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

Shared genetic risk between anorexia nervosa and cardiovascular disease events: Evidence from genome-wide association studies

OBJECTIVE

Cardiovascular complications occur in up to 80% of patients with anorexia nervosa (AN), yet the underlying mechanisms warrant further investigation. We assessed the genetic correlation (rg ) between AN and cardiovascular disease (CVD) events to inform whether elevated cardiovascular risk among individuals with AN is due to shared genetic effects.

METHOD

We used genome-wide association study summary statistics for AN (N = 72,517), AN with binge eating (N = 12,630), AN without binge eating (N = 12,516), and six CVD events (N = 390,142 to 977,323). We calculated the rg s via linkage disequilibrium score regression and corrected for multiple testing using false discovery rate.

RESULTS

Significant rg s emerged between AN with heart failure (rg  = -0.11, SE = 0.05, q = .04) and myocardial infarction (rg  = -0.10, SE = 0.03, q = .01). AN with binge eating had a significant rg with myocardial infarction (rg  = -0.15, SE = 0.06, q = .02). No significant rg emerged between AN without binge eating and any CVD event.

DISCUSSION

Some loci affect the liability to AN and CVD in opposite directions and the shared genetic effects may not be consistent across all CVD events. Our results provide further evidence suggesting that the elevated cardiovascular risk in AN may not be due to shared genetic underpinnings, but more likely a downstream consequence of the disease.

Cardiac involvement and its clinical significance in patients with anorexia nervosa

Cardiac complications are a major concern in patients with anorexia nervosa (AN) which contribute to morbidity and mortality. However, limited information exists regarding risk factors for the development of these complications. Our objective was to investigate the prevalence and associated risk factors of cardiac involvement among children and adolescents with AN admitted to a tertiary pediatric hospital. We collected demographic, clinical, and laboratory data from individuals with AN hospitalized between 2011 and 2020 in Schneider Children's Medical Center in Israel. Diagnosis was based on established criteria (DSM-5). Patients with other co-morbidities were excluded. Cardiac investigations included electrocardiograms (ECG) and echocardiograms. We conducted correlation tests between cardiac findings and clinical and laboratory indicators. A total of 403 AN patients (81.4% were females) with a median age of 15 ± 2 years were included in the study. Sinus bradycardia was the most common abnormality, observed in 155 (38%) participants. Echocardiogram was performed in 170 (42.2%) patients, of whom 37 (22%) demonstrated mild cardiac aberrations. Among those aberrations, 94.6% could be attributed to the current metabolic state, including pericardial effusion (15.3%) and valve dysfunction (8.8%). Systolic or diastolic cardiac dysfunction, tachyarrhythmias, or conduction disorders were not observed. Patients with new echocardiographic aberration had significantly lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension was higher in this group.

CONCLUSIONS

The prevalence of cardiac involvement, except for sinus bradycardia, was notably low in our cohort. The presence of cardiac aberrations is correlated with several clinical variables: lower body mass index (BMI) and the presence of amenorrhea and hypotension at admission. Patients presenting with these variables may be at high risk for cardiac findings per echocardiography. Dividing the patients into high and low risk groups may enable targeted evaluation, while avoiding unnecessary cardiac investigations in low-risk patients.

WHAT IS KNOWN

• Cardiac involvement in anorexia nervosa (AN) patients is a major concern, which contributes to morbidity and mortality. • It is unknown which patients are prone to develop this complication.

WHAT IS NEW

• Cardiac complications in our cohort are less frequent compared to previous studies, and it is correlated with lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension.

The involvement of the adrenergic system in feeding and eating disorders. A systematic review

BACKGROUND

Adrenergic dysregulation has been proposed as a possible underlying mechanism in feeding and eating disorders (FED). This review aims to synthesise the current evidence on the role of adrenergic dysregulation in the pathogenesis and management of FED.

METHODS

A systematic review was conducted in MEDLINE, Cochrane Library, and Clinicaltrials.gov. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was adopted. Preclinical, clinical, and pharmacological studies assessing the adrenergic system in FED were included.

RESULTS

Thirty-one out of 1415 recognised studies were included. Preclinically, studies on adrenaline's anorectic impact, receptor subtypes, and effects on hepatic function in rats show that catecholamine anorexia is primarily alpha-adrenergic, whereas beta-adrenergic anorexia can be obtained only after puberty, implying an impact of sexual hormones. Clinically, catecholamine levels may be higher in FED patients than in healthy controls (HC). Individuals with anorexia nervosa (AN) may show higher epinephrine-induced platelet aggregability response than HC. Pharmacological trials suggest that the alpha-2-adrenergic medication clonidine may not lower AN symptoms, but agents regulating the adrenaline-noradrenaline neurotransmission (bupropion, reboxetine, duloxetine, sibutramine) have been found to improve binge eating symptoms.

CONCLUSION

Adrenergic dysregulation may be involved in the pathophysiology of FED. More research is needed to comprehend underlying mechanisms and treatment implications.

A Guide to the Postmortem Investigation of Starvation in Adults

ABSTRACT

Starvation is a rare cause of death in developed countries and is a complex multifaceted pathological process. To complicate the forensic investigation of starvation further, many medical conditions independent of starvation may cause wasting. This article provides one of the first comprehensive guides to the postmortem investigation of starvation in adults, with reference tables on organ-specific macroscopic and microscopic features, as well as features for excluding alternative causes of wasting. The eclectic literature on this complex topic is summarized in an accessible and easily referenced format, including mechanisms of death and ancillary postmortem investigations.

Expression of immune-related proteins and their association with neuropeptides in adolescent patients with anorexia nervosa

Anorexia nervosa (AN) is a metabo-psychiatric disorder where alterations of cytokines, neuropeptides, neurotransmitters, and the interactions between these factors can play an important role. Thus, the primary goal of the presented study was a cross-sectional analysis of immune-related proteins in patients with AN. Moreover, the correlations between these molecules and selected neuropeptides were studied. Twenty-five adolescent inpatients girls in the acute stage of a restrictive type of AN were enrolled in the study within the first year of the disease. Additionally, thirty similar in age and height controls (CG) were also assessed. The levels of 24 immune-related proteins, including cytokines, chemokines, and proteases, were measured. Moreover, selected adipocytokines, gastrointestinal hormones, and centrally produced neuropeptides levels were determined. Finally, the correlations between these molecules were analyzed. The fasting levels of CXCL1, CXCL9, FGF2, GrB, IL1, IL6, IL8, MMP8, MMP9, CTSS were statistically lower in AN than in the CG. The concentrations of many immune-related proteins remain unchanged despite their metabolic and mental condition. Moreover, significant correlations were found between leptin and CXCL1, CXCL9, GrB, IL1, IL6, and MMP8. Leptin receptors were correlated with GrB, while resistin was associated with MMP9. Our findings suggest that the initial stage of restrictive AN among adolescents within the first year of the disease is not connected with a pro-inflammatory state. Some immune-related protein changes may be associated with altered neuropeptides, primarily leptin, its receptors, and resistin. Future research should clarify which changes are primary and secondary to weight loss and whether these changes normalize with increasing weight. This would aid in understanding the complex etiopathogenesis of AN and in the search for new methods of treatment.

Blood-Brain Barrier Dysfunction in the Pathogenesis of Major Depressive Disorder

Major depression represents a complex and prevalent psychological disease that is characterized by persistent depressed mood, impaired cognitive function and complicated pathophysiological and neuroendocrine alterations. Despite the multifactorial etiology of depression, one of the most recent factors to be identified as playing a critical role in the development of depression is blood-brain barrier (BBB) disruption. The occurrence of BBB integrity disruption contributes to the disturbance of brain homeostasis and leads to complications of neurological diseases, such as stroke, chronic neurodegenerative disorders, neuroinflammatory disorders. Recently, BBB associated tight junction disruption has been shown to implicate in the pathophysiology of depression and contribute to increased susceptibility to depression. However, the underlying mechanisms and importance of BBB damage in depression remains largely unknown. This review highlights how BBB disruption regulates the depression process and the possible molecular mechanisms involved in development of depression-induced BBB dysfunction. Moreover, insight on promising therapeutic targets for treatment of depression with associated BBB dysfunctions are also discussed.

Is the Activity-Based Anorexia Model a Reliable Method of Presenting Peripheral Clinical Features of Anorexia Nervosa?

Anorexia nervosa (AN) causes the highest number of deaths among all psychiatric disorders. Reduction in food intake and hyperactivity/increased anxiety observed in AN are also the core features of the activity-based anorexia animal model (ABA). Our aim was to assess how the acute ABA protocol mimics common AN complications, including gonadal and cardiovascular dysfunctions, depending on gender, age, and initial body weight, to form a comprehensive description of ABA as a reliable research tool. Wheel running, body weight, and food intake of adolescent female and male rats were monitored. Electrocardiography, heart rate variability, systolic blood pressure, and magnetic resonance imaging (MRI) measurements were performed. Immediately after euthanasia, tissue fragments and blood were collected for further analysis. Uterine weight was 2 times lower in ABA female rats, and ovarian tissue exhibited a reduced number of antral follicles and decreased expression of estrogen and progesterone receptors. Cardiovascular measurements revealed autonomic decompensation with prolongation of QRS complex and QT interval. The ABA model is a reliable research tool for presenting the breakdown of adaptation mechanisms observed in severe AN. Cardiac and hormonal features of ABA with underlying altered neuroendocrine pathways create a valid phenotype of a human disease.

A Comprehensive Review of Complications and New Findings Associated with Anorexia Nervosa

Anorexia nervosa is a complex and deadly psychiatric disorder. It is characterized by a significant degree of both co-occurring psychiatric diseases and widespread physiological changes which affect nearly every organ system. It is important for clinicians to be aware of the varied consequences of this disorder. Given the high rate of mortality due to AN, there is a need for early recognition so that patients can be referred for appropriate medical and psychiatric care early in the course of the disorder. In this study, we present a comprehensive review of the recent literature describing medical findings commonly encountered in patients with AN. The varied and overlapping complications of AN affect pregnancy, psychological well-being, as well as bone, endocrine, gastrointestinal, cardiovascular, and pulmonary systems.

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.

Obesity, Nutrition and Heart Rate Variability

Heart rate variability (HRV) represents the activity and balance of the autonomic nervous system and its capability to react to internal and external stimuli. As a measure of general body homeostasis, HRV is linked to lifestyle factors and it is associated with morbidity and mortality. It is easily accessible by heart rate monitoring and gains interest in the era of smart watches and self-monitoring. In this review, we summarize effects of weight loss, training, and nutrition on HRV with a special focus on obesity. Besides weight reduction, effects of physical activity and dietary intervention can be monitored by parameters of HRV, including its time and frequency domain components. In the future, monitoring of HRV should be included in any weight reduction program as it provides an additional tool to analyze the effect of body weight on general health and homeostasis. HRV parameters could, for example, be monitored easily by implementation of an electrocardiogram (ECG) every two to four weeks during weight reduction period. Indices presumibly showing beneficial changes could be a reduction in heart rate and the number of premature ventricular complexes as well as an increase in standard deviation of normal-to-normal beat intervals (SDNN), just to name some.

Associations between depression, nutrition, and outcomes among individuals with coronary artery disease

OBJECTIVES

Depression and malnutrition are prevalent among people with coronary artery disease (CAD) and can affect their prognosis, but the relationship between depression and malnutrition and its co-effect on prognosis is not clear. We sought to explore that relationship and its effects.

METHODS

In this study, the nutritional and emotional statuses of 547 people with CAD were assessed using the Controlling Nutritional Status (CONUT) score and the Patient Health Questionnaire-9. The average follow-up period was 2.1 y, after which we explored the relationship between depression and nutrition and prognosis.

RESULTS

A total of 41% of the participants were found to have mild malnutrition, 10% moderate to severe malnutrition, 26% had mild depression, and 11% had moderate to severe depression. A total of 20.6% of the participants were found to have comorbidities of depression and malnutrition; and both moderate to severe depression (adjusted hazard ratio [HR], 1.674; 95% confidence interval [CI], 1.098-2.551) and moderate to severe malnutrition (adjusted HR, 1.686; 95% CI, 1.073-2.648) were observed to be risk factors for the composite end point. Participants with comorbidities of depression and malnutrition were found to have increased risk of cardiovascular death (HR, 5.390; 95% CI, 1.483-19.589) and composite end point (adjusted HR, 1.791; 95% CI, 1.133-2.833) compared to those without both depression and malnutrition.

CONCLUSIONS

Depression and malnutrition were found to be risk factors for adverse outcomes in people with CAD. People with CAD should pay attention to their emotional and nutritional statuses, and interventions must be timely and efficient.