A phase II randomised controlled trial of intranasal oxytocin in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is an eating disorder (ED) with high mortality rates and limited response to existing treatments, prompting the need to identify effective agents and adjuncts. There is evidence for an emerging role for the neuropeptide oxytocin (OT) in the pathophysiology of AN, with studies showing a perturbed oxytocinergic system in patients with AN. Preliminary evidence has demonstrated that intranasal OT (IN-OT) can produce anxiolytic effects in AN, as well as reducing concern about eating, and dysfunctional attentional biases related to the disorder. IN-OT is a non-invasive treatment option for AN that requires investigation as an adjunct to nutritional rehabilitation.

METHODS

This multi-site study (Trial Registration:ACTRN1261000897460) sought to replicate and extend a previous randomised placebo-controlled pilot trial of repeated dose IN-OT in patients with AN hospitalised for nutritional rehabilitation. Patients with AN (N=61) received daily IN-OT (18 IU twice per day) or placebo for four weeks, whilst undergoing inpatient hospital treatment. Outcome measures included ED psychopathology (primary) as measured by the Eating Disorder Examination (EDE) and Body Mass Index (BMI; secondary). Participants were assessed pre- and post-treatment, and at six months following the intervention. The effects of the first and last doses of IN-OT on responses (anxiety ratings and salivary cortisol) to a high-energy snack were also examined.

RESULTS

Sixty-one female inpatients (Mage=24.36,SD=7.87) with an average BMI of 16.24 (range: 11.43-18.55), were recruited into the study. No significant differences were found between placebo and OT groups at any of the time points on the outcomes of interest, but significant improvements in almost all psychological parameters in both groups were evident over time. IN-OT did not significantly reduce anxiety nor salivary cortisol in response to a high-calorie snack.

CONCLUSION

This is the largest randomised placebo-controlled trial of repeated dose intranasal OT in people with AN, during refeeding. The therapeutically promising findings of the pilot study were not replicated. Limitations and reasons for the non-replication included relatively large variance, baseline psychopathology scores being higher in this patient group, potential ceiling effects in BMI and ED psychopathology as well as differing comorbidities.

Hyoro-zeme in the Battle for Tottori Castle: The first description of refeeding syndrome in Japan

Eating after a period of starvation can cause refeeding syndrome, a fatal condition caused by a shift in fluids and electrolytes that can result in sudden death. The Battle for Tottori Castle (1581) during the Warring States Period of Japan, which witnessed the use of hyoro-zeme, the tactic of intentionally starving a besieged enemy, was followed by a dramatic episode of mass death among starving soldiers not from fighting but from eating; accounts from the period relate that many of the besieged soldiers survived the hyoro-zeme only to die soon afterwards when they were fed immediately after surrendering. We herein reviewed the Japanese historical records of the Battle for Tottori Castle and hypothesized that the hyoro-zeme episode they recount is possibly the oldest description of refeeding syndrome to be documented in Japan. Our investigation revealed sufficient evidence that refeeding syndrome was the cause of the mass deaths reported after the famous battle.

Day hospital program for anorexia nervosa in children and adolescents: Assessment, management and specific focus on early onset anorexia nervosa

INTRODUCTION

The French day hospital program specialized in eating disorders (ED) opened in January 2018. Our study presents preliminary data on clinical profiles of patients with anorexia nervosa (AN). We describe more specifically clinical characteristics of patients with early onset AN and according to their therapeutics orientations. Then, we compare the weight gain of patients managed only in day-patient (DP) treatment with those managed initially inpatient (IP) treatment and relays in DP.

METHODS

Ninety-two patients with AN, aged between 8 and 18 years, were evaluated with several questionnaires (EDI-2, EDE-Q, BSQ, EDS-R, CDI, STAI-Y, VSP-A, EPN-13).

RESULTS

Patients with early onset AN, n = 23 (25.3%), presented more restrictive behaviors, less marked dietary symptomatology, a lower degree of clinical perfectionism and a less marked feeling of ineffectiveness than adolescent patients with AN. Regarding the choice of hospitalization modality (DP alone or IP-DP), the only difference highlighted was the severity of patient undernutrition. Among the patients who were treated (IP-DP n = 27 vs DP alone n = 25), the weight evolution after one month and at discharge was favorable for both groups.

CONCLUSION

These preliminary data suggest the effectiveness of DP in the care of AN in children and adolescents.

Can we predict the development of acute gastric dilatation in patients with anorexia nervosa?

BACKGROUND

Acute gastric dilatation can develop in patients with anorexia nervosa who are being refed to achieve weight restoration. If unrecognized, this condition is associated with significant morbidity and mortality. Patients with acute gastric dilatation usually have abdominal pain, nausea, and vomiting. Abdominal imaging confirms the diagnosis. This study aims to identify risk factors associated with the development of acute gastric dilatation in patients with severe restrictive eating disorders in order to hasten diagnosis and guide treatment. This study also aims to define the clinical outcomes of patients with acute gastric dilatation.

METHODS

In this retrospective case series, 15 patients with a restrictive eating disorder were studied. Multiple variables were assessed for significant correlation with stomach size.

RESULTS

15 patients with a restrictive eating disorder were identified as being diagnosed with acute gastric dilatation through chart review during the study period. The average dilated stomach size was 20.5 cm. There was no significant correlation of stomach size with any of the following: % ideal body weight on day of admission, % ideal body weight on day of imaging study, rate of weight gain (kg per week), or duration of illness. Serum levels of sodium, potassium, phosphorus, magnesium, calcium, bicarbonate, blood urea nitrogen, glucose, albumin, and hematocrit on the day of imaging, did not correlate with stomach size. All patients were treated with conservative management. None of the patients required surgical intervention or progressed to gastric necrosis or perforation, and there were no recurrences of the acute gastric dilatation.

CONCLUSIONS

There are no specific risk factors significantly associated with the development of acute gastric dilatation in patients with severe restrictive eating disorders. Clinicians should maintain a high index of suspicion for this condition when patients are experiencing abdominal pain, nausea, or vomiting. When promptly diagnosed and treated, outcomes are good. If diagnosis is delayed, the outcome can be dire.

Multi-electrolyte disturbance and supplementation in severely malnourished hospitalized adolescents with restrictive eating disorders

BACKGROUND

This study describes the prevalence of hypophosphatemia, hypokalemia, and/or hypomagnesemia and resulting electrolyte supplementation during refeeding in severely malnourished youths hospitalized for restrictive eating disorders.

METHODS

Hospitalized patients between 11-26y (N = 81) at < 75% treatment goal weight (TGW) were assessed through retrospective chart review. Outcomes were compared between participants < 70% TGW and those 70-75% TGW. Nutritional rehabilitation started at 1750 kcals/day and advanced by 500 kcal every other day until target intake was achieved. Associations between %TGW on admission; hypophosphatemia, hypokalemia, and/or hypomagnesemia; and electrolyte supplementation were examined.

RESULTS

Of the 24 (29.6%) participants with hypophosphatemia, hypokalemia, and/or hypomagnesemia, 7 (8.6%) received supplementation; the remainder corrected without supplementation. Participants < 70% TGW did not differ from those 70-75% TGW on rates of these conditions or need for supplementation.

CONCLUSIONS

Hospital-based nutritional rehabilitation did not confer increased rates of hypophosphatemia, hypokalemia, and/or hypomagnesemia or need for electrolyte supplementation in patients < 70% TGW compared to those 70-75% TGW. While additional research is needed to establish clinical practice guidelines on electrolyte management in this population, our findings suggest that nutritional rehabilitation may be reasonably undertaken without prophylactic electrolyte supplementation, even in patients < 70% TGW.

elegans

Fasting is a popular dietary strategy because it grants numerous advantages, and redox regulation is one mechanism involved. However, the precise redox changes with respect to the redox species, organelles and tissues remain unclear, which hinders the understanding of the metabolic mechanism, and exploring the precision redox map under various dietary statuses is of great significance. Twelve redox-sensitive C. elegans strains stably expressing genetically encoded redox fluorescent probes (Hyperion sensing H2O2 and Grx1-roGFP2 sensing GSH/GSSG) in three organelles (cytoplasm, mitochondria and endoplasmic reticulum (ER)) were constructed in two tissues (body wall muscle and neurons) and were confirmed to respond to redox challenge. The H2O2 and GSSG/GSH redox changes in two tissues and three organelles were obtained by confocal microscopy during fasting, refeeding, and satiation. We found that under fasting condition, H2O2 decreased in most compartments, except for an increase in mitochondria, while GSSG/GSH increased in the cytoplasm of body muscle and the ER of neurons. After refeeding, the redox changes in H2O2 and GSSG/GSH caused by fasting were reversed in most organelles of the body wall muscle and neurons. In the satiated state, H2O2 increased markedly in the cytoplasm, mitochondria and ER of muscle and the ER of neurons, while GSSG/GSH exhibited no change in most organelles of the two tissues except for an increase in the ER of muscle. Our study systematically and precisely presents the redox characteristics under different dietary states in living animals and provides a basis for further investigating the redox mechanism in metabolism and optimizing dietary guidance.

A systematic review of people's lived experiences of inpatient treatment for anorexia nervosa: living in a "bubble"

BACKGROUND

Treatment for anorexia nervosa (AN) is typically delivered on a continuum of care, starting with outpatient treatment, and moving onto intensive outpatient, day or residential treatment and/or inpatient hospitalisation. However, minimal attention has been afforded to the lived experiences of persons undergoing inpatient treatment for AN. In particular, qualitative literature pertaining to the lived experiences of specialist inpatient or residential treatment of AN remains fragmented and incomplete. The aim of this review was to synthesise current literature exploring patients' lived experiences of residential and inpatient treatment for AN within eating disorder-specific treatment services.

METHODS

Five databases were searched and a qualitative thematic systematic review and meta-synthesis of 11 studies were conducted.

RESULTS

Eleven studies of 159 participants were included. Four meta-themes were constructed from the data: (1) a medical discourse-"I don't think it's individualised here"; (2) restrictive practice-living in a "bubble"; (3) myself, others and "a similar demon"; and (4) I am "not just another anorexic". The data also revealed two cross-cutting themes: (1) more than a single experience; and (2) meaning making and identity.

CONCLUSIONS

These findings highlight the complex and multifaceted nature of the inpatient treatment experience as well as the inherent conflicts in balancing the necessity of medical and psychological intervention with person-centred treatment approaches in the treatment of AN.

Comparative analysis of whole blood transcriptomics between European and local Caribbean pigs in response to feed restriction in a tropical climate

BACKGROUND

Feed restriction occurs frequently during pig growth, either due to economic reasons or stressful environmental conditions. Local breeds are suggested to have better tolerance to periods of feed restriction. However, the mechanisms underlying the response to feed restriction in different breeds is largely unknown. The aims of the present study were (1) to compare the blood transcriptome profile in response to feed restriction and refeeding of two contrasted breeds, Large White (LW), which has been selected for high performance, and Creole (CR), which is adapted to tropical conditions, and (2) to investigate the effect of a moderate feed restriction and refeeding on whole blood transcriptome. Analysis of blood transcriptome allows to study the response to feed restriction and refeeding in a dynamic way. RNAseq was performed on blood samples of growing LW and CR pigs at two time points: after 3 weeks of feed restriction and after 3 weeks of refeeding. The data was compared with samples from control animals offered the same diet on an ad libitum basis throughout the whole experiment.

RESULTS

In terms of performance (body weight and feed efficiency), CR pigs were less impacted by feed restriction than LW. The transcriptional response to feed restriction and refeeding between CR and LW was contrasted both in terms of number of DEGs and enriched pathways. CR demonstrated a stronger transcriptional response to feed restriction whereas LW had a stronger response to refeeding. Differences in the transcriptional response to feed restriction between CR and LW were related to cell stress response (Aldosterone Signalling, Protein ubiquitination, Unfolded Protein Signalling) whereas after refeeding, differences were linked to thermogenesis, metabolic pathways and cell proliferation (p38 MAPK, ERK/MAPK pathway). In both breeds, transcriptional changes related to the immune response were found after restriction and refeeding.

CONCLUSIONS

Altogether, the present study indicates that blood transcriptomics can be a useful tool to study differential genetic response to feed restriction in a dynamic way. The results indicate a differential response of blood gene expression to feed restriction and refeeding between breeds, affecting biological pathways that are in accordance with performance and thermoregulatory results.

Monitoring and treating hypoglycemia during meal-based rapid nutritional rehabilitation in patients with extreme anorexia nervosa

PURPOSE

Hypoglycemia, a complication of prolonged starvation, can be life-threatening and is presumed to contribute to the high mortality of anorexia nervosa. Furthermore, early refeeding in severe anorexia nervosa can precipitate paradoxical post-prandial hypoglycemia. Few studies have analyzed the course of hypoglycemia during nutritional rehabilitation in patients with extremely low-weight anorexia nervosa. No standard practice guidelines exist and recommended strategies for managing hypoglycemia (i.e., nasogastric feeds, high-fat diets) have limitations.

METHODS

This cohort study assessed prevalence and correlates of hypoglycemia in 34 individuals with very low body mass index (BMI < 14.5 kg/m²) anorexia nervosa treated in an intensive eating disorders program with an exclusively meal-based rapid weight gain nutritional protocol. Hypoglycemia was monitored with frequent point of care (POC) glucose testing and treated with oral snacks and continuous slow intravenous 5% dextrose in 0.45% saline (IV D5 1/2 NS) infusion.

RESULTS

POC hypoglycemia was detected in 50% of patients with highest prevalence noted on the day of admission. Hypoglycemia resolved during the first week of hospitalization in most cases and was generally asymptomatic. Seven patients (20.6%) experienced at least one episode of severe hypoglycemia with POC glucose < 50 mg/dl. Lower admission BMI was associated with higher likelihood of developing hypoglycemia and longer duration of hypoglycemia.

CONCLUSION

Meal-based management of hypoglycemia supplemented by continuous IV D5 1/2 NS appears a viable alternative to alternate strategies such as enteral tube feeding. We discuss recommendations for hypoglycemia monitoring during nutritional rehabilitation and directions for future research.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Renal Function in Patients Hospitalized With Anorexia Nervosa Undergoing Refeeding: Findings From the Study of Refeeding to Optimize Inpatient Gains

PURPOSE

Among complications of malnutrition secondary to anorexia nervosa (AN) or atypical anorexia nervosa (AAN), renal impairment remains poorly elucidated. Evaluating renal function in hospitalized pediatric patients with AN and AAN undergoing refeeding will yield important information to guide clinicians in screening and managing renal dysfunction in this population.

METHODS

This is a secondary analysis of data from the Study of Refeeding to Optimize Inpatient Gains trial, a multicenter randomized clinical trial comparing higher calorie refeeding versus lower calorie refeeding in 120 adolescents and young adults hospitalized with medical instability secondary to AN or AAN. Baseline disease characteristics were obtained. Vital sign measurements, weight, electrolytes, and fluid status were evaluated daily to ascertain medical stability. Renal function on admission and throughout hospitalization was quantified using daily creatinine measurement and calculation of the estimated glomerular filtration rate (eGFR) using the modified Schwartz equation. Regression analysis and mixed linear models were utilized to evaluate factors associated with eGFR.

RESULTS

Of the 111 participants who completed treatment protocol, 33% had a baseline eGFR less than 90, suggesting renal impairment. Patients who experienced more rapid weight loss and more severe bradycardia were more likely to have low admission eGFR. While eGFR improved during refeeding, eGFR change by day based on refeeding treatment assignment did not reach statistical significance (95% confidence interval, -1.61, 0.15]; p = .095).

DISCUSSION

Renal impairment is evident on admission in a significant number of adolescents and young adults hospitalized with AN and AAN. We demonstrate that short-term medical refeeding yields improvement in renal function.

Stoma recycling in a surgical neonatal unit: Prevalence, challenges, and review of nursing attitudes

AIM

Recycling has been shown to improve growth, nutrition and facilitate early stoma closure. We aim to review current practice and nursing experience at a tertiary paediatric surgical unit and to evaluate possible areas for improvement.

METHOD

Retrospective study of all neonates who underwent a stoma closure between January 2018 and October 2020, alongside a nursing staff survey on experience and barriers to effective recycling. Data presented as median (range) and number (percentage). P value <0.05 was regarded as significant.

RESULTS

A total of 71 neonates were included; median birthweight 869.5 (500-3600)g and gestation 26 (23-40) for a median of 15.5 (1-51) days. Rates of early stoma closure were similar in both the recycling (RG) and non recycling groups (NRG); 15/29 vs. 21/42, p > 0.999. Thirty-nine neonatal nurses responded to the survey with 36/39 (92%) having prior experience of recycling. Time constraints were the main reason nurses felt it was difficult to achieve effective recycling, with some also being worried about causing damage. Increased training and parental involvement were two potential solutions suggested by nurses to overcome these issues.

CONCLUSION

Despite the known benefits, less than half of our cohort had successful recycling prior to stoma closure. Increased training, development of a uniform policy and involvement of the parents may help to improve the rates of stoma recycling.

LEVEL OF EVIDENCE

Level III (Retrospective Comparative Study).

Aging and short-term calorie restriction differently affect the cardiac and skeletal muscle expression of genes regulating energy substrate utilization in male rats

Aging affects the energy metabolism differently in the cardiac and skeletal muscles. The study aim was to assess the effects of short-term calorie restriction (SCR) and refeeding on the expression of genes involved in the control of cardiac and skeletal muscle energy metabolism in old vs. young male rats. Young (4 mo) and old (24 mo) rats were subjected to 60% SCR for 30 days, and refed ad libitum for 2 or 4 days. In the cardiac (CM) and skeletal muscles (SM) we compared the gene expression (qPCR) of carnitine palmitoyltransferase-I (Cpt-I), peroxisome proliferator-activated receptor beta/delta (Ppar-β/δ), glucose transporter 4 (Glut4), peroxisome proliferator-activated receptor-γ coactivator-1α (Pgc-1α), and sirtuin 3 (Sirt3). In CM, aging increased Cpt-I expression but did not affect the other genes. In SM, Cpt-I, Glut4, Pgc-1α, and Sirt3 mRNA levels were lower in old than young rats. In CM of only young rats SCR increased Cpt-I expression which remained elevated after refeeding. Upon SCR, the expression of Ppar-β/δ, Glut4, Pgc-1α, and Sirt3 in CM increased in young but not old rats, and refeeding re-established control levels. In SM of young rats SCR increased Ppar-β/δ and Pgc-1α, and decreased Sirt3 expression, whereas refeeding generally decreased these mRNA levels. In SM of old rats SCR decreased only Pgc-1α expression. The adaptive response to SCR and subsequent refeeding is muscle tissue-specific and differs in young and old male rats. SCR appears to increase the efficiency of glucose and fatty acid utilization in the cardiac muscle of young, but not old male rats.

Comparison of a low carbohydrate intake and standard carbohydrate intake on refeeding hypophosphatemia in children and adolescents with anorexia nervosa: a pilot randomised controlled trial

BACKGROUND

Nutritional rehabilitation for patients with anorexia nervosa involves balancing the need for weight gain whilst mitigating the risk of refeeding syndrome. Graded caloric increases and restriction of calories from carbohydrate have been used to minimise the risk of developing refeeding hypophosphatemia. There is little evidence to support the recommended nutrient composition, specifically the recommended carbohydrate intake that is safe in this population. The aim of this pilot study was to compare the effect of a low and a standard carbohydrate feeding protocol on serum phosphate levels in children and adolescents with anorexia nervosa.

METHODS

A pilot study of 23 children and adolescents with anorexia nervosa admitted for medical stabilisation to the adolescent ward of a tertiary hospital was undertaken. Participants were commenced on an oral feeding protocol and were randomly allocated to isocaloric meal plans that were either low carbohydrate (< 40% total energy from carbohydrate) or standard carbohydrate (50-60% total energy from carbohydrate). Serum phosphate levels were monitored daily across the first week and twice weekly thereafter. Clinical status, including weight gain, was monitored throughout admission.

RESULTS

52% (n = 12) of participants were allocated to the low carbohydrate group and 48% (n = 11) were allocated to the standard carbohydrate group. No patients in either of the diet groups developed refeeding hypophosphatemia in the first seven days of admission. Weight gain during the first week was significantly higher in the standard carbohydrate diet (1.4 kg/wk ± 0.5) compared to the low carbohydrate diet (0.6 kg/wk ± 0.9), p value 0.03. Participants from both diet groups were largely orally fed with less than 10% of the total number of meals and/or snacks across both groups provided as nutrition supplement drinks, either orally or enterally.

CONCLUSION

This pilot study supports that a standard carbohydrate intake (providing 50-60% of total energy from carbohydrate) optimises nutritional rehabilitation without increasing the risk of refeeding hypophosphatemia in adolescent inpatients with anorexia nervosa. CTN: ACTRN12621000300875. Plain English Summary: People with eating disorders who are underweight or malnourished, such as patients with anorexia nervosa, are at risk of refeeding syndrome when they receive treatment and return to regular eating. Refeeding syndrome may cause fluid and electrolyte shifts. This can occur as a result of the reintroduction of carbohydrates, and can have potentially life-threatening consequences if not managed appropriately. Refeeding hypophosphatemia is one of the early markers of refeeding syndrome. This study compared patients who were provided a low carbohydrate diet (40% total energy from carbohydrate) to those who were provided a standard carbohydrate diet (50-60% total energy from carbohydrate) to see if patients from either group were more at risk of developing refeeding syndrome. No patients in either of the diet groups developed refeeding hypophosphatemia. This pilot study may help to ensure that when patients get treated for their eating disorder in hospital, they can return to a normal diet as soon as possible with close medical monitoring.

Molecular cloning and tissue distribution of the leptin gene in gibel carp (Carassius auratus gibelio): Regulation by postprandial and long-term fasting treatment

Leptin is a multifunctional hormone that serves as a feeding regulator in mammals. However, the effect of leptin on fish remains unclear. We sequenced the leptin gene from gibel carp (Carassius auratus gibelio) and designated it gLEP. The length of the gLEP cDNA sequence was 562 bp, including an open reading frame (ORF) of 516 bp. The ORF putatively encodes a peptide of 171 amino acids, including a signal peptide of 20 amino acids. gLEP shared low primary amino acid sequence homology with leptin genes in vertebrates, whereas three-dimensional (3D) structural modeling revealed strong identity with the structures in other vertebrates. gLEP mRNA was widely distributed in all of the tissue that we examined, with the highest levels of expression in the hepatopancreas. Hepatopancreas gLEP mRNA expression levels showed no changes following postprandial treatment. However, hepatopancreas gLEP mRNA expression levels greatly decreased (P < 0.05) after fasting but substantially increased (P < 0.05) after refeeding in the long-term fasting treatment. In summary, these results indicate that leptin expression could be influenced by the regulation of food intake. These results provide the initial step toward elucidating the appetite regulatory systems associated with leptin in gibel carp.

Refeeding activates neurons in the dorsomedial hypothalamus to inhibit food intake and promote positive valence

Objective

The regulation of food intake is a major research area in the study of obesity, which plays a key role in the development of metabolic syndrome. Gene targeting studies have clarified the roles of hypothalamic neurons in feeding behavior, but the deletion of a gene has a long-term effect on neurophysiology. Our understanding of short-term changes such as appetite under physiological conditions is therefore still limited.

Methods

Targeted recombination in active populations (TRAP) is a newly developed method for labeling active neurons by using tamoxifen-inducible Cre recombination controlled by the promoter of activity-regulated cytoskeleton-associated protein (Arc/Arg3.1), a member of immediate early genes. Transgenic mice for TRAP were fasted overnight, re-fed with normal diet, and injected with 4-hydroxytamoxifen 1 h after the refeeding to label the active neurons. The role of labeled neurons was examined by expressing excitatory or inhibitory designer receptors exclusively activated by designer drugs (DREADDs). The labeled neurons were extracted and RNA sequencing was performed to identify genes that are specifically expressed in these neurons.

Results

Fasting-refeeding activated and labeled neurons in the compact part of the dorsomedial hypothalamus (DMH) that project to the paraventricular hypothalamic nucleus. Chemogenetic activation of the labeled DMH neurons decreased food intake and developed place preference, an indicator of positive valence. Chemogenetic activation or inhibition of these neurons had no influence on the whole-body glucose metabolism. The labeled DMH neurons expressed prodynorphin (pdyn), gastrin-releasing peptide (GRP), cholecystokinin (CCK), and thyrotropin-releasing hormone receptor (Trhr) genes.

Conclusions

We identified a novel cell type of DMH neurons that can inhibit food intake and promote feeding-induced positive valence. Our study provides insight into the role of DMH and its molecular mechanism in the regulation of appetite and emotion.

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Fasting-refeeding activates a subset of neurons in the dorsomedial hypothalamus (DMH).

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Chemogenetic inhibition of the DMH neurons increases food intake.

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Chemogenetic activation of the DMH neurons inhibits food intake and promotes positive valence.

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The DMH neurons express pdyn, GRP, CCK and Trhr genes.

Two Acute Liver Injuries in a Patient With Malnutrition

Chronic starvation and refeeding have been associated with liver injury (LI). We present a patient with anorexia nervosa who exhibited both phenomena of malnutrition-related LI. At presentation, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated at 154 and 136 U/L, respectively, and rose rapidly to peaks of 750 and 638 U/L, respectively, as nutrition was introduced. Mechanisms of starvation-related LI include impaired degradation and secretion of lipids, as well as starvation-induced autophagy. LI during refeeding may be related to rapid increase in glucose availability. These phenomena are crucial to consider in patients with chronic starvation undergoing refeeding.

Hypokalemia in patients with anorexia nervosa during refeeding is associated with binge-purge behavior, lower body mass index, and hypoalbuminemia

BACKGROUND

Hypokalemia is frequently found in patients with anorexia nervosa and sometimes leads to life-threatening conditions. Although their serum potassium levels are considered to further decrease during refeeding, no previous studies have addressed actual changes in the serum potassium levels and potential mechanisms underlying hypokalemia during the refeeding period of patients with anorexia nervosa. In this study, we investigated factors associated with hypokalemia during refeeding of patients with anorexia nervosa.

METHODS

We recruited 52 independent patients from 89 admissions with anorexia nervosa (body mass index, 13.0 ± 3.3) from the psychiatry unit in Ashikaga Red Cross Hospital during the period from April 2003 to March 2018 and analyzed serum potassium levels at admission. Of the 89 admissions, 66 admissions with > 1-week hospitalization were recruited to determine the lowest potassium levels during the refeeding period. We analyzed these levels with multiple linear regression analysis with explanatory variables, including data upon admission and treatment-related indicators.

RESULTS

The initial serum potassium level of 3.6 ± 0.9 mg/dl decreased to 3.1 ± 0.7 mg/dl at nadir hypophosphatemia, which was observed an average of 2.5 days after admission. A lower serum potassium level at admission and a lower nadir potassium level during refeeding were associated with a lower body mass index, hypoalbuminemia, and binge-purge behavior. Similar results were obtained when the analysis included restrictive or binge-purge types as well as the independent patient group.

CONCLUSIONS

Lower body mass index, hypoalbuminemia, and binge-purge behavior might be used as indicators to guide clinical approaches for controlling serum potassium levels in patients with anorexia nervosa during refeeding. Hypokalemia, low levels of serum potassium, in patients with anorexia nervosa sometimes leads to life-threatening conditions. Thus, it is of great importance to predict the risk of hypokalemia in patients with anorexia nervosa during the refeeding period. Our study found that hypokalemia in patients with anorexia nervosa during refeeding is associated with a lower body mass index and hypoalbuminemia (low levels of serum albumin), in addition to binge-purge behavior.

Severe neutropenia in an anorexic adolescent girl: a stigma of underfeeding syndrome?

PURPOSE

We describe a case of severe, prolonged neutropenia in an adolescent girl hospitalized for anorexia nervosa (AN) which occurred during a refeeding procedure in the absence of refeeding syndrome.

METHODS

This case report includes retrospective anamnestic, clinical and biological data from the patient's medical record. A literature review was conducted on the haematological changes described in the undernutrition and refeeding periods, and also on recent data for underfeeding syndrome in patients with anorexia nervosa.

CONCLUSION

Leuconeutropenia is an adaptive condition observed in undernutrition in AN, usually rapidly and completely reversible in the course of refeeding and weight gain. We describe a rare case of severe, prolonged neutropenia despite appropriate care in the absence of refeeding syndrome and without gelatinous bone marrow transformation. We suggest that neutropenia in adolescent anorexia nervosa could be a stigma of underfeeding syndrome resulting from an overly cautious refeeding strategy.

LEVEL OF EVIDENCE

Level V, descriptive study.

Clinical Factors Associated With Survival Outcomes in Starved Equids: A Retrospective Case Series

Each year in the United States, unwanted horses may become neglected, starved, or abandoned. Recovery therapies include refeeding and veterinary care, often requiring substantial time and financial investments. To better understand the likelihood for starved horses to successfully survive the first 100 days after initial evaluation, a retrospective case series was performed using hospital records of starved horses at the University of Tennessee College of Veterinary Medicine. A body condition score (BCS) of 3 or less and a malnourished diagnosis were utilized to select case records from an 11-year period (n = 82). Animal descriptors, vital signs, complete blood count data, blood chemistry panels, parasite load, and refeeding diet information were analyzed as available within the case record. Mixed model analyses of variance (PROC GLIMMIX, SAS 9.4) were utilized to test if response variables differed in horses that lived or died. Generalized linear mixed models were used to test factors associated with survival probability 100 days postinitial hospitalization. Body temperature (P = .05) and BCS (P = .0002) were significantly lower in horses that died compared with horses that survived. In addition, white blood cells were increased in horses that died (11.6 ± 1.3 cells/μL) compared with horses that survived (8.6 ± 0.5 cells/μL; P = .03). The initial BCS was associated with probability for survival, where survival likelihood increased 14.6 times for each 1 whole unit increase in the BCS. These results indicate the relevance of using the BCS as a predictor for future survival and as a measure for clinical decision-making.

Body mass index and blood urea nitrogen to creatinine ratio predicts refeeding hypophosphatemia of anorexia nervosa patients with severe malnutrition

AIM

To investigate development of refeeding hypophosphatemia during the refeeding period and the extent of the decrease in the serum phosphorus level among anorexia nervosa patients with severe malnutrition.

OBJECTIVE

The accurate prediction of the severity of refeeding hypophosphatemia in patients with anorexia nervosa during acute treatment is of great importance. Although some predictors were found in previous reports, these studies used binominal data-the presence or absence of hypophosphatemia-as an outcome indicator but not the extent of serum phosphorus level decrease. It is crucial in clinical settings to predict the extent of the serum phosphorus level decrease as well as development of refeeding hypophosphatemia, in particular, for patients with severe malnutrition, who has a higher risk of death.

METHODS

We investigated 63 admissions from 37 patients with anorexia nervosa who had severe malnutrition (admission body mass index 11.5 ± 1.6) and carried out a linear discriminant regression analysis for the development of refeeding hypophosphatemia. The extent of the decrease in the serum phosphorus level were investigated using multiple linear regression analysis. Explanatory variables included data upon admission (age, sex, body mass index, blood urea nitrogen to creatinine ratio, albumin, initial serum phosphorus level, anorexia nervosa type, i.e., restrictive or binge-purge) as well as treatment-related indicators (calorie intake, amount of phosphate administered, and rate of weight gain).

RESULTS

Development of refeeding hypophosphatemia and a change in serum phosphorus levels were predicted by body mass index and elevated blood urea nitrogen to creatinine ratio.

CONCLUSIONS

Our study found that refeeding hypophosphatemia among patients with severe malnutrition was predicted by a lower body mass index and elevated blood urea nitrogen to creatinine ratio.

Hunger and satiety perception in patients with severe anorexia nervosa

OBJECTIVES

Appetite is a subjective essential sense. In patients with severe anorexia nervosa (AN), controversy remains whether this sensation is altered. The objectives were to clarify, in patients with severe AN: (1) Whether the appetite changes during partial weight restoration, (2) Whether potential changes in appetite are related to (i) diagnostic subtype of AN, (ii) psychopharmacological treatment, (iii) disease duration, (iv) duration of hospitalization, and (v) baseline body mass index (BMI).

METHODS

The study consisted of 39 patients, with a mean age of 23.7 ± 8 and an admission mean BMI of 13.1 ± 2.0 kg/m². The patients were consecutively admitted to a specialized somatic nutrition unit between 2015 and 2016. They were asked to rate their hunger and satiety on a numeric visual analog scale (VAS), before and after a lunch meal at admission and at discharge in the same standardized environment. The patients could participate more than once if readmitted, resulting in a total of 119 observed meals. Data were analyzed in a regression model for repeated measures.

RESULTS

At admission, changes in hunger and satiety perception were weak. After weight gain of 10.4% ± 8.5% within a median of 26 (IQR: 25) days, there was a slight increase in hunger perception, p = 0.049. However, there was no detectable change in satiety perception. There was no noticeable correlation between appetite change and psychopharmacological treatment, diagnostic subtype, BMI, duration of hospitalization, and disease duration.

CONCLUSION

Hospitalized patients with severe AN exhibit strikingly weak changes in hunger and satiety perception during standardized and supervised meals.

LEVEL OF EVIDENCE

Level IV, evidence obtained from multiple time series analysis.

Extremely severe anorexia nervosa: Hospital course of 354 adult patients in a clinical nutrition-eating disorders-unit

BACKGROUND AND AIMS

The clinical nutrition-eating disorders-unit in Raymond Poincaré Hospital is a reference center for the management of severe malnutrition and its complications in patients with anorexia nervosa (AN). The purpose of this study is to specify socio-demographic, anamnesic and clinical characteristics of AN patients hospitalized for extreme malnutrition, to identify types and prevalence of medical complications presented during their hospitalization for refeeding and the evolution of patients nutritional status.

METHODS

Demographic, clinical and paraclinical data of 354 severely malnourished AN patients were collected, during their first hospitalization in the unit, between November 1997 and January 2014, through medical records. The prevalence of medical complications was compared between the 2 AN subtypes (restricting and binging-purging).

RESULTS

339 patients were female and mean age was 28.7 ± 10.7 years old. Duration of AN was 9.5 ± 9 years, 173 (48.9%) patients had a restricting AN subtype. BMI at admission was 12.2 ± 1.6 kg/m², 280 (79.3%) patients had already been hospitalized for AN in other hospitals before. Psychiatric comorbidities were present in 168 (47.5%) patients. Associated somatic comorbidities concerned 70 (19.8%) patients. Outcomes during hospitalization were marked by 4.1 ± 3.9 kg weight gain on 36.9 ± 30.5 days. Enteral nutrition was provided in 304 (85.9%) patients. Main medical complications during hospitalization were: anemia (79%), neutropenia (53.9%), hypertransaminasemia (53.7%), osteoporosis (46.3%), hypokalemia (39.5%), hypophosphatemia (26%), hypoglycemia (13.8%), infectious complications (24.3%), cardiac dysfunction (7.1%), and proven gelatinous bone marrow transformation (6.5%). Hypokalemia was more frequent in binging-purging subtype. Lympho-neutropenia and hypertransaminasemia were more frequent in restricting subtype. During their hospitalization, 35 (10%) patients were referred to medical intensive care unit and 5 patients died.

CONCLUSIONS

AN patients hospitalized for severe malnutrition in a specialized clinical nutrition unit have severe and frequent medical complications. Psychiatric comorbidities are also frequent and could complicate medical care. A specialized and multidisciplinary management of these patients is therefore essential.

Evaluation of cognitive function in patients with severe anorexia nervosa before and after medical stabilization

BACKGROUND

The purpose of this study was to quantify cognitive deficits in severe anorexia nervosa (AN) before and after medical stabilization.

METHODS

This was a prospective study of 40 females between the ages of 18 and 50 admitted to a medical stabilization unit with severe AN (%IBW < 70). The primary outcome of the study was change in test scores on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline and after medical stabilization.

RESULTS

There were no statistically significant differences in baseline RBANS scores between AN patients overall and controls (p = 0.0940). There was a statistically significant change in RBANS from baseline 94.1 + 12.7 to medical stabilization 97.1 + 10.6 (p = 0.0173), although notably both mean values fell within the average range. There were no significant differences in baseline RBANS scores between controls and AN-BP patients (p = 0.3320) but significant differences were found between controls and AN-R patients (p = 0.0434).

CONCLUSIONS

No baseline deficits in cognition were found in this sample of women with severe AN.

Response of metabolic hormones and blood metabolites to realimentation in rehabilitated harbor seal (Phoca vitulina) pups

Mammals with increased requirements for adipose tissue stores, such as marine mammals, have altered nutrient allocation priorities compared to many terrestrial mammals and thus the physiological response to undernutrition (low nutritional status) and realimentation (refeeding) may differ. Key regulators of nutrient allocation and tissue specific growth include metabolic hormones of the somatotropic axis, growth hormone (GH) and insulin-like growth factor (IGF)-I, as well as satiety and adipose promoting ghrelin and the stress hormone cortisol. Longitudinal measurements of metabolic hormones, blood metabolites, and morphometrics were collected over a 10-week period in twelve (male n = 3, female n = 9) harbor seal pups (< 6 weeks of age). Blood metabolites were used to indicate metabolic response during realimentation while morphometrics estimated tissue specific growth priorities. Harbor seal pups undergoing refeeding after nutritional deprivation show a preference for protein sparing despite severe malnutrition. Both BUN and total protein were negatively associated with GH and positively associated with IGF-I and ghrelin highlighting the importance of these metabolic hormones in the regulation of protein metabolism. While the response of the somatotropic axis to realimentation was typical of the mammalian pattern, the surprising increase of ghrelin across the study period suggests the priority of adipose accretion in addition to a possible mechanism regulating compensatory growth of vital adipose stores in a species, which prioritizes adipose accretion for survival.

Molecular characterization of two leptin genes and their transcriptional changes in response to fasting and refeeding in Northern snakehead (Channa argus)

Leptin has been proved to play critical roles in energy metabolism, body weight regulation, food intake, reproduction and immunity in mammals. However, its roles are still largely unclear in fish. Here, we report two leptin genes (lepA and lepB) from the Northern snakehead (Channa argus) and their transcriptions in response to different feeding status. The snakehead lepA is 781 bp in length and contains a 480 bp open reading frame (ORF) encoding a 159-aa protein, while the snakehead lepB is 553 bp in length and contains a 477 bp ORF encoding a 158-aa protein. Multi-sequences alignment, three-dimensional (3D) model prediction, syntenic and genomic comparison, and phylogenetic analysis confirm two leptin genes are widely existing in teleost. Tissue distribution revealed that the two leptin genes exhibit different patterns. In a post-prandial experiment, the hepatic lepA and brain lepB showed a similar transcription pattern. In a long-term (2-week) fasting and refeeding experiment, the hepatic lepA and brain lepB showed a similar transcription change pattern induced by food deprivation stimulation but differential changes after refeeding. These findings suggest snakehead lepA and lepB are differential both in tissue distribution and molecular functions, and they might play as an important regulator in energy metabolism and food intake in fish, respectively.

HFD refeeding in mice after fasting impairs learning by activating caspase-1 in the brain

BACKGROUND

Diets that include some aspect of fasting have dramatically increased in popularity. In addition, fasting reduces inflammasome activity in the brain while improving learning. Here, we examine the impact of refeeding a low-fat diet (LFD) or high-fat diet (HFD) after fasting.

METHODS

Male wildtype (WT), caspase-1 knockout (KO) and/or IL-1 receptor 1 (IL-1R1) KO mice were fasted for 24 h or allowed ad libitum access to food (chow). Immediately after fasting, mice were allowed to refeed for 2 h in the presence of LFD, HFD or chow. Mouse learning was examined using novel object recognition (NOR) and novel location recognition (NLR). Caspase-1 activity was quantified in the brain using histochemistry (HC) and image analysis.

RESULTS

Refeeding with a HFD but not a LFD or chow fully impaired both NOR and NLR. Likewise, HFD when compared to LFD refeeding increased caspase-1 activity in the whole amygdala and, particularly, in the posterior basolateral nuclei (BLp) by 2.5-fold and 4.6-fold, respectively. When caspase-1 KO or IL-1R1 KO mice were examined, learning impairment secondary to HFD refeeding did not occur. Equally, administration of n-acetylcysteine to fasted WT mice prevented HFD-dependent learning impairment and caspase-1 activation in the BLp. Finally, the free-fatty acid receptor 1 (FFAR1) antagonist, DC260126, mitigated learning impairment associated with HFD refeeding while blocking caspase-1 activation in the BLp.

CONCLUSIONS

Consumption of a HFD after fasting impairs learning by a mechanism that is dependent on caspase-1 and the IL-1R1 receptor. These consequences of a HFD refeeding on the BLP of the amygdala appear linked to oxidative stress and FFAR1.

Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort

BACKGROUND

Extreme anorexia nervosa (AN) is defined as a BMI < 15 kg/m² in those meeting DSM-V diagnostic criteria for AN. This study seeks to define the frequency of medical complications in this group of patients in order to help inform the care of individuals < 65% ideal body weight who seek treatment for their extreme eating disorders.

METHODS

Through retrospective chart review and computerized data collection, we obtained the baseline characteristics and medical findings of 281 adult patients, with AN restricting and binge-purge subtypes, admitted to the ACUTE unit for medical stabilization between May 2013 and August 2018.

RESULTS

In this population, with a mean admitting BMI of 12.1 kg/m² (range = 7.5-15.7), 56% admitted with bradycardia, 45% demonstrated increased liver function tests (LFTs) on admission, 64% admitted with leukopenia, 47% with anemia, and 20% presented with thrombocytopenia. During admission, 38% developed hypoglycemia, 35% developed refeeding hypophosphatemia, nearly 33% of patients developed edema, and low bone mineral density was diagnosed in almost 90% of the patients. Highly elevated LFTs (>3x upper limits of normal) predicted hypoglycemia, and low BMI predicted refeeding hypophosphatemia (p = .001).

CONCLUSIONS

Although conclusions drawn from the findings presented in this descriptive study must be tempered by relevant clinical judgement, these findings showcase that patients with extreme AN are at significantly increased risk for many serious medical complications secondary to their state of malnutrition and also with initial refeeding.

Changes of BMI, steroid metabolome and psychopathology in patients with anorexia nervosa during hospitalization

Anorexia nervosa (AN) is associated with various alterations including the dysfunction of the HPA axis and consequently the hypercortisolemia and deficit in sex hormones but the comprehensive evaluation of changes in circulating steroids during the hospitalization of AN patients is lacking. We investigated the effect of realimentation of women with AN during hospitalization on 45 circulating steroids, the relationships between BMI, its change during hospitalization and physical activity, on one side and initial levels and their changes for two adipokines, circulating steroids, anorexia-specific (hunger, appetite and satiety), and anorexia non-specific symptoms (anxiety, depression fatigue, sleep, and body pain) on the other side. We included 33 women with anorexia who were hospitalized for 38(35, 44) days (median with quartiles). The increase of BMI from the initial value 15.2 (13.2, 16.6) kg/m² was 1.69 (1.37, 2.66) kg/m². The patients with more severe anorexia showed higher activity in 7β-, and 16α-hydroxylation of androgen precursors, which declined during hospitalization. Otherwise, the 7α-hydroxylation activity is higher in AN patients with less severe malnutrition and the ratio of 5-androstene-3β,7α,17β-triol to 5-androstene-3β,7β,17β-triol increased during the realimentation. Our data allow to speculate that the intensive 7β-, and 16α- and possibly also the 7α-hydroxylation of C19 Δ⁵ steroids participate in the pathophysiology of anorexia by additional catabolism of substrates available for synthesis of active androgens and estrogens. However, the question remains whether the synthetic analogues of 7α/β- and 16α-hydroxy-steroids prevent the catabolism of the sex steroid precursors, or further activate the "energy wasting" mitochondrial thermogenic metabolism.

Molecular cloning of two kcnk3 genes from the Northern snakehead (Channa argus) for quantification of their transcriptions in response to fasting and refeeding

Potassium channel subfamily K member 3 (KCNK3) has been reported to play important roles in membrane potential conduction, pulmonary hypertension and thermogenesis regulation in mammals. However, its roles remain largely unknown and scarce reports were seen in fish. In the present study, we for the first time identified two kcnk3 genes (kcnk3a and kcnk3b) from the carnivorous Northern snakehead (Channa argus) by molecular cloning and a genomic survey. Subsequently, their transcription changes in response to different feeding status were investigated. Full-length coding sequences of the kcnk3a and kcnk3b genes are 1203 and 1176 bp, encoding 400 and 391 amino acids, respectively. Multiple alignments, 3D-structure prediction and phylogenetic analysis further suggested that these kcnk3 genes may be highly conserved in vertebrates. Tissue distribution analysis by real-time PCR demonstrated that both the snakehead kcnk3s were widely transcribed in majority of the examined tissues but with different distribution patterns. In a short-term (24-h) fasting experiment, we observed that brain kcnk3a and kcnk3b genes showed totally opposite transcription patterns. In a long-term (2-week) fasting and refeeding experiment, we also observed differential change patterns for the brain kcnk3 genes. In summary, our findings suggest that the two kcnk3 genes are close while present different transcription responses to fasting and refeeding. They therefore can be potentially selected as novel target genes for improvement of production and quality of this economically important fish.

Effect of starvation and refeeding on oxidative stress and antioxidant defenses in Yangtze sturgeon (Acipenser dabryanus)

The present research aimed to evaluate the effects of long-term fasting and refeeding on the growth and antioxidant defenses in the liver and serum in Yangtze sturgeon (Acipenser dabryanus). The results showed that body mass and hepatosomatic index significantly decreased with long-term fasting, but they could be recovered after 4 weeks refeeding. Compared with controls, the antioxidant defense parameters of starvation indicated that the malondialdehyde (MDA) levels increased significantly in both tissues; the activities of superoxide dismutase (SOD) and glutathione peroxidase (GPx) increased obviously in serum and liver, respectively (p < 0.05). However, the activities of catalase (CAT) always decreased in two tissues including liver and serum during the whole starvation, as was the SOD in the liver (p < 0.05). Interestingly, the T-AOC levels of Yangtze sturgeon presented higher at early stage of starvation and dropped down at the end of starvation (p < 0.05). However, all of the antioxidant index above returned to origin level after 4 weeks refeeding. In conclusion, the present study indicated that long-time fasting induced oxidative stress in Yangtze sturgeon and it may easily adjust their physiological status under situations characterized by a long-term starvation and refeeding.

Proteomic analysis of the fast-twitch muscle of pacu (Piaractus mesopotamicus) after prolonged fasting and compensatory growth

Protocols that improve growth performance in fish while assuring product quality are important for aquaculture. Fasting followed by refeeding may promote compensatory growth, thus optimizing growth performance. During fasting and refeeding, fast-twitch muscle, which comprises most of fish fillet, undergoes intense plasticity. In this work, we studied the proteome of pacu (Piaractus mesopotamicus) fast-twitch muscle after 30 days of fasting (D30), 30 days of refeeding (D60) and 60 days of refeeding (D90) with two-dimensional electrophoresis, mass spectrometry and bioinformatics. Body mass, growth rate and muscle histology were also assessed. At D30, fish presented muscle catabolism and decreased growth. Proteomic analysis showed that metabolism proteins were the most affected, up and downregulated. Cytoskeleton and amino acid biosynthesis proteins were downregulated, while nuclear and regulatory proteins were upregulated. At D60, fish showed accelerated growth, despite the body mass not completely recovering. Metabolism proteins were still the most affected. Amino acid biosynthesis proteins became upregulated, while cytoskeleton proteins remained downregulated. At D90, the fish presented total compensatory growth. Many metabolic proteins were up or downregulated. Few cytoskeleton proteins remained differentially expressed. Amino acid biosynthesis proteins were mostly upregulated, but less than at D60. Prolonged fasting followed by refeeding also led to the regulation of possible meat quality biomarkers, such as antioxidant enzymes. This fact suggests possible consequences of this protocol on fish meat quality. Our work also enriches our knowledge on proteomic changes during muscle plasticity that occur during fasting and refeeding diet protocols.

The less weight loss due to modest food restriction drove more fat accumulation in striped hamsters refed with high-fat diet

Food restriction (FR) has been commonly used to decrease body fat, reducing the risk of overweight in humans and animals. However, the lost weight has been shown to be followed by overweight when food restriction ends. It remains uncertain whether the weight loss drives the overweight, or not. In the present study, striped hamsters were restricted by 15%, 30% and 40% of ad libitum food intake for 2 weeks, followed by high-fat refeeding for 6 weeks (FR15%-Re, FR30%-Re and FR40%-Re). The hamsters in FR15%, FR30% and FR40% groups decreased by 21.1%, 37.8% and 50.0% in fat mass (P < 0.01), and 16.8%, 42.8% and 53.4% in leptin levels (P < 0.01) compared with the hamsters fed ad libitum. The FR15%-Re, FR30%-Re and FR40%-Re groups showed 77.0%, 37.2% and 23.7% more body fat than ad libitum group (P < 0.01). The FR15%-Re group showed considerable decreases in gene expression of arcuate nucleus co-expressing proopiomelanocortin (POMC), cocaine - and amphetamineregulated transcript (CART) and the long isoform of leptin receptor (LepRb) in the hypothalamus and of several genes associated with fatty acid transport to mitochondria and β-oxidation in brown adipose tissue and liver. It suggests that less weight loss is likely to drive more fat accumulation when food restriction ends, in which the impaired function of LepRb, POMC and CART in the brain and fatty acid oxidation in brown adipose tissue and liver may be involved.

Refeeding in anorexia nervosa

Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/"underfeeding syndrome" and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients. What is Known: • Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice. • The risk of a refeeding syndrome is well known and well managed in severely malnourished patients ("conservative approaches"). What is New: • There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness. • The risks of "underfeeding syndrome" and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Graphical abstract.

The gut microbiome in anorexia nervosa: relevance for nutritional rehabilitation

Rapidly accumulating evidence supports the important role of gut microbiome in the regulation of mood, behaviour, appetite, gastrointestinal symptomology, and nutrient metabolism. These are all core features frequently altered in individuals with anorexia nervosa (AN). Current treatment recommendations for AN support the use of high-calorie diets as an essential part of nutritional rehabilitation, commonly achieved by elevating the fat content of the diet. However, in contrast to this approach, there is accumulating evidence suggesting the importance of balanced, high-fibre diets on the gut microbiome. Studies have demonstrated profound differences in the microbial composition of underweight people with AN and those of normal- or overweight individuals. Specific alterations vary widely between studies. It is thus far unclear to what extent the observed differences are brought on by iatrogenic effects of nutritional rehabilitation or the disorder itself. To date, only two studies have investigated the changes in the intestinal microbiota during nutritional rehabilitation and corresponding weight restoration. These studies suggest that the gut microbiome of AN patients was different to healthy controls both prior and following nutritional rehabilitation, though it is noted that these states were associated with lower and higher nutritional intakes, respectively. There is a clear need for further investigation regarding the effects of nutritional rehabilitation on the gut microbiome. Such research would provide insights into the potential role of gut microbiome in modulating the pathophysiology of AN and inform future treatment strategies.

Hypophosphataemia in severe acute malnutrition: a prospective observational study

Severe acute malnutrition (SAM) is a major cause of child mortality and morbidity. Children treated for SAM are at risk of refeeding hypophosphataemia (HP). The study was done to find out the incidence and various predictors of moderate/severe HP in SAM among North Indian children. This prospective observational study was conducted from August 2014 to July 2015 in the inpatients' department of Department of Paediatrics at King George's Medical University, Lucknow, Uttar Pradesh, North India, a tertiary care teaching hospital. Before inclusion, ethical approval and written informed consent was obtained. Included in the study were sixty-five children aged 6-59 months of age, who were admitted to the hospital with SAM as per the WHO guidelines. SAM was defined as a mid-upper arm circumference <115 mm and/or weight-for-height/length <-3 z-scores of the WHO growth standards and/or have bilateral oedema. Serum P levels were measured on admission and for five consecutive days after starting feed. HP was defined as mild, moderate and severe with a cut-off of 1·19-0·65, 0·65-0·32 and <0·32 mmol/l, respectively. About 60 % children had HP, with 20 % having moderate/severe HP at admission. The proportion of HP increased to 83·1 %, with 38·5 % having moderate/severe HP on day 3 after feeding. It was concluded that HP is a common biochemical abnormality in SAM. Considering its impact on the health of the child, serum P levels should be monitored in patients with SAM who are treated with enteral feeding.

Treatment with granulocyte colony-stimulating factor in the refeeding phase of anorexia nervosa complicated with severe neutropenia and sepsis: a case report

Leukopenia is frequently observed in patients with anorexia nervosa (AN). However, serious infectious diseases are infrequent in patients with AN. We present the case of a 13-year-old girl with AN complicated with severe neutropenia and sepsis upon refeeding. Her body mass index was 11 kg/m² and her absolute neutrophil count (ANC) was 1555/µL on admission. After the initiation of refeeding, her ANC gradually declined to 346/µL. High fever occurred and a blood culture tested positive for Enterobacter cloacae. Although fever subsided with administration of antibiotics, human recombinant granulocyte colony-stimulating factor (G-CSF) was administered to improve her severe neutropenia. After administration of G-CSF, initially for 5 days and again for 3 days, her ANC became normal and stable. The combination of neutropenia and low body mass index may contribute to severe bacterial infection. Usually, hematological abnormalities such as neutropenia improve spontaneously with the recovery of nutritional status in AN patients. Therefore, it is difficult to determine the indication for treatment with G-SCF. Although a careful consideration is required, treatment with G-CSF is effective in AN patients with sepsis caused by severe neutropenia.

Stunting, starvation and refeeding: a review of forgotten 19th and early 20th century literature

AIM

To scrutinize to what extent modern ideas about nutrition effects on growth are supported by historic observations in European populations.

METHOD

We reviewed 19th and early 20th century paediatric journals in the Staatsbibliothek zu Berlin, the third largest European library with an almost complete collection of the German medical literature. During a three-day visit, we inspected 15 bookshelf meters of literature not available in electronic format.

RESULTS

Late 19th and early 20th century breastfed European infants and children, independent of social strata, grew far below World Health Organisation (WHO) standards and 15-30% of adequately-fed children would be classified as stunted by the WHO standards. Historic sources indicate that growth in height is largely independent of the extent and nature of the diet. Height catch-up after starvation was greater than catch-up reported in modern nutrition intervention studies, and allowed for unimpaired adult height.

CONCLUSION

Historical studies are indispensable to understand why stunting does not equate with undernutrition and why modern diet interventions frequently fail to prevent stunting. Appropriateness and effect size of modern nutrition interventions on growth need revision.

Uncoupling protein 1 in snakehead (Channa argus): Cloning, tissue distribution, and its expression in response to fasting and refeeding

In mammals, uncoupling protein 1 (UCP1) is well known for its thermogenic role in brown adipose tissue (BAT). However, the UCP1 physiological roles are still unclear in fish, although several teleost ucp1 genes have been identified. The aim of this study is to investigate the potential roles of fish UCP1 involved in food intake regulation and energy homeostasis. We herein report on the molecular cloning, tissue distribution and the effect of fasting and refeeding on the expression of ucp1 in Channa argus. UCP1 consisted of a 921 bp open reading frame predicted to encode 306 amino acids. Sequence analysis revealed that snakehead UCP1 was highly conserved (>80%) with teleost UCP1, but shared a lower identity (60-72%) with mammals. Phylogenetic analysis supported that snakehead UCP1 was closely related to piscine UCP1. In addition, ucp1 was found to extensively expressed in all detected tissues, with the highest level in liver. Futhermore, the hepatic ucp1 was found to significantly increased after short-term and long-term food deprivation, and dramatically increased following refeeding. These findings suggested that snakehead UCP1 might play important roles in food intake regulation and fatty acid metabolism in snakehead fish, and it could be as a potential target locus to improve commercial production of this kind of fish.

Molecular cloning, tissue distribution, and effect of fasting and refeeding on the expression of neuropeptide Y in Channa argus

Neuropeptide Y (NPY) is a 36 amino-acid amidated peptide of the pancreatic polypeptide (PP) family, which plays an important role in appetite regulation and energy expenditure in mammals. Although several teleost NPY have been identified, its roles remain unclear in fish. We herein reported on the molecular cloning, tissue distribution and the effect of fasting on the expression of NPY in Channa argus, and designated as CaNPY. It consisted of a 300 bp open reading frame predicted to encode a prepro-NPY of 99 amino acids. Sequence analysis revealed that CaNPY was highly conserved (>60%) with other vertebrate NPY. Phylogenetic analysis highly supported CaNPY was closely related to piscine NPY. In addition, except for muscle and spleen tissues, CaNPY was found to extensively expressed in all other detected tissues, with the highest level in brain. Futhermore, the CaNPY transcript was found to significantly increase after short-term and long-term food deprivation, and dramatically decrease following refeeding. These findings suggested that CaNPY might be involved in food intake regulation and it could be as a potential target locus to improve commercial production of this kind of fish.

Medical Considerations in Children and Adolescents with Eating Disorders

Eating disorders are a group of psychiatric disorders with potentially fatal medical complications. Early integrated care including the family as well as pediatric medicine, nutrition, psychology and psychiatry is critical for improving prognosis and limiting negative outcomes. Mental health services are a critical component of treatment; timely weight restoration maximizes efficacy. Despite being relatively common, there are many misperceptions about eating disorders, their severity, and the associated morbidity and mortality. Opportunities exist within the medical and psychiatric communities for a better understanding of the complexity of diagnosing and treating patients with eating disorders.

Rebound Feeding in the Wake of Short-Term Suspension of Food Intake Differs in the Presence of Estrous Cycle Peak versus Nadir Levels of Estradiol

BACKGROUND

Short-term interruption of feeding is ordinary in modern life but negatively impacts appetite control and body weight. Estradiol (E) imposes long-term inhibitory tonus on food consumption; however, E influence on energy repletion secondary to food deprivation (FD) is unclear. This study investigated the hypothesis that E signal strength regulates hyperphagic responses to FD of varying duration.

METHODS

Ovariectomized female rats were implanted with E-containing silastic capsules (30 [E-30] or 300 μg [E-300]/mL) to replicate plasma concentrations at cycle nadir versus peak levels.

RESULTS

Data show that food intake was increased equally in E-30 and E-300 rats after 12 hours of food deprivation (FD-12); yet, FD of 18 hours (FD-18) amplified refeeding by E-300 versus E-30. Caudal fourth ventricular administration of the 5'-monophosphate-activated protein kinase (AMPK) inhibitor compound C (Cc) did not modify FD-induced hyperphagia in E-30 (regardless of FD interval) or E-300 animals exposed to FD-12, but diminished refeeding after FD-18 in E-300 rats. Cc-reversible hyperglycemia occurred in refed FD-18 groups. Serum insulin was resistant to FD-12 plus refeeding, but was elevated by AMPK-dependent mechanisms in refed E-300 FD-18 rats; equivalent Cc-insensitive decrements in circulating leptin occurred in all FD groups.

CONCLUSION

Current results show that estrous cycle peak, but not baseline, E levels engage hindbrain AMPK signaling to intensify hyperphagia in response to prolongation of FD. Observations of hindbrain AMPK-dependent hyperglycemia, alongside elevated insulin secretion, in refed rats exposed to FD-18 implicate this sensor in insulin resistance mechanisms of glucose partitioning in response to this metabolic imbalance.

Fast digestive, leucine-rich, soluble milk proteins improve muscle protein anabolism, and mitochondrial function in undernourished old rats

SCOPE

One strategy to manage malnutrition in older patients is to increase protein and energy intake. Here, we evaluate the influence of protein quality during refeeding on improvement in muscle protein and energy metabolism.

METHODS AND RESULTS

Twenty-month-old male rats (n = 40) were fed 50% of their spontaneous intake for 12 weeks to induce malnutrition, then refed ad libitum with a standard diet enriched with casein or soluble milk proteins (22%) for 4 weeks. A 13C-valine was infused to measure muscle protein synthesis and expression of MuRF1, and MAFbx was measured to evaluate muscle proteolysis. mTOR pathway activation and mitochondrial function were assessed in muscle. Malnutrition was associated with a decrease in body weight, fat mass, and lean mass, particularly muscle mass. Malnutrition decreased muscle mTOR pathway activation and protein FSR associated with increased MuRF1 mRNA levels, and decreased mitochondrial function. The refeeding period partially restored fat mass and lean mass. Unlike the casein diet, the soluble milk protein diet improved muscle protein metabolism and mitochondrial function in old malnourished rats.

CONCLUSIONS

These results suggest that providing better-quality proteins during refeeding may improve efficacy of renutrition in malnourished older patients.

Gluconeogenesis during starvation and refeeding phase is affected by previous dietary carbohydrates levels and a glucose stimuli during early life in Siberian sturgeon (Acipenser baerii)

Gluconeogenesis responses was assessed during a short starvation period and subsequent refeeding in Siberian sturgeon (Acipenser baerii) previously fed different dietary carbohydrates levels and experienced to a glucose stimuli during early life. The sturgeon larvae were previously fed either a high glucose diet (G) or a low glucose diet (F) from the first feeding to yolk absorption (8 to 12 d post-hatching [dph]). Each group of fish was sub-divided into 2 treatments at 13 dph and was fed either a high-carbohydrate diet (H) or a low carbohydrate diet (L) until 20 wk. In the current study, the fish in 4 groups (GL, FL, GH and FH) were experienced to starvation for 21 d following by re-feeding of their corresponding diets for 21 d. Fish were sampled at postprandial 6 and 24 h before starvation (P6h and P24h), starvation 7, 14 and 21 d (S7, S14 and S21) and 1, 7, 14 and 21 d during refeeding (R1, R7, R14 and R21). Plasma samples during refeeding were taken at P6h at each time point. Glycaemia levels, liver and muscle glycogen contents, activities and mRNA levels of hepatic gluconeogenic enzymes were examined. We found that both dietary carbohydrate levels and early glucose stimuli significantly affected the metabolic responses to starvation and refeeding in Siberian sturgeon (P < 0.05). During prolonged starvation, Siberian sturgeon firstly mobilized the liver glycogen and then improved gluconeogenesis when the dietary carbohydrates were abundant, whereas preserved the liver glycogen stores at a stable level and more effectively promoted gluconeogenesis when the dietary carbohydrates are absent to maintain glucose homoeostasis. During refeeding, as most teleostean, Siberian sturgeon failed controlling the activities and mRNA levels of phosphoenolpyruvate carboxykinase cytosolic forms (PEPCK-C), fructose-1,6-bisphosphatase (FBPase), but particularly controlled phosphoenolpyruvate carboxykinase mitochondrial forms (PEPCK-M) activities and mRNA expression of glucose-6-phosphatase (G6Pase, except in GL group). Siberian sturgeon has a full compensatory ability on growth, but this ability would be obstructed by early glucose stimuli when refeeding the low carbohydrate diet after S21.

Refeeding Syndrome in Oncology: Report of Four Cases

The term refeeding syndrome (RFS) refers to the metabolic perturbations and its attendant complications in subjects who are refed after fasting. The syndrome is characterized by profound shifts of electrolytes and fluids. Its consequences are widespread and sometimes fatal. Patients with malignancies are especially vulnerable due to the presence of multiple comorbidities. We report the course of four patients with malignant or hematological disorders who developed RFS while being treated for their underlying illness. All physicians caring for susceptible patients should be cognizant of the risks of refeeding and treat RFS appropriately to reduce patient morbidity as well as mortality.

Response to starvation and refeeding

The objective of the present study is to characterize the metabolic and antioxidant profile of white muscle of shi drum in two sites of the body, anterior dorsal (AM) and posterior dorsal (PM) portions. In addition, it will be analyzed the possible effect of starvation and a subsequent refeeding, with two different protocols, pair feeding and ad libitum. Activities of key enzymes of intermediary metabolism and of antioxidant enzymes, as well as lipid peroxidation, as an index of oxidative stress, were evaluated. The results indicate the existence of a regional asymmetry of the metabolic capacities of the white muscle of shi drum, which is likely related to the different contribution to swimming of the body regions examined. Starvation induces a metabolic depression that is more marked in those activities that support burst swimming in PM, while those activities supporting maintenance requirements are conserved. The greatest energy demands during starvation appear to lie in AM, which showed the highest oxidative metabolism rate. The increased use of fatty acids as energy source for AM leads to oxidative stress. A period of more than four weeks of refeeding for full restoration of metabolic capacities in AM is needed, probably related to the higher muscle mass located in this region. On the contrary, all enzyme activities in PM returned to control levels in both refeeding protocols, but pair feeding seems to be advantageous since compensatory growth has been taking place without signs of oxidative stress. This work was addressed to gain knowledge on the physiology of a promising fish species in aquaculture like shi drum. The results displayed here show how the starving and further re-feeding events could generate oxidative stress situations characterized by high lipid peroxidation levels which may influence negatively on the quality of the edible part of the fish. This study opens an interesting field on this fish species which deserves being investigated in the future.

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Research on the metabolism of a new fish species with potential aquaculture practices is depicted.

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Starving and refeeding promote different metabolic alterations depending on body region of white muscle.

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Fasting and refeeding may influence the quality of the edible part of the fish.

Long-Term Energy Deficit in Mice Causes Long-Lasting Hypothalamic Alterations after Recovery

Although the short-term effects of fasting or energy deficit on hypothalamic neuropeptide circuitries are now better understood, the effects of long-term energy deficit and refeeding remain to be elucidated. We showed that after a long-term energy deficit, mice exhibited persistent hypoleptinemia following the refeeding period despite restoration of fat mass, ovarian activity, and feeding behavior. We aimed to examine the hypothalamic adaptations after 10 weeks of energy deficit and after 10 further weeks of nutritional recovery. To do so, we assessed the mRNA levels of the leptin receptor and the main orexigenic and anorexigenic peptides, and their receptors regulated by leptin. Markers of hypothalamic inflammation were assessed as leptin can also participate in this phenomenon. Long-term time-restricted feeding and separation induced significant increase in mRNA levels of hypothalamic orexigenic peptides, while both Y1 and Y5 receptor mRNAs were downregulated. No changes occurred in the mRNA levels of orexin (OX), melanin-concentrating hormone, pro-opiomelanocortin, 26RFa (26-amino acid RF-amide peptide), and their receptors despite an increase in the expression of melanocortin receptors (MC3-R and MC4-R) and OXR1 (OX receptor 1). The refeeding period induced an overexpression of leptin receptor mRNA in the hypothalamus. The other assessed mRNA levels were normalized except for Y2, Y5, MC3-R, and MC4-R, which remained upregulated. No convincing changes were observed in neuroinflammatory markers, even if interleukin-1β mRNA levels were increased in parallel with those of Iba1 (ionized calcium-binding adaptor molecule 1), a marker of microglial activation. Normalization of leptin-regulated functions and hypothalamic gene expressions in refed mice with low plasma leptin levels could be sustained by recalibration of hypothalamic sensitivity to leptin.

Outcomes of an inpatient refeeding protocol in youth with Anorexia Nervosa and atypical Anorexia Nervosa at Children's Hospitals and Clinics of Minnesota

BACKGROUND

Historically, inpatient protocols have adopted relatively conservative approaches to refeeding in Anorexia Nervosa (AN) in order to reduce the risk of refeeding syndrome, a potentially fatal constellation of symptoms. However, increasing evidence suggests that patients with AN can tolerate higher caloric prescriptions during treatment, which may result in prevention of initial weight loss, shorter hospital stays, and less exposure to the effects of severe malnutrition. Therefore the present study sought to examine the effectiveness of a more accelerated refeeding protocol in an inpatient AN and atypical AN sample.

METHODS

Participants were youth (ages 10-22) with AN (n = 113) and atypical AN (n = 16) who were hospitalized for medical stabilization. A retrospective chart review was conducted to assess changes in calories, weight status (percentage of median BMI, %mBMI), and indicators of refeeding syndrome, specifically hypophosphatemia, during hospitalization. Weight was assessed again approximately 4 weeks after discharge.

RESULTS

No cases of refeeding syndrome were observed, though 47.3 % of participants evidenced hypophosphatemia during treatment. Phosphorous levels were monitored in all participants, and 77.5 % were prescribed supplemental phosphorous at the time of discharge. Higher rates of caloric changes were predictive of greater changes in %mBMI during hospitalization. Rates of caloric and weight change were not related to an increased likelihood of re-admission.

CONCLUSIONS

Results suggest that a more accelerated approach to inpatient refeeding in youth with AN and atypical AN can be safely implemented and is not associated with refeeding syndrome, provided there is close monitoring and correction of electrolytes. These findings suggest that this approach has the potential to decrease length of stay and burden associated with inpatient hospitalization, while supporting continued progress after hospitalization.

Effect of diet composition on growth performance, hepatic metabolism and antioxidant activities in Siberian sturgeon (Acipenser baerii, Brandt, 1869) submitted to starvation and refeeding

Many fish species undergo natural starvation periods. Adaptation to starvation is possible through the activation of behavioral, biochemical and physiological mechanisms. Knowledge of the effect of dietary nutrients on the intermediary metabolism during starvation and refeeding can be useful to improve fish health and optimize aquaculture production. To analyze the effect of dietary nutrients on liver metabolism of Siberian sturgeon (Acipenser baerii) submitted to starvation and refeeding, four isoenergetic diets differing in nutrient composition were designed: LP-St (38 % protein, 12 % lipid, 36 % carbohydrate), HP-St (44 % protein, 10 % lipid, 30 % carbohydrate), LP-L (38 % protein, 18 % lipid, 25 % carbohydrate) and HP-L (44 % protein, 16 % lipid, 22 % carbohydrate). Four groups of fish were fed 3 weeks to satiety with the corresponding diet, starved for 2 weeks and then refeed 5 weeks to satiety on the same diet. Starvation mobilized the hepatic lipid store to a greater extent than glycogen. Starvation increased superoxide dismutase activity irrespective of the diet, while low protein diets (LP-St and LP-L) increased catalase activity. The oxidative damage decreased after 5 weeks of refeeding. Refeeding the starved fish on the HP-St diet promoted the greatest growth performance. In addition to reporting for the first time the effect of diet composition on growth, liver composition and antioxidant activities in Siberian sturgeon submitted to starvation and refeeding, our findings suggest that refeeding on HP-St diet stimulated the use of dietary carbohydrates and allowed a protein sparing effect in Siberian sturgeon.