Microbiome-metabolomics signature in anorexia nervosa (AN) before and after weight regain

Introduction

The intestinal microbiota has been indicated to have a role in the pathophysiology of AN.

Objectives

Aim of this study was to analyze fecal microbiome profiles of AN women before and after weight restoration and to combine them with fecal metabolomic profiles according to a multi-omics approach.

Methods

The gut microbiome and fecal metabolites were characterized in 21 underweight AN women and after weight restoration and compared with those of 20 healthy women. Microbiome data were correlated with the relevant fecal metabolites.

Results

AN subjects showed a decreased intra-individual bacterial richness, an increased Bacteroidetes-to-Firmicutes abundance ratio and significant changes in the relative abundances of several bacteria at different order levels in both the underweight and weight-restored condition compared to healthy women. The untargeted metabolomic procedure allowed the characterization of 224 metabolites involved in energy, lipid and amino acid metabolism. A genetic algorithm identified 49 relevant metabolites. The relationships among these fecal metabolites and bacteria genera showed structures of different complexity in the 3 groups. In particular, a quarter of those relationships showed a divergent direction in the acute phase of AN than in the weight-restored phase or normal controls. Finally, in acute AN 70% of those correlations showed a negative sign suggesting a prevalent metabolites consummation by gut microbiome.

Conclusions

Our results provide a picture of the connections between gut bacteria and fecal metabolites in both the acute phase of AN and after short-term weight restoration. Further studies should aim to investigate the significance of gut microbiome perturbations in development and treatment of AN.

Physical performance measures in screening for reduced lean body mass in adult females with obesity

BACKGROUND & AIMS

Little is known about the reduction of lean body mass (LBM) in obesity, or how to identify it in standard clinical settings. We therefore aimed to assess the prevalence of low LBM in adult females with obesity, and to identify the reliability of simple tools for its screening in this population.

METHODS AND RESULTS

Dual-energy X-ray absorptiometry (DXA) body composition assessment was used to categorise 147 female participants with obesity as with or without low LBM, according to the new definition that takes into account both appendicular lean mass (ALM) and body mass index (BMI)-ALM/BMI <0.512. Participants were also administered the six-minute walking test, handgrip-strength test and 4-metre gait-speed test. Of the sample of 147 participants, 93 (63.3%) met the criteria for reduced LBM. Stepwise multivariate logistic regression analysis showed that the six-minute walking test was the only independent test associated with low LBM (OR = 0.992, 95%CI 0.987-0.998). Receiver operating characteristic (ROC) curve analysis found that the discriminating cut-off points of the tests considered were 470 m, 3.30 s (gait speed = 1.2 m/sec) and 23.5 kg respectively; the 4-metre gait-speed test seems to provide the best balance of sensitivity and specificity, and the greatest discriminatory power at 90% sensitivity.

CONCLUSIONS

Treatment-seeking adult females with obesity display a great prevalence of reduced LBM. The six-minute walking test was the only independent test associated with low LBM, but the 4-metre gait-speed test seems to be the most accurate functional test for screening for this condition in that population.

Bone metabolism in patients with anorexia nervosa and amenorrhoea

PURPOSE

Aim of this study is focusing on bone metabolism in AN patients with amenorrhoea and related estrogen deficiency effects.

METHODS

AN patients were compared both with healthy females and with postmenopausal women (reference model for estrogen deficiency). The study sample included 81 females with AN. Laboratory tests [25-OH vitamin D, bone turnover markers, intact parathyroid hormone, sclerostin (SOST) and dickkopf-related protein (DKK1)] and dual energy X-ray absorptiometry (DXA) were taken into account.

RESULTS

AN patients had higher levels of C-terminal telopeptide of type I collagen (CTX) than both control groups. AN adolescents had CTX higher than AN young adults. In postmenopausal women, intact N-propeptide of type I collagen was higher if compared with each other group. In AN groups, Dickkopf-related protein 1 was significantly lower than the two control groups. No differences were found in sclerostin except in adolescents. In AN adolescents, DXA values at femoral sites were higher than in AN young adults and a positive correlation was found with body weight (p < 0.01) and with fat mass evaluated using DXA (p < 0.01).

CONCLUSIONS

AN women with amenorrhoea have an increased bone resorption like postmenopausal women but bone formation is depressed. The consequent remodeling uncoupling is considerably more severe than that occurring after menopause.

Responses of peripheral endocannabinoids and endocannabinoid-related compounds to hedonic eating in obesity

PURPOSE

Hedonic eating occurs independently from homeostatic needs prompting the ingestion of pleasurable foods that are typically rich in fat, sugar and/or salt content. In normal weight healthy subjects, we found that before hedonic eating, plasma levels of 2-arachidonoylglycerol (2-AG) were higher than before nonhedonic eating, and although they progressively decreased after food ingestion in both eating conditions, they were significantly higher in hedonic eating. Plasma levels of anandamide (AEA), oleoylethanolamide (OEA) and palmitoylethanolamide (PEA), instead, progressively decreased in both eating conditions without significant differences. In this study, we investigated the responses of AEA, 2-AG, OEA and PEA to hedonic eating in obese individuals.

METHODS

Peripheral levels of AEA, 2-AG, OEA and PEA were measured in 14 obese patients after eating favourite (hedonic eating) and non-favourite (nonhedonic eating) foods in conditions of no homeostatic needs.

RESULTS

Plasma levels of 2-AG increased after eating the favourite food, whereas they decreased after eating the non-favourite food, with the production of the endocannabinoid being significantly enhanced in hedonic eating. Plasma levels of AEA decreased progressively in nonhedonic eating, whereas they showed a decrease after the exposure to the favourite food followed by a return to baseline values after eating it. No significant differences emerged in plasma OEA and PEA responses to favourite and non-favourite food.

CONCLUSION

Present findings compared with those obtained in our previously studied normal weight healthy subjects suggest deranged responses of endocannabinoids to food-related reward in obesity.

Personality, attrition and weight loss in treatment seeking women with obesity

Studies on small samples or in single units applying specific treatment programmes found an association between some personality traits and attrition and weight loss in individuals treated for obesity. We aimed to investigate whether pre-treatment personality traits were associated with weight loss outcomes in the general population of women with obesity. Attrition and weight loss outcomes after 12 months were measured in 634 women with obesity (mean age, 48; body mass index (BMI), 37.8 kg m(-2)) seeking treatment at eight Italian medical centres, applying different medical/cognitive behavioural programmes. Personality traits were assessed with the Temperament and Character Inventory (TCI), eating disorder features with the Binge Eating Scale (BES) and Night Eating Questionnaire (NEQ). Within the 12-month observation period, 32.3% of cases were lost to follow-up. After adjustment for demographic confounders and the severity of eating disorders, no TCI personality traits were significantly associated with attrition, while low scores of the novelty seeking temperament scale remained significantly associated with weight loss ≥ 10% (odds ratio, 0.983; 95% confidence interval, 0.975-0.992). Additional adjustment for education and job did not change the results. We conclude that personality does not systematically influence attrition in women with obesity enrolled into weight loss programmes in the community, whereas an association is maintained between novelty seeking and weight loss outcome. Studies adapting obesity interventions on the basis of individual novelty seeking scores might be warranted to maximize the results on body weight.

Assessing the appropriateness of the level of care for morbidly obese subjects: validation of the CASCO-R scale

AIM

Aim of this study was to validate the Comprehensive Appropriateness Scale for the Care of Obesity in Rehabilitation (CASCO-R) and to determine the cut-off score for indicating the most appropriate health care setting for patients with obesity.

METHODS

The CASCO-R scale was developed according to the available scientific literature and expertise of an expert panel working for a Consensus document endorsed by the Italian Society of Obesity (SIO) and the Italian Society for the Study of Eating Disorders (SISDCA). 16 Italian centres, specialized in the treatment of obesity, characterised by different settings of care (specialist outpatient service, day-hospital service, intensive inpatient rehabilitation), participated in the study.

RESULTS

449 obese subjects were enrolled in the study (30.5% males and 69.5% females): 38.3% from outpatient services, 20.7% from day-hospital services and 40.9% from intensive inpatient rehabilitation units. After 2-month of treatment, a workload summary sheet, including medical and nursing interventions, number of expert advices and diagnostic procedures, and adverse clinical events (ACEs) was fulfilled for each patient. Statistically significant correlation was found between the CASCO-R scale score, overall workload and ACEs. The CASCO-R scale demonstrated also an excellent performance in terms of internal validity and test-retest analysis. Three total score cut-off have been proposed: >25 for inpatient intensive rehabilitation; 20-25 for day-hospital service; <20 for outpatient treatment.

CONCLUSIONS

In conclusion, the CASCO-R scale was demonstrated to be a valid tool for assessing the appropriateness of the choice of the level of care. Hence, it can be used to verify the proper allocation of patients, as it was well correlated with measures of workload and the incidence of ACEs.

Physical fitness before and after weight restoration in anorexia nervosa

AIM

The aims of this paper were: 1) to evaluate the feasibility of test for evaluating physical fitness (PF) in patients with anorexia nervosa (AN); 2) to investigate the effects of nutritional rehabilitation in this population of patients; and 3) to compare their level of fitness scores (at baseline and after weight restoration) with an age-matched healthy control group.

METHODS

PF was assessed with an adapted version of the Eurofit Physical Fitness Test Battery (EPFTB) administered to 37 consecutive female AN patients, at baseline and after weight restoration, and to 57 healthy age-matched females.

RESULTS

The inpatient treatment, based on cognitive behavior therapy, was associated with a significant improvement in BMI (from 14.5±1.5 to 18.8±1.1, P<0.001) and in 5 out of 6 EPFTB tests (P<0.05) in the AN group. However, both in pre and post, AN patients showed significant lower EPFTB than the control group (all P<0.001) with the exception of the Sit-Up score.

CONCLUSION

Results indicated that PF is lower in AN patients than in controls both at baseline and after weight restoration. Future studies should evaluate if the inclusion of an individualized health-enhancing physical activity program might improve the restoration of physical fitness.

Weight loss and clinical characteristics of young adults patients seeking treatment at medical centers: data from the QUOVADIS Study

OBJECTIVE

To compare clinical characteristics, attrition, weight loss, and psychological changes of obese young adults and obese adults seeking treatment.

MATERIALS AND METHODS

1530 individuals seeking treatment in 18 Italian medical centers were evaluated. 382 cases (25%) were classified as young adults (age≤35 years), 1148 (75%) as adults (>35 years). Psychological distress, binge eating, body uneasiness, and attitude towards eating were evaluated, at baseline and after a 12-month weight-loss program, together with BMI changes. Weight-loss expectations and primary motivation for seeking treatment were also recorded.

RESULTS

At baseline, young adults reported significantly higher BMI at age 20, weight loss expectations and body uneasiness scores than adults. A significantly higher percentage of young adults also reported improving appearance as primary reason for seeking treatment. The attrition rate was significantly larger in young adults. Among completers, the mean percent weight loss at 12 months and improvement of psychosocial variables were significantly higher in young adults than in adults. By intention to treat, BMI changes were no longer significant between groups.

DISCUSSION

Obese young adults lose more weight and considerably improve psychological distress, but show a higher attrition rate after 12 months of continuous care in a real world medical setting.

Effects of cognitive-behavioral therapy on Eating Disorders: neurotransmitter secretory response to treatment

The effects of cognitive-behavioral therapy (CBT) on central dopamine (DA), noradrenaline (NE) and serotonin (5-HT) secretion were studied in a group of 50 female inpatients, of which 14 suffered from anorexia nervosa restricted type (AN-R), 14 from anorexia nervosa bingeing-purging type (AN-BP), and 22 from bulimia nervosa (BN). The aim of the study was to see whether or not CBT modifies the secretion of central DA (blood homovanillic acid=HVA), NE (blood 3-methoxy-4-hydroxy-phenylglycol=MHPG) and the 5-HT transporter (as evaluated by the platelet paroxetine binding=[(3)H]-Par-binding), if the physical and psychological effects of CBT correlate with changes of the neurotransmitter secretion; and if the biological effects of CBT are linked to specific psychopathological aspect of the disorders. The treatment lasted 20 weeks. Body-mass Index, bingeing and purging, specific AN-BN psychopathological (EDE 12-OD), depression (Beck Inventory), anxiety (STAY Form-Y-1), impulsiveness (Barratt Impulsiveness Scale), self-esteem (Rosenberg Self-Biochemical Scale) and temperament (Temperament and Character Inventory, Cloninger Scale) were assessed at baseline and at the end of the treatment. CBT significantly improved the psychophysical aspects of the diseases. HVA and MHPG concentrations did not change. The [(3)H]-Par-binding parameters, the maximum binding capacity (B(max)) and dissociation constant (K(d)) values did not change in either AN-R or AN-BP patients, while the [(3)H]-Par B(max) (and not the K(d)) increased significantly in BN patients. Correlations emerged between basal and final [(3)H]-Par B(max) values and psychopathological scores, but not between CBT-induced differences between basal and final values. Our data suggest that only in BN CBT may act through changes in 5-HT system function.

Night eating syndrome in class II-III obesity: metabolic and psychopathological features

OBJECTIVE

To investigate the relationship of metabolic disorders and psychological features with the night eating syndrome (NES) in individuals with moderate-to-severe obesity.

DESIGN

Cross-sectional observation.

SUBJECTS

A total of 266 consecutive participants with class II-III obesity, entering an inpatient weight loss program.

MEASUREMENTS

Participants who reported consuming either a large amount of their caloric intake after the evening meal (roughly self-assessed as > or =25% of daily calories) or the presence of nocturnal feeding at the Night Eating Questionnaire (NEQ) (N=49) were interviewed by the Night Eating Syndrome History and Inventory (NESHI). Assessment also included the clinical/biochemical parameters of the metabolic syndrome and several questionnaires of psychopathology. NES was diagnosed by NESHI criteria (evening hyperphagia (> or =25% of daily food intake after the evening meal) and/or waking at night to eat at least three times a week) in the last 3 months.

RESULTS

Twenty-seven participants (10.1%) met NESHI criteria. Differences were not observed between participants with and without NES as to age, body mass index (BMI), prevalence of metabolic syndrome, Binge Eating Scale and Body Shape Questionnaire. NES participants had significantly higher scores of Beck Depression Inventory (BDI) and Impact of Weight on Quality of Life (IWQOL). Among NES cases, the BDI score was indicative of moderate depression in 18.5% of cases and of severe depression in 44.4%. Logistic regression analysis, adjusted for confounders, identified the BDI score as the only variable significantly associated with the diagnosis of NES.

CONCLUSION

Diagnosing NES does not help identify obese individuals with specific medical complications, but indicates more severe psychological distress and depression.

The interpretation of symptoms of starvation/severe dietary restraint in eating disorder patients

The aims of the study were to test the hypotheses that some symptoms of starvation/severe dietary restraint are interpreted by patients with eating disorders in terms of control. Sixty-nine women satisfying the Diagnostic and Statistical Manual of Mental Disorders-IV edition (DSM-IV) criteria for a clinical eating disorder and 107 controls participated in the study. All the participants completed an ambiguous scenarios paradigm, the Eating Disorder Examination Questionnaire (EDE-Q) and the Beck Depression Inventory (BDI). Significantly more eating disorder patients than non clinical participants interpreted the starvation/dietary restraint symptoms of hunger, heightened satiety, and dizziness in terms of control. The data give further support to the recent cognitive-behavioural theory of eating disorders suggesting that eating disorder patients interpret some starvation/dietary restraint symptoms in terms of control.

Validating the Body Uneasiness Test (BUT) in obese patients

OBJECTIVE

To investigate the psychometric properties of the Body Uneasiness Test (BUT) in a large sample of subjects with obesity seeking treatment. BUT is a 71-item self-report questionnaire in two parts: BUT-A which measures weight phobia, body image concerns, avoidance, compulsive self-monitoring, detachment and estrangement feelings towards one's own body (depersonalization); and BUT-B, which looks at specific worries about particular body parts or functions.

METHODS

We recruited a clinical sample of 1,812 adult subjects (age range 18-65 years, females 1,411, males 401) with obesity (Body Mass Index, BMI > or = 30 kg/m2) and a normal weight (BMI value between 18.5 and 25 kg/m2) non-clinical sample of 457 adult subjects (females 248, males 209) with an Eating Attitudes Test-26 (EAT-26) score under the cut-off point 20 (scores > or = 20 indicate possible cases of eating disorders).

RESULTS

The exploratory and confirmatory analyses confirmed a structural five-factor model for BUT-A and an eight-factor model for BUT-B. Internal consistency was satisfactory. Concurrent validity with Binge Eating Scale (BES) and Three-Factor Eating Questionnaire (TFEQ) was evaluated. The authors calculated mean values for BUT scores in adult (18-65 years) patients with obesity, and evaluated the influence of gender, age and BMI. Females obtained statistically significant higher scores than males in all age groups and in all classes of obesity; patients with obesity, compared with normal weight subjects, generally obtained statistically significant higher scores, but few differences could be attributed to the influence of BMI.

CONCLUSION

The BUT can be a valuable multidimensional tool for the clinical assessment of body uneasiness in obesity; the scores of its sub-scales do not show a linear correlation with BMI values.

School prevention program for eating disorders in Croatia: a controlled study with six months of follow-up

The main purpose of this pilot study was to evaluate the efficacy of a schoolbased program of eating disorder prevention on a sample of young adolescents in Croatia. The program was designed to reduce dietary restraint and preoccupation with shape and weight. One hundred and thirty-nine students (69 boys and 70 girls; mean age 12.8 years) were evaluated; 75 participated in the program (experimental group) and 64 formed the control group. Outcome measures included eating disorder attitudes, dieting behavior, selfesteem, and knowledge of the topics covered by the program. Outcome measures were evaluated one week before the intervention, one week afterwards, and during a follow-up of 6 months. The program significantly reduced eating disorder attitudes and dieting behavior, and improved knowledge in the female experimental group. A significant and positive effect on eating disorders attitude and knowledge, but not on dietary habits, was noticed in the male experimental group. No significant effects were observed in the control group. The findings of this prevention program give encouraging results and should be evaluated in further studies on larger samples.

Complexity of attrition in the treatment of obesity: clues from a structured telephone interview

OBJECTIVES

To investigate the causes of attrition reported by obese patients treated by medical centres.

DESIGN

Observational study.

SETTING

Obese patients enrolled in a long-term study involving 18 Italian medical centres.

PARTICIPANTS

A total of 940 obese patients (727 female; mean age, 49 years; mean BMI, 38.6 kg/m2).

MEASUREMENTS

Causes of attrition reported by dropouts during a structured telephone interview.

RESULTS

After a median observation period of 41 months (range, 25-50), 766 of 940 patients (81.5%) discontinued treatment. Sixty-two per cent of total dropout occurred in the first year of follow-up. Seventy-four per cent of dropouts reported a single primary reasons for treatment interruption. Two primary reasons were reported by 22.4% of patients, and three reasons by 3.4%. Practical difficulties, alone or in combination, were reported by more than half of dropouts (55%), and were the leading cause of attrition followed by perceived failure of treatment. Among practical difficulties, family problems or problems at work and logistics, coupled with health problems other than obesity, were the most frequent reasons of attrition, but also a perceived sense of abandonment or a bad interaction with therapists were frequently reported.

CONCLUSION

Practical difficulties and psychological problems are the most important reasons of attrition reported by patients. A therapeutic alliance addressing these issues has a large potential to reduce treatment interruption and to improve outcome in obesity.

Continuous care in the treatment of obesity: an observational multicentre study

OBJECTIVES

To investigate weight loss and reasons for attrition in obese patients on long-term continuous care.

DESIGN

Observational study with 36 months of follow-up. Setting. Fifteen Italian obesity centres applying a continuous care model of medical treatment.

SUBJECTS

One thousand treatment-seeking obese subjects (785 females, median age 45.1 years, median BMI 37.4 kg m(-2)). Weight loss expectations were systematically recorded at baseline.

INTERVENTIONS

An initial intensive treatment period (3-6 months) was followed by a less intensive continuous care (a follow-up control every 2-4 months). Main outcome measures. Attrition, reasons for treatment interruption and BMI change. Data were recorded by telephone interview in dropouts.

RESULTS

Only 157 patients (15.7%) were in continuous treatment at 36 months. The main reasons of attrition were logistics, unsatisfactory results and lack of motivation. The only basal predictor for continuous care was lower Expected One-Year BMI Loss (P = 0.016). The probability of dropout increased systematically for any 5% expected BMI loss (Hazard ratio, 1.05; 96% confidence interval, 1.01-1.09). The mean percentage weight loss was greater in continuers (5.2% vs. 3.0% in dropouts; P = 0.016). However, the dropouts satisfied with the results or confident to lose additional weight without professional help reported a mean weight loss of 9.6% and 6.5% respectively.

DISCUSSION

Continuous care produces long-term weight loss only in a subgroup of obese patients seeking treatment in medical centres. The finding that subgroups of dropouts report long-term weight loss has implication for the treatment of obesity.

Aminotransferase and gamma-glutamyltranspeptidase levels in obesity are associated with insulin resistance and the metabolic syndrome

Fatty liver at ultrasounds, with/ without raised plasma levels of hepatic enzymes, is common in obesity. In most cases, it is the hallmark of non-alcoholic fatty liver disease (NAFLD), a potentially progressive disease associated with insulin resistance and the metabolic syndrome (MS). We tested the hypothesis that insulin resistance per se might be associated with hepatocellular necrosis. Alanine and aspartate aminotransferases (ALT and AST; no.=799) and gamma-glutamyltranspeptidase (GGT; no.=459) were analyzed in a group of treatment-seeking obese patients recruited in 12 Italian medical centers. Insulin resistance was calculated by the homeostasis model assessment method (HOMA-IR; no.=522). Median ALT and AST increased with increasing obesity class (p=0.001 and p=0.005) and exceeded normal limits in 21.0% of cases. Also HOMA-IR increased with the obesity class (p<0.0001), and was higher in subjects with elevated ALT (median, 4.93 vs 2.89; p<0.0001). A significant correlation was observed between HOMA-IR and ALT (R2=0.208; p<0.0001), as well as between HOMA-IR and AST or GGT (R2=0.112 and R2=0.080; p<0.0001). The correlation was maintained when cases with elevated enzyme levels were omitted from analysis. Diabetes and hypertriglyceridemia were the features of the MS most commonly associated with raised liver enzymes. In logistic regression, after correction for age, gender, BMI and features of the MS, HOMA-IR maintained a highly predictive value for raised ALT, AST and GGT. We conclude that in obesity insulin resistance is a risk factor for raised liver enzyme levels, possibly related to NAFLD.

Weight cycling in treatment-seeking obese persons: data from the QUOVADIS study

OBJECTIVE

To determine parameters of weight history useful for the assessment of weight cycling and their association with psychological distress and binge eating.

DESIGN

Cross-sectional.

SUBJECTS

A total of 1889 treatment-seeking obese subjects, enrolled by 25 Italian centers (78% female subject), aged 20-65 y (median 45); 1691 reported previous efforts to lose weight (median age of first dieting, 30 y).

MEASUREMENTS

The number of yearly attempts to lose weight, weight gain since age 20 y, cumulative weight loss and gain were checked by a predefined structured interview. Psychological distress was tested by means of Symptom Check-List 90 (SCL-90), Binge Eating Scale (BES) and Three Factor Eating Questionnaire (TFEQ).

RESULTS

Differences in anthropometric, clinical and psychological parameters were observed in relation to previous attempts to lose weight. Patients in the upper quartile of parameters of weight history were considered weight cyclers. In multivariate logistic regression analysis, after correction for age, sex and BMI, a high BES score was the only factor systematically associated with a high frequency of dieting (OR, 1.70; 95% confidence interval, 1.22-2.36; P=0.022), with higher cumulative weight loss (1.42; 1.12-1.80; P=0.003) and cumulative weight gain (1.38; 1.06-1.79; P=0.017). However, the sensitivity, specificity and positive predictive value of a high BES score were very low to detect cyclers. Weight cycling did not carry a higher risk of complicating diseases.

CONCLUSIONS

Weight cycling is associated with psychological distress, and binge eating independently increases the risk, but cannot be used to predict cycling. Also, obese patients who do not experience overeating as a loss of control discontinue treatment or regain weight following therapy.

Which factors do provoke binge eating? An exploratory study in eating disorder patients

OBJECTIVE

To study the different factors (external, emotional, cognitive, and physiological) which may trigger binge eating in eating disorder patients and to make a comparison of binge eating triggers in different eating disorder samples, i.e. anorexia nervosa bingeing-purging type and bulimia nervosa (BN).

METHOD

A total of 242 eating disorder patients filled out the Binge Eating Trigger Checklist (BETCH), a new screening device to evaluate the type of situations (and their experienced discomfort) which subjects identify as antecedents of a binge eating episode.

RESULTS

Eating disorder patients report a combination of negative emotions, physiological states (urge for sweets) and negative cognitions as most important antecedents for their bingeing episodes. External stimuli were only reported by a small number of patients and provoked significantly lower levels of discomfort. A comparison of binge eating triggers in bingeing anorexia nervosa patients and bulimic patients showed only a few significant differences.

CONCLUSIONS

Binge eating, as perceived and reported by eating disorder patients, seems to be provoked by a combination of different antecedents, both emotional, cognitive and physiological. Remarkably enough, binge eating triggers did not differ between bingeing anorectic patients and patients suffering from BN.

Which factors do provoke binge-eating? An exploratory study in female students

To study the different factors (external, emotional, cognitive, and physiological) which may trigger binge-eating in young females. A total of 110 female students (between 14 and 25 years of age) filled out the Eating Disorder Inventory (EDI) and the Binge Eating Trigger Checklist (BETCH), a new screening device to evaluate the type of situations (and their experienced discomfort) which subjects identify as antecedents of a binge-eating episode. Approximately 41% of the female students reported binge-eating and 15% admitted they have daily binges. The binge-eating triggers most frequently reported and at the same time having the highest level of discomfort were emotional triggers (feeling bored, depressed, anxious, tense, and sad) and physiological triggers (being hungry and feeling an urge to eat sweets). Fewer food-related cues have been reported whereas dysfunctional cognitions were rarely mentioned as antecedents of binge-eating. Binge-eating, as perceived and reported by female students, seems to be provoked by a combination of different antecedents, both emotional and physiological.

Cognitive-behavioural guided self-help for obesity: a preliminary research

This study examined the effectiveness of the manual for obesity Perdere peso senza perdere la testa (Losing weight without losing your mind) used in form of guided self-help on 161 patients. Three levels of treatments were compared: (a) guided self-help treatment (GSH); (b) minimal guided self-help treatment (M-GSH); (c) control condition (CC). At the end of the treatment, a significant reduction in body weight was observed in GSH and M-GSH, but not in the CC. At six-month follow-up 32.7% of GSH subjects and 15.1% of M-GSH subjects were able to maintain at least a 5% weight loss. The findings show that GSH is more effective than M-GSH in determining a significant short-term reduction of body weight.

The stepped-care approach in anorexia nervosa and bulimia nervosa: progress and problems

The stepped-care approach is based on the assumption that treatment should be less intensive and hence less expensive and intrusive at the start. Current data suggest that cognitive behaviour therapy (CBT) should be the preferred first treatment for bulimia nervosa (BN) patients. By comparison with the numerous trials supporting its efficacy, in fact, the evidence sustaining similar therapies, e.g. interpersonal psychotherapy (IPT) or pharmacological therapy, is weaker. There are now sufficient data to justify the use of less intensive and shorter treatment (i.e. psychoeducational groups and self-help) in less serious cases. If CBT fails, IPT, pharmacological treatment, alternative psychotherapies, modified CBT, day-hospital and inpatient treatments are available, though it is not clear which is the most efficacious second step. The lower level of stepped-care models seems inapplicable in anorexia nervosa (AN). Current data do not suggest first-choice therapies. Management of this disorder is very expensive and requires a very high level of professional treatment and the highest level of the service hierarchy (intensive outpatient treatment, day-hospital, or inpatient treatment). One of the major obstacles to the employment of the stepped-care approach in eating disorders is that few therapists are trained in CBT and IPT. Academic structures and the scientific societies of eating disorders should promote training and dissemination of these effective forms of treatment.

Middle school primary prevention program for eating disorders: a controlled study with a twelve-month follow-up

The aim of this pilot study was to evaluate the efficacy of a new school-based eating disorder prevention program designed to reduce dietary restraint and the level of preoccupation with regard to shape and weight. One hundred and six (61 females and 45 males) 11 to 12-year-old students were evaluated, 55 of whom participated in the program (experimental group). An additional 51 students formed the control group. The program met for six sessions, two hours per session. After six months, the experimental group received two booster sessions of two hours in two consecutive weeks. Outcome measures included the Eating Disorder Examination Questionnaire (EDE-Q), the children's version of the Eating Attitudes Test (EAT), the Rosenberg Self-Esteem Scale (RSES), and a Knowledge Questionnaire (KQ) devised by the authors of the program. The questionnaires were administered in both the experimental and control groups, one week before the intervention, one week afterwards, and at six-month and 12-month follow-ups. Unlike a previous school-based eating disorder prevention program, in the experimental group both an increase in knowledge and a decrease in some attitudes were maintained at 12-month follow-up (Eating Concerns EDE-Q scores). Although more intensive interventions seem necessary to modify shape and weight concern and self-esteem, these findings suggest that the intervention had been useful since it led to both an increase in knowledge and a decrease in some dysfunctional eating attitudes.

Efficacy and tolerability of moclobemide in bulimia nervosa: a placebo-controlled trial

A 6-week double-blind placebo-controlled trial was carried out to examine the efficacy and tolerability of moclobemide, a monoamine oxidase type A selective and reversible inhibitor, in the treatment of bulimia nervosa. Patients were admitted to the study even if they were unable to adhere to a tyramine-free diet. Fifty-two normal-weight women (age range 18-40 years) suffering from bulimia nervosa (DSM-IV criteria) completed the trial. Particular emphasis was placed on evaluating the incidence of hypertension and other side-effects in chronically treated patients. At the usual antidepressant dose of 600 mg, moclobemide was not significantly superior to placebo in the reducing the weekly number of binge eating episodes or in improving several measures of eating attitudes and behaviour (BITE, EDI, TFEQ) in normal-weight bulimia nervosa. The dropout rate was relatively low (29%), and the side-effects were limited and equally distributed between the two treatment groups. No patient experienced a hypertensive crisis during the study and no serious side-effect was detected. The study indicates that moclobemide 600 mg pro die is not efficacious in bulimia nervosa, but it can be safely administered, even to young subjects, at a very high risk of consuming large amounts of tyramine-rich foods without dietary restrictions.

Impact of a history of physical and sexual abuse in eating disordered and asymptomatic subjects

The present study aimed to explore the impact of sexual and/or physical abuse among eating disordered patients (ED) and asymptomatic subjects. A total of 86 patients with anorexia nervosa, 69 patients with bulimia nervosa and 81 asymptomatic subjects were assessed. Among ED, we did not find a significant association between abuse experiences and the severity of the eating disorder, or between abuse and dissociative symptoms. Among ED, self-destructive behaviour appears to be the most important predictor of a history of sexual and/or physical abuse. In contrast, in the asymptomatic group, the score on the Dissociation Questionnaire is the only significant predictor of reported abuse experiences.

Guided self-help of bulimia nervosa in a specialist setting: a pilot study

Seventeen patients meeting the DSM-IV criteria for bulimia nervosa were treated in a specialist setting according to the "guided self-help" approach as outlined in the self-help handbook "Overcoming Binge Eating" by Fairburn. This self-help manual is essentially a condensed version of the cognitive-behavioural therapy for bulimia nervosa developed by the same author. Every patient took part in 8 bimonthly sessions each lasting 20 minutes. All subjects were evaluated both before and after the treatment through a semi-structured interview. Overall, 10 patients (58.8%) did well; 6 of these 10 patients (35.3%) stopped binge-eating and vomiting altogether. Although the conclusions arising from this pilot study have yet to be confirmed by a controlled study, the preliminary findings seem to suggest that "guided self-help" in a specialist setting could, indeed, be not only sufficient in some cases but may also be the most accessible approach in treating many patients affected by bulimia nervosa.

Eating attitudes and prevalence of eating disorders: a survey in secondary schools in Lecce, southern Italy

Epidemiological studies on eating disorders in southern Italy are practically non-existent. This study evaluated the eating attitudes and the prevalence of eating disorders in a sample of 795 students (588 females and 207 males) among 6 secondary schools from Lecce. A two-stage study was conducted: a first screening stage followed by a clinical interview. 58.4% of girls and 19.7% of boys displayed dissatisfaction with regard to their own body. Current dieting was more prevalent in girls (18.7%) than in boys (4.8%); 17.9% of normal weight girls and 11.7% of underweight girls were on a restrictive diet; while only 2.5% of normal weight boys were on a diet. Point prevalence rates of eating disorders found in our sample were: 0.2% anorexia nervosa, 1.7% bulimia nervosa, and 4% eating disorders not otherwise specified category. Although southern Italians are stereotypically different from the northern Italians in terms of physical traits, historical, cultural and social backgrounds, the prevalence of eating disorders in southern Italian adolescent sample is surprisingly similar to those reported by the areas of both northern and central Italy as well as other western countries.

Body fat distribution before and after weight gain in anorexia nervosa

OBJECTIVE

To study abdominal fat distribution in anorexia nervosa subjects and to assess the effects of initial weight regain on abdominal fat distribution.

DESIGN

Longitudinal, clinical study. The baseline measurement was acquired within four days of admission to the eating disorders clinic. All patients were treated by re-feeding, reinforced by psychotherapy. Following weight regain of at least 5 kg, a second body fat distribution evaluation was performed. Of the 21 subjects evaluated at baseline, 14 achieved the goal of body weight regain and were retested.

PATIENTS

Fourteen subjects (age: 18-38 y; body mass index: 11.5-18.3; relative body weight: 54.9-88.3%).

MEASUREMENTS

Total, subcutaneous and visceral abdominal adipose tissue areas at the L4-L5 level were evaluated by computed tomography.

RESULTS

At baseline the subjects showed a higher proportion of visceral adipose tissue (% visceral adipose tissue = 55.3 +/- 26.1). A significant association was observed between body weight and both subcutaneous adipose tissue and total adipose tissue. A regain of body weight of 7.3 +/- 1.6 kg was accompanied by a significant increase in total adipose tissue, comprising both subcutaneous and visceral adipose tissue. The increase observed in subcutaneous adipose tissue, however, was significantly greater than for visceral adipose tissue (212.6% vs 116.8%, respectively, P < 0.01).

CONCLUSION

The results of the current study show a higher proportion of visceral adipose tissue than subcutaneous adipose tissue in anorexia nervosa subjects. With regain of body weight there is a preferential regain of subcutaneous adipose tissue. These data demonstrate a redistribution of abdominal adipose tissue with weight regain in anorexia nervosa subjects.

Family backgrounds and eating disorders

The aim of this study was to assess the possible relationship between the presence of a pathological family background and various eating disorders subgroups. A semi-structured interview was used to assess the socio-demographic and clinical characteristics and the presence of psychological complaints among family members of 79 subjects with anorexia nervosa (AN) and 34 subjects with bulimia nervosa (BN). The subjects were also administered the following self-assessment questionnaires: BITE, EDI, and HSCL-90. There were nonsignificant differences between AN and BN in terms of parental mental disorders. A further subdivision of the patients (as indicated in DSM-IV) revealed significant differences in the distribution of psychiatric family history. In particular, it seems that the presence of purgative behavior is associated with a higher incidence of a pathological family background. These results suggest that pathological family histories are not responsible for the development of ED, but they are an aggravating factor both in AN and BN.

Effect of insulin on lipolysis in adipose tissue of rats of different ages

Several authors have not been able to find any antilipolytic effect of insulin in adipose tissue "in vitro". We investigated the possible role of cell size and/or age of donors on this phenomenon. The lipolytic rates (glycerol release per cell) were lower in the small cells of the 4-6 weeks old rats than in the larger cells of the 25-30 weeks old animals; however, the difference disappeared when the data were expressed per unit of cell surface area. Insulin (0.5-50 ng/ml) failed to inhibit both maximally and submaximally noradrenaline stimulated lipolysis in the adipocytes of the young rats, but its antilipolytic action was fully restored by using glucose-free medium. Therefore, at our experimental conditions, a glucose dependent factor, possibly involving the preferential hydrolysis of newly synthetized triglycerides, seems to blunt or to mask the insulin induced inhibition of glycerol release. Relatively higher rates of glucose metabolism and a lower lipolysis in small fat cells might explain the difference in the action of insulin on glycerol release in the adipose tissue of young rats as compared to the older ones.