disorders: population, prevalence, disease burden and quality of life informing public policy in Australia-a rapid review

BACKGROUND

Understanding of the epidemiology and health burden of eating disorders has progressed significantly in the last 2 decades. It was considered one of seven key areas to inform the Australian Government commissioned National Eating Disorder Research and Translation Strategy 2021-2031, as emerging research had highlighted a rise in eating disorder prevalence and worsening burden-of-illness. The aim of this review was to better understand the global epidemiology and impact of eating disorders to inform policy decision-making.

METHODS

Using a systematic Rapid Review methodology, ScienceDirect, PubMed and Medline (Ovid) were searched for peer-reviewed studies published between 2009 and 2021. Clear inclusion criteria were developed in consultation with experts in the field. Purposive sampling of literature was conducted, which predominately focused on higher-level evidence (meta-analyses, systematic reviews, and large epidemiological studies), synthesised, and narratively analysed.

RESULTS

135 studies were deemed eligible for inclusion in this review (N = 1324). Prevalence estimates varied. Global Lifetime prevalence of any eating disorder ranged from 0.74 to 2.2% in males, and 2.58-8.4% in females. Australian 3-month point-prevalence of broadly defined disorders was around 16% in females. Eating disorders appeared more prevalent in young people and adolescents, particularly females (in Australia: eating disorders ~ 22.2%; disordered eating ~ 25.7%). Limited evidence was found on sex, sexuality and gender diverse (LGBTQI +) individuals, particularly males, who had a six-fold increase in prevalence compared to the general male population, with increased illness impact. Similarly, limited evidence on First Australian's (Aboriginal and Torres Strait Islander) suggests prevalence rates similar to non-Indigenous Australians. No prevalence studies were identified specifically assessing culturally and linguistically diverse populations. Global disease burden of any eating disorder was 43.4 age-standardised disability-adjusted-life-years per 100,000; increasing by 9.4% between 2007 and 2017. Australian's total economic cost was estimated at $84 billion from years-of-life lost due to disability and death, and annual lost earnings ~ $1.646 billion."

CONCLUSIONS

There is no doubt that eating disorder prevalence and impact are on the rise, particularly in at-risk and understudied populations. Much of the evidence came from female-only samples, and Western, high-income countries which more readily have access to specialised services. Future research should examine more representative samples. There is an urgent need for more refined epidemiological methods to better understand these complex illnesses over time, to guide health policy and development-of-care.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Executive dysfunction in eating disorders: Relationship with clinical features

Eating disorders (ED) are severe mental disorders that may result in significant functional impairment and disability. Neuropsychological studies have consistently found impaired executive function (EF) among ED patients. EF is particularly involved in fundamental skills of daily living and in behavioral and emotional regulation. In this study, impairment of executive functioning is investigated in patients with eating disorders and the associations with clinical features and clinical subtypes are analyzed.

METHOD

75 female patients (m = 22.01 years, sd = 9.15) with eating disorder (43 restrictive anorexia, 30 binge-eating anorexia and 13 bulimia nervosa) and 37 healthy controls (m = 18.54 years, sd = 4.21) were included in the study. An extensive assessment of executive function domains (verbal fluency, set shifting, attention span, selective attention, working memory, inhibitory control and processing speed) was carried out in both groups. Clinical scales for food intake restriction, binge-eating/purging, depression, anxiety and impulsivity were also administered and correlated with scores on executive function tests.

RESULTS

Patients with an ED had significantly lower scores than healthy controls in performance of several executive function tests, particularly in set shifting, interference control and processing speed (p < .01, in all three domains). Executive function impairment was related to anxious, depressive and eating disorder symptoms (p < .05), regardless of clinical subtype.

CONCLUSIONS

Executive function impairment in eating disorders is associated with greater ED symptomatic severity and might involve a negative treatment outcome. Therefore, cognitive remediation techniques should probably be considered in a number of severe patients with ED.

Pharmacotherapy in anorexia nervosa: A Danish nation-wide register-based study

OBJECTIVE

No medications have been indicated for the treatment of anorexia nervosa (AN). Nonetheless, individuals with AN are frequently treated pharmacologically. The present study maps nationwide pharmacotherapy two years before to five years after first AN diagnosis.

METHODS

We identified all medication prescriptions in a national register-based study of patients with a first diagnosis of AN between 1998 and 2011, and age and gender matched controls (1:10). Medication classes were compared using odds ratios (OR) between patients and controls; between patients below and above 15 years; between patients with and without comorbidity; and between those diagnosed before or after 2005.

RESULTS

The odds of pharmacotherapy were increased in patients for all classes of medication except a small residual class. Highest odds were found for alimentary (OR 2.8, p < 0.001) and psychopharmacological (OR 5.5, p < 0.001) medication. The former peaked one year prior to first diagnosis and the latter one year after. Older patients had increased risk of almost all medication classes with cardiovascular medication showing a fivefold OR (p < 0.001). Patients with psychiatric comorbidity had a threefold OR for psychopharmacological medication (p < 0.001) compared to patients without psychiatric comorbidity. Calendar year showed few and small differences.

CONCLUSION

The extended use of all medication classes both prior to and after first diagnosis of AN highlights the severe cause and complexity of AN. The results encourage clinical caution of pharmacotherapy, highlight the need for pharmacotherapy guidelines for AN, and emphasize the urgency of research in pharmacotherapy in AN.

Sex hormone influence on female-biased autoimmune diseases hints at puberty as an important factor in pathogenesis

The majority of autoimmune diseases affect more women than men, suggesting an important role for sex hormones in regulating immune response. Current research supports this idea, highlighting the importance of sex hormones in both immune and metabolic regulation. Puberty is characterized by drastic changes in sex hormone levels and metabolism. These pubertal changes may be what forms the gulf between men and women in sex bias towards autoimmunity. In this review, a current perspective on pubertal immunometabolic changes and their impact on the pathogenesis of a select group of autoimmune diseases is presented. SLE, RA, JIA, SS, and ATD were focused on in this review for their notable sex bias and prevalence. Due to both the scarcity of pubertal autoimmune data and the differences in mechanism or age-of-onset in juvenile analogues often beginning prior to pubertal changes, data on the connection between the specific adult autoimmune diseases and puberty often relies on sex hormone influence in pathogenesis and established sex differences in immunity that begin during puberty.

Use of Population-Level Administrative Data in Developmental Science

Population-level administrative data-data on individuals' interactions with administrative systems (e.g., health, criminal justice, and education)-have substantially advanced our understanding of life-course development. In this review, we focus on five areas where research using these data has made significant contributions to developmental science: (a) understanding small or difficult-to-study populations, (b) evaluating intergenerational and family influences, (c) enabling estimation of causal effects through natural experiments and regional comparisons, (d) identifying individuals at risk for negative developmental outcomes, and (e) assessing neighborhood and environmental influences. Further advances will be made by linking prospective surveys to administrative data to expand the range of developmental questions that can be tested; supporting efforts to establish new linked administrative data resources, including in developing countries; and conducting cross-national comparisons to test findings' generalizability. New administrative data initiatives should involve consultation with population subgroups including vulnerable groups, efforts to obtain social license, and strong ethical oversight and governance arrangements.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Associations between parental socioeconomic-, family-, and sibling status and risk of eating disorders in offspring in a Danish national female cohort

OBJECTIVE

Studies on parental socioeconomic status (SES) and family risk factors for eating disorders (EDs) have yielded inconsistent results; however, several studies have identified high parental educational attainment as a risk factor. The aim was to evaluate associations of parental SES and family composition with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS) in the offspring, adjusting for parental age and parental mental health.

METHODS

The cohort included women born in Denmark between January 1, 1989 and December 31, 2010, derived from Danish national registers. Each person was followed from their sixth birthday until onset of the disorder of interest or to December 31, 2016. Exposure variables were: childhood SES, defined as individually evaluated parental level of income, occupation, and education; sibling status; and family composition. Outcomes were: AN, BN, EDNOS, and major depressive disorder (MDD), included as a psychiatric comparison disorder. Risks were estimated using Cox proportional hazards.

RESULTS

High parental SES was associated with increased risk of especially AN, and less so BN and EDNOS, in offspring. In comparison, low SES was associated with a higher risk of MDD. No differences between maternal or paternal socioeconomic risk factors were found. Family composition and sibling status showed limited influence on ED risk.

DISCUSSION

SES shows opposite associations with AN than MDD, whereas associations with BN and EDNOS are intermediate. The socioeconomic backdrop of AN differs markedly from that reported in other psychiatric disorders. Whether that is due to genetic and/or environmental factors remains unknown.

PUBLIC SIGNIFICANCE STATEMENT

Parental socioeconomic background (SES) may influence eating disorders risk in offspring somewhat differently than other psychiatric disorders. In Denmark, higher parental SES was associated with increased risk of, particularly, anorexia nervosa (AN). Importantly AN does strike across the SES spectrum. We must ensure that individuals of all backgrounds have equal access to care and are equally likely to be detected and treated appropriately for eating disorders.

Immunoinflammatory processes: Overlapping mechanisms between obesity and eating disorders?

Obesity and eating disorders are conditions that involve eating behaviors and are sometimes comorbid. Current evidence supports alterations in immunoinflammatory processes in both obesity and eating disorders. A plausible hypothesis is that immunoinflammatory processes may be involved in the pathophysiology of obesity and eating disorders. The aim of this review is to highlight the link between obesity and eating disorders, with a particular focus on immunoinflammatory processes. First, the relation between obesity and eating disorders will be presented, followed by a brief review of the literature on their association with immunoinflammatory processes. Second, developmental factors will be discussed to clarify the link between obesity, eating disorders, and immunoinflammatory processes. Genetic and epigenetic risk factors as well as the potential roles of stress pathways and early life development will be presented. Finally, implications of these findings for future research are discussed. This review highlighted biological and developmental aspects that overlap between obesity and EDs, emphasizing the need for biopsychosocial research approaches to advance current knowledge and practice in these fields.

Risk Factors from Pregnancy to Adulthood in Multiple Sclerosis Outcome

Multiple sclerosis (MS) is an autoimmune disease characterized by a robust inflammatory response against myelin sheath antigens, which causes astrocyte and microglial activation and demyelination of the central nervous system (CNS). Multiple genetic predispositions and environmental factors are known to influence the immune response in autoimmune diseases, such as MS, and in the experimental autoimmune encephalomyelitis (EAE) model. Although the predisposition to suffer from MS seems to be a multifactorial process, a highly sensitive period is pregnancy due to factors that alter the development and differentiation of the CNS and the immune system, which increases the offspring’s susceptibility to develop MS. In this regard, there is evidence that thyroid hormone deficiency during gestation, such as hypothyroidism or hypothyroxinemia, may increase susceptibility to autoimmune diseases such as MS. In this review, we discuss the relevance of the gestational period for the development of MS in adulthood.

In pursuit of biomarkers for predicting susceptibility to activity-based anorexia in adolescent female rats

OBJECTIVE

Identifying risk factors that contribute to the development of anorexia nervosa (AN) is critical for the implementation of early intervention strategies. Anxiety, obsessive-compulsive behavior, and immune dysfunction may be involved in the development of AN; however, their direct influence on susceptibility to the condition remains unclear. Here, we used the activity-based anorexia (ABA) model to examine whether activity, anxiety-like behavior, compulsive behavior, and circulating immune markers predict the subsequent development of pathological weight loss.

METHOD

Female Sprague-Dawley rats (n = 44) underwent behavioral testing before exposure to ABA conditions after which they were separated into susceptible and resistant subpopulations. Blood was sampled before behavioral testing and after recovery from ABA to screen for proinflammatory cytokines.

RESULTS

Rats that were vulnerable to pathological weight loss differed significantly from resistant rats on all key ABA parameters. While the primary measures of anxiety-like or compulsive behavior were not shown to predict vulnerability to ABA, increased locomotion and anxiety-like behavior were both associated with the extent of weight loss in susceptible but not resistant animals. Moreover, the change in expression of proinflammatory markers IL-4 and IL-6 evoked by ABA was associated with discrete vulnerability factors. Intriguingly, behavior related to risk assessment was shown to predict vulnerability to ABA.

DISCUSSION

We did not find undisputable behavioral or immune predictors of susceptibility to pathological weight loss in the ABA rat model. Future research should examine the role of cognition in the development of ABA, dysfunction of which may represent an endophenotype linking anorectic, anxiety-like and compulsive behavior.

PUBLIC SIGNIFICANCE

Anorexia nervosa (AN) has among the highest mortality rates of all psychiatric disorders and treatment options remain limited in their efficacy. Understanding what types of risk factors contribute to the development of AN is essential for implementing early intervention strategies. This study describes how some of the most common psychological features of AN could be used to predict susceptibility to pathological weight loss in a well-established animal model.

Skin signs in eating disorders: a literature review

PURPOSE

To summarize and describe the available knowledge on dermatological manifestation of eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified, diagnosed according to Diagnostic and Statistical Manual of Mental Disorders IV-TR and 5th edition.

METHODS

We searched in PubMed, Scopus and Web of Science databases from January 1, 1980 through May 1, 2020 for papers in English language on the skin manifestation of eating disorders. Results were screened using the PRISMA tool.

RESULTS

The study yielded 207 results. According with PRISMA guidelines, 26 papers were included in the review. More than 73% of screened papers (19/26) were case reports. Cross-sectional studies represented the 19.2% of screened papers (5/26). Each eligible study has been screened and analyzed.

CONCLUSION

Huge heterogeneity of skin signs of eating disorders were identified. The number of controlled studies available is very limited, and most papers of interest are case reports or narrative review articles. Larger, more methodologically rigorous studies to evaluate the presence of dermatological issue in eating disorder patients are needed.

LEVEL OF EVIDENCE

Level IV. Evidence obtained from multiple time series analysis such as case studies.

Anorexia nervosa and gut microbiome: implications for weight change and novel treatments

INTRODUCTION

Host-microbiota interactions may be involved in many physical and psychological functions ranging from the digestion of food, maintenance of immune homeostasis, to the regulation of mood and cognition. Microbiome dysbiosis has been consistently described in many diseases. The pathogenesis and weight regulation mechanism in anorexia nervosa (AN) also seem to be implicated in the dynamic bidirectional adjustment of the microbiota-gut-brain axis. This review aims at elucidating this relationship.

AREA COVERED

This review starts with a description of pathogenic gut-brain pathways. Next, we focus on the latest research on the associations between gut microbiota and weight change in the condition of AN. The strategies to alter the intestinal microbiome for the treatment of this disorder are discussed, including dietary, probiotics, prebiotics, synbiotics, and fecal microbiota transplantation.

EXPERT OPINION

Gut microbiome is inextricably linked to AN. It may regulate weight gain in the process of refeeding via the microbiota-gut-brain axis, while the specific mechanism has yet to be clearly established. In the future, a better understanding of gut microbiome could have implications for developing microbiome-based prevention, diagnostics and therapies.

Eating disorders in the U.S. Medicare population

OBJECTIVE

The social and economic burden of eating disorders is significant and often financially devastating. Medicare is the largest public insurer in the United States and provides coverage for older adults and some disabled individuals. This study explores prevalence, sociodemographic and clinical characteristics, and health care spending for Medicare enrollees with eating disorders.

METHOD

A cross-sectional study was conducted with the nationally representative 20% sample of 2016 Medicare inpatient, outpatient, carrier, and home health fee-for-service claims and Medicare Advantage encounter records. Sociodemographic characteristics and comorbid somatic conditions were compared between individuals with versus without an eating disorder diagnosis. Mean spending was compared overall and separately for inpatient, outpatient, home health, and pharmacy claims.

RESULTS

The sample included 11,962,287 Medicare enrollees of whom 0.15% had an eating disorder diagnosis. Compared to those without a 2016 eating disorder diagnosis, a greater proportion of individuals with an eating disorder were female (73.8% vs. 54.3%), under age 65 (41.6% vs. 15.5%), and dually eligible for Medicaid due to disability or low-income qualification (48.0% vs. 19.6%). Individuals with eating disorders had higher rates of comorbid conditions, with the greatest differences in cardiac arrythmias (35.3% vs. 19.9%), arthritis (40.1% vs. 26.6%), and thyroid conditions (32.2% vs. 19.4%). Spending was higher for enrollees with eating disorders compared to those without overall ($29,456 vs. $7,418) and across settings.

DISCUSSION

The findings establish that eating disorders occur in the Medicare population, and that enrollees with these illnesses have risk factors associated with significant healthcare spending and adverse health outcomes.

Anorexia nervosa and inflammatory bowel diseases-Diagnostic and genetic associations

Background

Anorexia nervosa (AN), a serious eating disorder, and inflammatory bowel diseases (IBD) share a number of key symptoms, for example, discomfort during eating and early satiety. Despite the symptom overlap, studies on comorbidity are limited and mostly conducted in relatively small samples. This study investigates the comorbidity of diagnosed AN with IBD, and the subtypes Crohn's disease and ulcerative colitis, in a population-based sample and explores whether genetic factors could play a role in the overlap.

Methods

The study included 1,238,813 individuals born in Denmark 1981-2005 selected from the population register (5067 diagnosed with AN and 6947 diagnosed with any IBD), including a subsample of 23,236 individuals with genetic information (4271 with AN and 176 with any IBD). By combining hospital-based diagnoses recorded in health registers until 2013 with polygenic scores (PGS) of AN and IBD, we investigated possible associations between diagnoses of each disorder, both within individuals and families, and between PGS of one disorder and diagnosis of the other disorder. Analyses were conducted using Cox regression and logistic regression.

Results

We found that a prior diagnosis of AN was associated with hazard ratios of 1.44 (1.05, 1.97) for any IBD, 1.60 (1.04, 2.46) for Crohn's disease, and 1.66 (1.15, 2.39) for ulcerative colitis, whereas IBD diagnoses were not significantly associated with later AN diagnosis. No significant within-families associations were observed. We found no associations between AN and IBD using PGS.

Conclusions

AN was associated with later risk of IBD, Crohn's disease, and ulcerative colitis; however, the reverse was not observed. It is important for clinicians to be aware of this association to evaluate IBD as a differential diagnosis or an emergent condition in patients with AN.

Stressful life events among individuals with a history of eating disorders: a case-control comparison

BACKGROUND

Experiencing stressful life events (SLEs) can negatively impact mental health and increase risk for psychiatric disorders including eating disorders (EDs). Previous research has shown that childhood sexual abuse is associated with some EDs, but less is known about the association between other non-sexual SLEs and EDs.

METHOD

A case-control study of individuals with (n = 495, age mean ± SD = 29.1 ± 9.8 years) and without (n = 395, age = 30.2 ± 11.7) self-reported lifetime history of EDs was conducted to compare history of self-reported SLEs. Participants reported history of sexual (e.g., rape, other sexual assault) and non-sexual (e.g., emotional abuse, assault, bereavement) life events using an adaptation of the Stressful Life Events Screening Questionnaire. Individuals with EDs were divided into ED subtypes along the restricting - binge eating/purging spectrum to examine subtype differences. Logistic regressions were conducted for each SLE and ED subtype to obtain odds ratios (ORs). We report p-values corrected for multiple comparisons.

RESULTS

Exposure to any SLE was significantly more common in individuals with EDs than in controls (OR = 2.47, p < .001). Specifically, rape, other sexual assault, and emotional abuse were significantly more common among individuals with a history of binge-eating/purging ED subtypes (ORs = 2.15-3.58, p's < .01) compared with controls. Furthermore, history of life-threatening disease and loss of a close relative/partner/friend were associated with some ED subtypes. The association between SLEs and EDs was stronger for individuals who had experienced multiple SLEs.

CONCLUSION

By investigating a range of different SLEs, we showed that both sexual and non-sexual SLEs were more common in individuals with a history of EDs (binge-eating/purging subtypes) than controls. Results highlight the importance of assessing a variety of past SLEs in risk assessment for different EDs.

Association Study among Comethylation Modules, Genetic Polymorphisms and Clinical Features in Mexican Teenagers with Eating Disorders: Preliminary Results

Eating disorders are psychiatric disorders characterized by disturbed eating behaviors. They have a complex etiology in which genetic and environmental factors interact. Analyzing gene-environment interactions could help us to identify the mechanisms involved in the etiology of such conditions. For example, comethylation module analysis could detect the small effects of epigenetic interactions, reflecting the influence of environmental factors. We used MethylationEPIC and Psycharray microarrays to determine DNA methylation levels and genotype from 63 teenagers with eating disorders. We identified 11 comethylation modules in WGCNA (Weighted Gene Correlation Network Analysis) and correlated them with single nucleotide polymorphisms (SNP) and clinical features in our subjects. Two comethylation modules correlated with clinical features (BMI and height) in our sample and with SNPs associated with these phenotypes. One of these comethylation modules (yellow) correlated with BMI and rs10494217 polymorphism (associated with waist-hip ratio). Another module (black) was correlated with height, rs9349206, rs11761528, and rs17726787 SNPs; these polymorphisms were associated with height in previous GWAS. Our data suggest that genetic variations could alter epigenetics, and that these perturbations could be reflected as variations in clinical features.

Comorbidity between types of eating disorder and general medical conditions

BACKGROUND

Comorbidity with general medical conditions is common in individuals with eating disorders. Many previous studies do not evaluate types of eating disorder.

AIMS

To provide relative and absolute risks of bidirectional associations between (a) anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified and (b) 12 general medical conditions.

METHOD

We included all people born in Denmark between 1977 and 2010. We collected information on eating disorders and considered the risk of subsequent medical conditions, using Cox proportional hazards regression. Absolute risks were calculated using competing risks survival analyses. We also considered risks for prior medical conditions and subsequent eating disorders.

RESULTS

An increased risk was seen for almost all disorder pairs (69 of 70). Hazard ratios for those with a prior eating disorder receiving a subsequent diagnosis of a medical condition ranged from 0.94 (95% CI 0.57-1.55) to 2.05 (95% CI 1.86-2.27). For those with a prior medical condition, hazard ratios for later eating disorders ranged from 1.35 (95% CI 1.26-1.45) to 1.98 (95% CI 1.71-2.28). Absolute risks for most later disorders were increased for persons with prior disorders, compared with reference groups.

CONCLUSIONS

This is the largest and most detailed examination of eating disorder-medical condition comorbidity. The findings indicate that medical condition comorbidity is increased among those with eating disorders and vice versa. Although there was some variation in comorbidity observed across eating disorder types, magnitudes of relative risks did not differ greatly.

Gastric symptoms and low perceived maternal warmth are associated with eating disorder symptoms in young adolescent girls

OBJECTIVE

This study sought to determine whether gastric symptoms are associated with later eating disorder (ED) symptoms during early adolescence, and whether this relationship is moderated by parental warmth/acceptance and/or the child's sex.

METHOD

Longitudinal data from the Adolescent Brain Cognitive Development^SM Study were utilized. Participants ages 9-10 years old (N = 4,950; 2,370 female) completed measures at baseline and 1 year later (Y1). At baseline, gastric symptoms were measured by parent-reported items from the Child Behavior Checklist (CBCL), and perceived parental acceptance was measured by youth report on the Children's Report of Parent Behavior Inventory (CRPBI) Acceptance subscale separately for mothers and fathers. ED symptoms at Y1 were assessed by parent report on a computerized version of the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). Linear mixed-effects models were conducted separately for maternal and paternal acceptance to test relationships among variables.

RESULTS

A three-way interaction between baseline gastric symptoms, sex, and maternal acceptance predicted Y1 ED symptoms (𝛽 = 0.08; p < .01). Post-hoc analyses revealed that the interaction between gastric symptoms and maternal acceptance was significant for girls only (𝛽 = -0.06, p < .01), such that low maternal acceptance was associated with a stronger relationship between baseline gastric symptoms and Y1 ED symptoms. No statistically significant main effects or interactions were found in the model for paternal acceptance.

DISCUSSION

Gastric symptoms and low perceived maternal acceptance may interact to result in heightened risk for EDs in young adolescent girls.

Peripheral Vascular Abnormalities in Anorexia Nervosa: A Psycho-Neuro-Immune-Metabolic Connection

Immune, neuroendocrine, and autonomic nervous system dysregulation in anorexia nervosa lead to cardiovascular complications that can potentially result in increased morbidity and mortality. It is suggested that a complex non-invasive assessment of cardiovascular autonomic regulation-cardiac vagal control, sympathetic vascular activity, and cardiovascular reflex control-could represent a promising tool for early diagnosis, personalized therapy, and monitoring of therapeutic interventions in anorexia nervosa particularly at a vulnerable adolescent age. In this view, we recommend to consider in the diagnostic route, at least in the subset of patients with peripheral microvascular symptoms, a nailfold video-capillaroscopy as an easy not invasive tool for the early assessing of possible cardiovascular involvement.

Anorexia Nervosa Caused by Polymicrobial Tick-Borne Infections: A Case Study

The etiology of anorexia nervosa (AN) is multifactorial, and infections may play a contributory and possibly a prominent role. A case is presented which is indicative of a causal association between tick-borne infections and AN. This adolescent female was diagnosed with AN at an eating disorder clinic after excessive food restriction and an irrational fear of weight gain necessitating nasogastric tube feeding. Her history was consistent with systemic infections and she tested serologically positive to Borrelia burgdorferi, Babesia microti, and Mycoplasma pneumoniae; in addition, her clinical presentation was consistent with a Bartonella infection. After treatment with oral and intravenous antimicrobials, she stopped food restriction and no longer had body image concerns. Physicians should be aware of the possibility that tick-borne infections could underly a diagnosis of AN. The role of tick-borne infections in the etiology of AN warrants further study.

Association and Familial Coaggregation of Type 1 Diabetes and Eating Disorders: A Register-Based Cohort Study in Denmark and Sweden

OBJECTIVE

To ascertain the association and coaggregation of eating disorders and childhood-onset type 1 diabetes in families.

RESEARCH DESIGN AND METHODS

Using population samples from national registers in Sweden (n = 2,517,277) and Demark (n = 1,825,920), we investigated the within-individual association between type 1 diabetes and eating disorders and their familial coaggregation among full siblings, half siblings, full cousins, and half cousins. On the basis of clinical diagnoses, we classified eating disorders into any eating disorder (AED), anorexia nervosa (AN) and atypical AN, and other eating disorder (OED). Associations were determined with hazard ratios (HRs) with 95% CIs from Cox regressions.

RESULTS

Swedish and Danish individuals with a type 1 diabetes diagnosis had a greater risk of receiving an eating disorder diagnosis (HR [95% CI] Sweden: AED 2.02 [1.80-2.27], AN 1.63 [1.36-1.96], OED 2.34 [2.07-2.63]; Denmark: AED 2.19 [1.84-2.61], AN 1.78 [1.36-2.33], OED 2.65 [2.20-3.21]). We also meta-analyzed the results: AED 2.07 (1.88-2.28), AN 1.68 (1.44-1.95), OED 2.44 (2.17-2.72). There was an increased risk of receiving an eating disorder diagnosis in full siblings in the Swedish cohort (AED 1.25 [1.07-1.46], AN 1.28 [1.04-1.57], OED 1.28 [1.07-1.52]); these results were nonsignificant in the Danish cohort.

CONCLUSIONS

Patients with type 1 diabetes are at a higher risk of subsequent eating disorders; however, there is conflicting support for the relationship between having a sibling with type 1 diabetes and an eating disorder diagnosis. Diabetes health care teams should be vigilant about disordered eating behaviors in children and adolescents with type 1 diabetes.

White matter microstructure in women with acute and remitted anorexia nervosa: an exploratory neuroimaging study

Anorexia nervosa (AN) is a highly heritable psychiatric disorder characterized by starvation and emaciation and associated with changes in brain structure. The precise nature of these changes remains unclear, as does their developmental time course and capacity for reversal with weight restoration. In this exploratory neuroimaging study, we sought to characterize changes in white matter microstructure in women with acute and remitted AN. Diffusion-weighted MRI data was collected from underweight women with a current diagnosis of AN (acAN: n = 23), weight-recovered women with a past diagnosis of AN (recAN: n = 23), and age-matched healthy control women (HC: n = 24). Image processing and analysis were performed with Tract-Based Spatial Statistics, part of FSL, and group differences in voxelwise, brain-wide fractional anisotropy (FA) and mean diffusivity (MD), indices of white matter microstructure, were tested with nonparametric permutation and threshold-free cluster enhancement. No significant main effect of group on FA was identified. A significant main effect of group on MD was observed in a large cluster covering 9.2% of white matter and including substantial portions of the corpus callosum, corona radiata, internal capsule, and superior longitudinal fasciculus, and post hoc analyses revealed similar effects of group on axial diffusivity (AD) and radial diffusivity (RD). Clusterwise MD was significantly higher in acAN participants (+3.8%) and recAN participants (+2.9%) than healthy controls, and the same was true for clusterwise AD and RD. Trait-based increases in diffusivity, changes in which have been associated with atypical myelination and impaired axon integrity, suggest a link between altered white matter microstructure and vulnerability to AN, and evidence of reduced oligodendrocyte density in AN provides further support for this hypothesis. Potential mechanisms of action include atypical neurodevelopment and systemic inflammation.

Anorexia nervosa and juvenile lupus erythematosus in a 16-year-old female patient - common disease origin or random coincidence?

Adolescence is a period in which eating disorders and juvenile systemic lupus erythematosus are typically diagnosed. The coexistence of both disorders prompts the search for a common aetiology.

In this paper, we present a case of a 16-year-old girl with life-threatening anorexia nervosa followed by clinical and immunological manifestations of systemic lupus erythematosus. The severity of the symptoms of anorexia nervosa resulted in significant delay in proper diagnosis of the concomitant systemic disease which had already been active. The administration of immunosuppressive treatment resulted in decreased lupus activity and resolution of the symptoms of anorexia nervosa.Being affected by one severe and chronic disease does not preclude the coexistence of another disease of different aetiology. However, such coexistence may suggest a common pathophysiology. Many authors have indicated a possible link between anorexia nervosa and many autoimmune disorders. Currently, modern genetic techniques have confirmed a significant correlation between these disorders. This issue needs further investigation and may be helpful in arriving at the final diagnosis in similar cases.

The Role of the Gut Microbiome, Immunity, and Neuroinflammation in the Pathophysiology of Eating Disorders

There is a growing recognition that both the gut microbiome and the immune system are involved in a number of psychiatric illnesses, including eating disorders. This should come as no surprise, given the important roles of diet composition, eating patterns, and daily caloric intake in modulating both biological systems. Here, we review the evidence that alterations in the gut microbiome and immune system may serve not only to maintain and exacerbate dysregulated eating behavior, characterized by caloric restriction in anorexia nervosa and binge eating in bulimia nervosa and binge eating disorder, but may also serve as biomarkers of increased risk for developing an eating disorder. We focus on studies examining gut dysbiosis, peripheral inflammation, and neuroinflammation in each of these eating disorders, and explore the available data from preclinical rodent models of anorexia and binge-like eating that may be useful in providing a better understanding of the biological mechanisms underlying eating disorders. Such knowledge is critical to developing novel, highly effective treatments for these often intractable and unremitting eating disorders.

Current Aspects of the Role of Autoantibodies Directed Against Appetite-Regulating Hormones and the Gut Microbiome in Eating Disorders

The equilibrium and reciprocal actions among appetite-stimulating (orexigenic) and appetite-suppressing (anorexigenic) signals synthesized in the gut, brain, microbiome and adipose tissue (AT), seems to play a pivotal role in the regulation of food intake and feeding behavior, anxiety, and depression. A dysregulation of mechanisms controlling the energy balance may result in eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN). AN is a psychiatric disease defined by chronic self-induced extreme dietary restriction leading to an extremely low body weight and adiposity. BN is defined as out-of-control binge eating, which is compensated by self-induced vomiting, fasting, or excessive exercise. Certain gut microbiota-related compounds, like bacterial chaperone protein Escherichia coli caseinolytic protease B (ClpB) and food-derived antigens were recently described to trigger the production of autoantibodies cross-reacting with appetite-regulating hormones and neurotransmitters. Gut microbiome may be a potential manipulator for AT and energy homeostasis. Thus, the regulation of appetite, emotion, mood, and nutritional status is also under the control of neuroimmunoendocrine mechanisms by secretion of autoantibodies directed against neuropeptides, neuroactive metabolites, and peptides. In AN and BN, altered cholinergic, dopaminergic, adrenergic, and serotonergic relays may lead to abnormal AT, gut, and brain hormone secretion. The present review summarizes updated knowledge regarding the gut dysbiosis, gut-barrier permeability, short-chain fatty acids (SCFA), fecal microbial transplantation (FMT), blood-brain barrier permeability, and autoantibodies within the ghrelin and melanocortin systems in eating disorders. We expect that the new knowledge may be used for the development of a novel preventive and therapeutic approach for treatment of AN and BN.

Alternative Frameworks for Advancing the Study of Eating Disorders

Eating disorders are life-interrupting psychiatric conditions with high morbidity and mortality, yet the basic mechanisms underlying these conditions are understudied compared with other psychiatric disorders. In this opinion, we suggest that recent knowledge gleaned from genomic and neuroimaging investigations of eating disorders in humans presents a rich opportunity to sharpen animal models of eating disorders and to identify neural mechanisms that contribute to the risk and maintenance of these conditions. Our article reflects the state of the science, with a primary focus on anorexia nervosa (AN) and binge-eating behavior, and encourages further study of all conditions categorized under feeding and eating disorders.

Gut Feelings: How Microbiota Might Impact the Development and Course of Anorexia Nervosa

Anorexia nervosa (AN) can probably be regarded as a "model" for studying the interaction of nutrition with the gut-brain axis, which has drawn increased attention from researchers and clinicians alike. The gut microbiota influences somatic effects, such as energy extraction from food and body weight gain, as well as appetite, gut permeability, inflammation and complex psychological behaviors, such as depression or anxiety, all of which play important roles in AN. As nutrition is one of the main factors that influence the gut microbiota, nutritional restriction and selective eating in AN are likely influencing factors; however, nutritional rehabilitation therapy is surprisingly understudied. Here, we review the general mechanisms of the interactions between nutrition, the gut microbiota and the host that may be relevant to AN, paying special attention to the gut-brain axis, and we present the first specific findings in patients with AN and corresponding animal models. In particular, nutritional interventions, including food selection, supplements, and pre-, pro- and synbiotics that have the potential to influence the gut microbiota, are important research targets to potentially support future AN therapy.

Characteristics of avoidant/restrictive food intake disorder in a general paediatric inpatient sample

OBJECTIVE

Although patients with avoidant/restrictive food intake disorder (ARFID) often consult general paediatric services initially, existing literature mostly concentrated on intensive eating disorder treatment settings. This cross-sectional study sought to describe symptoms of ARFID and their associations with eating disorder psychopathology, quality of life, anthropometry, and physical comorbidities in a general paediatric sample.

METHODS

In N = 111 patients (8-18 years) seeking treatment for physical diseases, prevalence of ARFID-related restrictive eating behaviours was estimated by self-report and compared to population-based data (N = 799). Using self-report and medical record data, further ARFID diagnostic criteria were evaluated. Patients with versus without symptoms of ARFID based on self-report and medical records were compared in diverse clinical variables.

RESULTS

The prevalence of self-reported symptoms of ARFID was not higher in the inpatient than population-based sample. Only picky eating and shape concern were more common in the inpatient than population-based sample. Although 68% of the inpatient sample reported any restrictive eating behaviours, only 7% of patients showed symptoms of ARFID based on medical records in addition to self-report, particularly those with underweight, without significant effects for age, sex, and medical diagnoses.

DISCUSSION

The study revealed the importance of considering ARFID within the treatment of children and adolescents with physical diseases, especially for those with underweight. Further research is needed to replicate the findings with interview-based measures and to investigate the direction of effects in ARFID and its physical correlates.

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.

Longitudinal associations between circulating interleukin-6 and C-reactive protein in childhood, and eating disorders and disordered eating in adolescence

OBJECTIVE

Few studies have explored the association between inflammation and eating disorders and none used a longitudinal design. We investigated the association between serum-levels of interleukin 6 (IL-6) and C-reactive protein (CRP) measured in childhood and eating disorders and related behaviours and cognitions in adolescence in a large general population sample.

METHODS

We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Our exposures were thirds of IL6 and CRP derived from serum measurements taken at age nine years, and outcomes were eating disorder diagnoses and self-reported disordered eating behaviours at ages 14, 16, and 18 years. We used univariable and multivariable multilevel logistic regression models adjusting for a number of potential confounders, including sex, fat mass, and pre-existing mental health difficulties.

RESULTS

Our sample included 3480 children. Those in the top third of CRP had lower odds of binge eating (odds ratio(OR):0.62, 95% confidence interval (CI):0.39,1.00,p "equals" 0.05) and fasting (OR:0.63, 95% CI:0.38,1.07,p "equals" 0.09) after adjustment for confounders. We also observed weak associations of comparable magnitude for purging, anorexia nervosa, and bulimia nervosa. We did not find any associations between levels of IL6 and any of the outcomes under study.

CONCLUSIONS

There was little evidence of an association between CRP and IL-6 and adolescent eating disorder outcomes. The inverse association observed between CRP and binge eating was unexpected, so caution is needed when interpreting it. One possible explanation is that higher CRP levels could have a protective role for disordered eating by affecting appetitive traits.

The Western diet: a blind spot of eating disorder research?-a narrative review and recommendations for treatment and research

Over the last 50 years, in parallel with the obesity epidemic, the prevalence of eating disorders has increased and presentations have changed. In this narrative review, we consider recent research exploring the implications of changing patterns of food consumption on metabolic and neurobiological pathways, a hitherto neglected area in eating disorder research. One of the major changes over this time has been the introduction of ultra-processed (NOVA-4) foods, which are gradually replacing unprocessed and minimally processed foods. This has resulted in the increased intake of various sugars and food additives worldwide, which has important metabolic consequences: triggering insulin and glucose response, stimulating appetite, and affecting multiple endocrine and neurobiological pathways, as well as the microbiome. A paradigm shift is needed in the conceptual framework by which the vulnerability to, and maintenance of, different eating disorders may be understood, by integrating recent knowledge of the individual metabolic responses to modern highly processed foods into existing psychological models. This could stimulate research and improve treatment outcomes.