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The medical complication of aneroxia nervosa
Abstract
The physical complications of anorexia nervosa are common and can be life threatening, but psychiatrists and the increasing number of non-medical therapists involved in treatment programmes often overlook these complications. Cardiovascular complications are the most common, and the most likely to result in fatalities, particularly in those patients who vomit, purge or abuse diuretics, because of the electrolyte abnormalities induced. Osteoporosis is an early and perhaps irreversible consequence of severe weight loss. Further, there are dangers in rapid intravenous hyperalimentation.
... A summary of some of the physical consequences of AN is provided in Table 11.3 . Although numerous physical abnormalities may be found in people with AN, research fi ndings indicate that laboratory results may be normal even in the presence of profound malnutrition [ 46 ]. ...
... Fingernails and hair are often brittle, and hair loss may occur in patches or uniformly over the scalp and other body areas [ 54 ]. A yellowish or orangish discoloration of the skin occurs in approximately 80 % of patients with AN [ 46 ]. This unusual skin color, which is "most noticeable on the palms of the hands, the soles of the feet, and the creases inside the elbows," is due to faulty metabolism of β-carotene in the liver leading an excessive level of β-carotene circulating in the blood, some of which is deposited under the skin [ 47 ]. ...
... Over 60 % of patients with AN have leukopenia (a reduction in the number of leukocytes in the blood), and this abnormality may be related to bone marrow hypoplasia and decreased neutrophil (a granular leukocyte having a nucleus of three to fi ve lobes) lifespan [ 46 ]. Leukopenia accompanied by a relative lymphocytosis has also been reported [ 59 ]. ...
Eating disorders (ED) are psychological disorders that are characterized by abnormal eating, dysfunctional relationships with food, and a preoccupation with one’s weight and shape. The incidence of EDs in women ranges from 0.5 to 3 % with the incidence increasing from 1963 to 2013. Currently, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) recognizes two specific EDs: anorexia nervosa (AN) and bulimia nervosa (BN), although there are subtypes associated with each. The DSM-IV-TR and the International Classification of Diseases (ICD-10) have different criteria for diagnosing AN and BN. Early identification of an ED is associated with shorter duration and fewer medical complications. Yet, it is estimated that only about 33 % of AN patients and 6 % of BN are receiving proper treatment for their illnesses. Gastrointestinal upset, fluid and electrolyte imbalances are common in AN in the short term and can eventually lead to long-term complications such as, pernicious anemia, osteoporosis, and heart disease. On the other hand, BN can cause short-term adverse effects like erosion of the teeth, enlargement of the parotid salivary glands, and acidic stomachs leading to heartburn. Long-term adverse effects caused by BN are gynecological problems, hormonal disturbances, hypercholesterolemia, and hypertension. Successful treatment of EDs should be managed with a team-based approach including the physician, psychologist, and registered dietitian.
... Одним з основних варіантів пошкодження нирок при РХП є нефролітіаз. Було припущено, що кілька факторів сприяють утворенню каменів у пацієнтів з нервовою анорексією, зокрема: низьке виділення сечі та збільшення виділення амонію з сечею, що супроводжує тривалий стан гіпофосфатурії; стан хронічного дефіциту рідини у пацієнтів, які обмежують споживання рідини, що призводить до насичення сечі сечовою кислотою, оксалатом і кальцієм, і останній фактор -гіперхлоремічний ацидоз, який спостерігається у пацієнтів із діареєю та зловживанням проносними [31]. Спричинений надмірним відкладенням кальцію в нирках, зазвичай у мозковому шарі, нефролітіаз може корелювати з нефрокальцинозом через спільні фактори ризику та причинні механізми [32]. ...
... Це стан із серйозним порушенням електролітного балансу та метаболічними відхиленнями в осіб, які проходять відновлення харчування після періоду недоїдання [29; 56]. Запаси фосфату в організмі можуть бути виснаженим, і рефідинг-синдром може посилити гіпофосфатемію з серйозними наслідками, такими як судоми та дисфункція міокарда [31]. ...
Eating Disorders (EDs), which are classified as psychoneurotic diseases, are defined by disordered eating habits that may involve insufficient or excessive food consumption, which is detrimental to a person's physical and mental health. According to current data, there is a close connection between eating disorders and damage to endocrine system and kidney functions. Patients with anorexia nervosa need both psychological and physical support. This review describes the underlying pathophysiological processes of the endocrine, renal, and electrolyte disturbances observed in patients with EDs. The purpose of the review is to present all aspects related to disorders of the function of the endocrine system and kidneys in EDs. Human organisms can adapt to changes in environment, including nutrition. However, compensatory mechanisms are temporary in terms of adaptation to malnourishment. One of the systems which is susceptible and impacted is the endocrine system. Disorders of the endocrine system in patients with EDs are multi-vector and include disorders of the hypothalamic-pituitary-gonadal system, thyroid gland, insulin system, growth hormone, gonads, leptin-ghrelin system. Background metabolic disorders in EDs are hypokalemia, hyponatremia, hypomagnesemia, metabolic alkalosis. They participate in the occurrence and progression of kidney damage. The compensatory functions of the kidneys are preserved until a certain time, which is determined by the level of water-electrolyte, metabolic disorders, tubulo-interstitial damage. The main morphological forms of kidney damage in patients with EDs are nephrocalcinosis and nephrolithiasis, clinical forms are acute kidney damage and chronic kidney disease. The multi-vector nature of disorders in EDs requires a comprehensive multidisciplinary approach. Management of patients with EDs requires a multidisciplinary approach. Keywords: endocrine disorders, kidney damage, pathophysiology.
... A court terme, ce sont surtout les complications somatiques liées à la dénutrition ou aux conduites compensatoires qui grèvent le pronostic. On peut observer des atteintes cardiovasculaire (bradycardie, complications de l'hypokaliémie) et rénale (insuffisance rénale fonctionnelle) [41], une atteinte hématologique (anémie, leucopénie, thrombopénie) [42], une atteinte dermatologique [43], des effets sur la structure du cerveau observé en imagerie [44], une hypercholestérolémie ou encore un métabolisme glucidique perturbé [41]. ...
... A court terme, ce sont surtout les complications somatiques liées à la dénutrition ou aux conduites compensatoires qui grèvent le pronostic. On peut observer des atteintes cardiovasculaire (bradycardie, complications de l'hypokaliémie) et rénale (insuffisance rénale fonctionnelle) [41], une atteinte hématologique (anémie, leucopénie, thrombopénie) [42], une atteinte dermatologique [43], des effets sur la structure du cerveau observé en imagerie [44], une hypercholestérolémie ou encore un métabolisme glucidique perturbé [41]. ...
L'anorexie mentale (AM) est un trouble du comportement alimentaire d'origine multifactorielle (environnementale et constitutionnelle). L'octadécaneuropeptide (ODN) est un neuropeptide hypothalamique possédant un puissant effet anorexigène chez le rat. Le but de notre étude était d'évaluer une éventuelle implication de l'ODN chez des adolescents souffrant d'AM. Nous avons étudié les variations des concentrations plasmatiques d'ODN chez les patients atteints d'anorexie mentale et nécessitant une hospitalisation, avant et après renutrition. Vingt adolescents de 11 à 16 ans ont été recrutés dans l'unité de Psychopathologie et Médecine de l'adolescent du CHU de Rouen dans le cadre du PHRC Evalhospitam. Les données clinico-biologiques et les résultats de tests psychiatriques évaluant le comportement alimentaire et l'état d'anxiété et de dépression ont été recueillis à l'admission et, pour certains également, à la sortie et un an après la sortie. Le dosage d'ODN a été effectué sur échantillon plasmatique par RIA (immunoréactivité de type ODN (ODNi)). Le seuil de détection était de 65pg/tube. Pour 6 patients, le dosage a été réalisé à l'admission, à la sortie et à un an de la sortie. À l'admission, l'âge moyen était de 14,4 ans, l'IMC moyen de 15 kg/m² et la perte de poids initiale de 14,6 kg en moyenne. L'ODNi à l'entrée était détectable pour 6 patients avec un taux moyen de 88,3 pg/mL, sans corrélation avec les différents marqueurs clinico-biologiques et tests psychiatriques à l'entrée. Pour les 6 patients ayant eu un dosage aux 3 temps de recueil, on observe une tendance à l'augmentation du taux sérique d'ODNi dans l'AM en phase aiguë versus après renutrition, et une tendance à la surexpression d'ODNi à un an chez les patients ayant un IMC faible ; tandis que les taux d'ODNi sont faibles ou indétectables chez les patients ayant conservé un IMC stable. Ces données suggèrent que l'ODN pourrait être surexprimé dans l'AM et jouer ainsi un rôle dans le maintien des conduites anorexiques.
... Half of these are due to medical causes, some cardiovascular in origin [5]. Cardiovascular abnormalities are common findings in patients with AN, occurring in up to 87% at some stage of the illness, and reflect the body's attempt to conserve energy and compensate for a lower blood volume, and poor nutrition [23]. The cardiovascular complications of AN involve structural and functional cardiac abnormalities, aberrations of heart rate and rhythm, haemodynamic changes and peripheral vascular abnormalities [5]. ...
Background
Eating disorders (EDs) are serious conditions predominantly affecting adolescents and young adults (AYAs) and pose a considerable threat to their health and wellbeing. Much of this increased morbidity and mortality is linked to medical compromise, especially cardiovascular abnormalities. Rates of presentation to both community and inpatient medical settings have increased in all age groups following the Covid-19 pandemic and subsequent “lockdowns”, with patients presentations being more medically compromised compared to previous years. This has implications for clinicians with regard to the performance of competent cardiovascular assessments and management of findings.
Aims
This paper is a practical resource for clinicians working with AYAs in whom EDs may present. It will provide a brief summary of the physiological context in which cardiovascular complications develop, systematically outline these complications and suggest a pragmatic approach to their clinical evaluation.
Methods
Relevant literature, guidelines and academic texts were critically reviewed. Conclusions were extracted and verified by a Child and Adolescent Psychiatrist and Adolescent Paediatrician, with suitable expertise in this clinical cohort.
Conclusions
The cardiovascular complications in EDs are primarily linked to malnutrition, and patients presenting with Anorexia Nervosa are most often at greatest risk of structural and functional cardiac abnormalities, including aberrations of heart rate and rhythm, haemodynamic changes and peripheral vascular abnormalities. Other cardiovascular abnormalities are secondary to electrolyte imbalances, as seen in patients with Bulimia Nervosa. More recently defined EDs including Avoidant/Restrictive Food Intake Disorder and Binge Eating Disorder are also likely associated with distinct cardiovascular complications though further research is required to clarify their nature and severity. Most cardiovascular abnormalities are fully reversible with nutritional restoration, and normalisation of eating behaviours, including the cessation of purging, though rare cases are linked to cardiac deaths. A detailed clinical enquiry accompanied by a thorough physical examination is imperative to ensure the medical safety of AYAs with EDs, and should be supported by an electrocardiogram and laboratory investigations. Consideration of cardiovascular issues, along with effective collaboration with acute medical teams allows community clinicians identify those at highest risk and minimise adverse outcomes in this cohort.
... The types and severity of cardiovascular complications that commonly occur in patients with eating disorders have been previously shown to vary widely [17,18]. It is important to recognize that cardiovascular complications, if not quickly detected and corrected, can be fatal, leading to sudden death in some patients [19][20][21][22]. ...
Purpose:
Eating disorders often result in somatic complications, including cardiac abnormalities. Cardiac abnormalities may involve any part of the heart, including the cardiac conduction system, and can lead to sudden cardiac death. The current study aimed to evaluate the incidence of cardiac complications in pediatric patients with eating disorders and their associated factors.
Methods:
We retrospectively analyzed patients aged 10-18 years who were diagnosed with DSM-V (Diagnostic and Statistical Manual of Mental Disorder-V) eating disorders and underwent electrocardiography (ECG) and/or echocardiography between January 2015 and May 2020.
Results:
In total, 127 patients were included, of whom 113 (89.0%) were female. The median body mass index (BMI) was 15.05±3.69 kg/m2. Overall, 74 patients (58.3%) had ECG abnormalities, with sinus bradycardia being the most common abnormality (91.9%). Patients with ECG abnormalities had significantly lower BMI (14.35±2.78 kg/m2 vs. 16.06± 4.55 kg/m2, p<0.001) than patients without ECG abnormalities, as well as lower phosphorus and higher cholesterol levels. Among the 46 patients who underwent echocardiographic evaluation, 23 (50.0%) had echocardiographic abnormalities, with pericardial effusion being the most common (60.9%). The median left ventricular mass (LVM) and ejection fraction were 67.97±21.25 g and 66.91±28.76%, respectively. LVM and BMI showed a positive correlation (r=0.604, p<0.001). After weight gain, the amount of pericardial effusion was reduced in 3 patients, and 30 patients presented with normal ECG findings.
Conclusion:
Cardiac abnormalities are relatively frequent in patients with eating disorders. Physicians should focus on this somatic complication and careful monitoring is required.
... It is estimated that up to 5.9% of mortality in AN is caused by cardiovascular complications, mainly sudden cardiac death due to QTc prolongation leading to ventricular arrhythmias [6,7]. This is remarkable, if one considers that 80% of anorexic patients develop cardiovascular abnormalities due to weight loss and malnutrition [8][9][10][11][12]. The specific physio-pathological mechanisms leading to the cardiac changes observed in AN are still not fully understood, as well as their correlation with BMI, amount of weight loss and laboratory markers (electrolytes, serum proteins, hormones like FT4 e IGF1) [13][14][15][16]. ...
PurposeAnorexia nervosa (AN) is the most frequent eating disorder (ED), whose cardiac complications may have life-threatening consequences for both the physical and psychological health of affected children. In this study, we reported and analysed the echocardiographic anomalies found in pediatric patients diagnosed with AN.Methods
We reported the demographic and clinical characteristics of children aged 8 to 18 years, who were diagnosed with AN and underwent a complete cardiological evaluation at the Emergency Department of the Bambino Gesù Children's Hospital, IRCCS, Rome between the 1st January 2021 and the 30th June 2021. Furthermore, we compared the patients according to the presence of pericardial effusion and a BMI (body mass index) cut-off 14.5 kg/m2.ResultsForty-nine patients were included in the study. The mean age was 15.1 years. Most patients were female (89.8%). The mean length of hospitalization was 18 days. The mean BMI at admission was 14.8 kg/m2, with a median weight loss of 9 kg in the last year. Eleven patients (22.4%) presented with cardiovascular signs or symptoms at admission. Most patients had pericardial effusion on heart ultrasound, with a mean thickness of 6 mm (SD ± 4). The LV (left ventricle) thickness over age was significantly higher in patients with pericardial effusion, with a Z score of −2.0 vs −1.4 (p = 0.014). The administration of psychiatric drugs was significantly more frequent in patients with a lower BMI (37.5% vs 12%, p = 0.038).Conclusion
Our study suggests that a non-urgent baseline echocardiographic evaluation with focus on left-ventricular wall thickness and mass in children with anorexia nervosa is advisable.Level IIIEvidence obtained from cohort or case-control analytic studies.
... It is estimated that up to 30% of mortality in AN is caused by cardiovascular complications [6,7]. In fact, 80% of anorexic patients develop cardiovascular abnormalities due to weight loss and malnutrition [8][9][10][11][12]. The speci c physio-pathological mechanisms leading to the cardiac changes observed in AN are still not fully understood, as well as their correlation with BMI, amount of weight loss and laboratory markers (electrolytes, serum proteins, hormones like FT4 e IGF1) [13][14][15][16]. ...
Purpose Anorexia nervosa (AN) is the most frequent eating disorder (ED), whose cardiac complications may have life-threatening consequences for both the physical and psychological health of affected children. In this study we reported and analysed the echocardiographic anomalies found in pediatric patients diagnosed with AN.
Methods We reported the demographic and clinical characteristics of children aged 8 to 18 years, who were diagnosed with AN and underwent a complete cardiological evaluation at the Emergency Department of the Bambino Gesù Children's Hospital, IRCCS, Rome between the 1st January 2021 and the 30th June 2021. Furthermore, we compared the patients according to the presence of pericardial effusion and a BMI (Body Mass Index) cut-off 14.5 kg/m².
Results Forty-nine patients were included in the study. The mean age was 15.1 years. Most patients were female (89.8%). The mean length of hospitalisation was 18 days. The mean BMI at admission was 14.8 kg/m², with a median weight loss of 9 kg in the last year. Eleven patients (22.4%) presented with cardiovascular signs or symptoms at admission. Most patients had pericardial effusion on heart ultrasound, with a mean thickness of 6 mm (SD ± 4). The LV (left ventricle) thickness over age was significantly higher in patients with pericardial effusion, with a Z score of -2.0 vs -1.4 (p = 0.014). The administration of psychiatric drugs was significantly more frequent in patients with a lower BMI (37.5% vs 12%, p = 0.038).
Conclusion Our results suggest that it is reasonable, in patients presenting with AN, to perform complete cardiologic work-up to early identify and manage cardiac complications and their life-threatening consequences. Prospective and multi-center studies are required in order to characterise the cardiovascular abnormalities in patients with AN and to describe the evolution of these abnormalities after weight recovery.
... EDs are serious psychological illnesses, and their typical prodrome (symptoms that indicate the future onset of a disorder that are also a feature of the disorder) of body dissatisfaction and dietary restriction 2 emerges throughout adolescence. 3 Clinical EDs are associated with significant under or overweight and physical complications, 4 poor quality of life, social adversity, 5 and significant care needs. 6 Contemporary models of EDs suggest that the ways individuals respond to risks and rewards may be perpetuating factors for EDs. ...
Objective:
Differences in decision-making under conditions of risk have been observed cross-sectionally in clinical groups of people with eating disorders but have never been studied longitudinally or in large cohorts. We investigated whether responses on the Cambridge Gambling Task (CGT), measured in the Millennium Cohort Study in childhood, would predict prodromal eating pathology in adolescence.
Method:
Regression models were built to explore relationships between CGT variables at age 11 years and prodromal eating pathology (body dissatisfaction, intention to lose weight, dietary restriction, significant under/overweight, and excessive exercise) at 14 years.
Results:
In 11,303 boys and girls, those with better quality decision-making were 34% less likely to show an intention to lose weight (b = -0.40, odds ratio [OR] = 0.66, p < 0.05) and 34% less likely to be overweight (b = -0.41, relative risk ratio [RRR] = 0.66, p < 0.05). Those with higher risk-taking were 58% more likely to report dietary restriction (b = 0.45, OR = 1.58, p < 0.05) and 46% more likely to report excessive exercise (b = 0.38, OR = 1.46, p < 0.05). In the complete-cases sample, higher risk-adjustment scores were associated with a 47% increased risk of underweight (b = 0.39, RRR = 1.47, p < 0.05), and better quality of decision-making was associated with a 46% lower risk of overweight (b = -0.60, RRR = 0.54, p < 0.05).
Conclusion:
Disadvantageous decision-making in childhood may predict prodromal eating pathology in adolescence and might represent a prevention target.
... Los principales sistemas que inluyen en la percepción, el estado de ánimo y la personalidad de los pacientes con AN incluyen la serotonina (5-HT). Los estudios en animales muestran efectos inhibidores sobre la alimentación, sugiriendo que la 5-HT actúa como un factor anorexígeno que promueve la saciedad3; la Sibutramina por ejemplo inhibe el consumo alimentario, entre otros mecanismos, bloqueando la recaptación de 5-HT (19). ...
La anorexia nerviosa (AN) en el adolescente es un diagnóstico difícil, que ha tenido reevaluación continua en sus criterios diagnósticos sugestivos de este trastorno alimentario, como presentar un peso inferior al normal del mínimo teniendo en cuenta lo normal por la edad y la altura, el cual estaba deinido en la Cuarta edición del Manual de los Trastornos mentales (DSM -IV) y han sido modiicadas por el grupo de trabajo del DSM -5. Esta patología es parte de una amplia gama de componentes desde el punto de vista de la neuroconducción: componentes perceptual, afectivo y cognitivo. El componente perceptual registra en la red del lóbulo parietal posterior, involucrado cuando hay una visualización distorsionada de la imagen del cuerpo; en el componente afectivo, el papel principal está vinculado a la red de la corteza prefrontal, la ínsula y la amígdala; las imágenes distorsionadas que se generan en los pacientes con AN restrictiva sugieren un menor control de las emociones como una manifestación de la inhibición reducida de la corteza prefrontal.
Los principales sistemas que inluyen en la percepción, el estado de ánimo y la personalidad de los pacientes con anorexia nerviosa incluyen la serotonina (5-HT); Norepinefrina (NE) las que puede aumentar o disminuir el deseo de ingesta, que depende del sistema nervioso central sitio de destino. El receptor de glutamato - N-Metil / D-aspartato (NMDA-R) se asocia en la función neuronal excitatoria y la regulación de la conducta alimentaria. Otros agentes moleculares como factor neurotróico derivado del cerebro (BDNF) se ha implicado en la patogénesis de la depresión mayor y aparentemente también desempeña un papel en la respuesta tardía a la terapia.
El principal órgano blanco afectado en pacientes con AN es el riñón, puede inducir insuiciencia renal aguda a través de mecanismos asociados a la hipovolemia, disminución de la ingesta de sodio en la dieta, los mecanismos de purga, y la disminución del volumen de eyección sistólica en las últimas etapas, que puede inducir la necrosis tubular aguda generada por la reducción de la perfusión renal y rabdomiolisis. El impacto social se aprecia en los mensajes que se difunden a través de los medios y la publicidad de una imagen irreal de la mujer. Estos son una idealización, por eso es muy importante promover dentro del desarrollo de los adolescentes un juicio crítico sobre el ideal de la belleza, el fortalecimiento de los valores y aprecio por el cuerpo con todas las posibilidades que ofrece, no sólo la estética.
... 26,27,31 Severe and chronic weight suppression is associated with cognitive impairments 101 and health effects, including kidney and bone damage. 102 Additionally, growth impairments are associated with adverse psychological consequences, including social anxiety and poor self-image. 103 ...
The abuse of volatile solvents such as toluene is a significant public health concern, predominantly affecting adolescents. To date, inhalant abuse research has primarily focused on the central nervous system; however, inhalants also exert effects on other organ systems and processes, including metabolic function and energy balance. Adolescent inhalant abuse is characterized by a negative energy balance phenotype, with the peak period of abuse overlapping with the adolescent growth spurt. There are multiple components within the central and peripheral regulation of energy balance that may be affected by adolescent inhalant abuse, such as impaired metabolic signaling, decreased food intake, altered dietary preferences, disrupted glucose tolerance and insulin release, reduced adiposity and skeletal density, and adrenal hypertrophy. These effects may persist into abstinence and adulthood, and the long‐term consequences of inhalant‐induced metabolic dysfunction are currently unknown. The signs and symptoms resulting from chronic adolescent inhalant abuse may result in a propensity for the development of adult‐onset metabolic disorders such as type 2 diabetes, however, further research investigating the long‐term effects of inhalant abuse upon energy balance and metabolism are needed. This review addresses several aspects of the short‐ and long‐term effects of inhalant abuse relating to energy and metabolic processes, including energy balance, intake and expenditure; dietary preferences and glycemic control; and the dysfunction of metabolic homeostasis through altered adipose tissue, bone, and hypothalamic‐pituitary‐adrenal axis function.
... [1] Sharp and Freeman declare that the medical complications of Anorexia Nervosa range from premature advanced osteoporosis to life endangering cardiovascular problems. [2] This manifold infestation of health issues may also hold good for Bulimia Nervosa as well as Binge Eating Disorder (BED). ...
... The long-term health consequences of body weight changes associated with substance abuse Despite the difficulties presented by these confounds the question of how substance abuse can affect body weight remains a highly relevant one, because dramatic changes to body weight (both positive and negative) are not healthy. Severe and chronic weight suppression is associated with cognitive impairments (Kretsch et al. 1997) and health effects, including kidney and bone damage (Sharp and Freeman 1993). Furthermore, weight regain after a period of weight suppression is associated with increased central adiposity and insulin resistance, both of which are risk factors for the development of metabolic syndrome (Dulloo et al. 2006). ...
Background: Substance abuse can cause a range of harmful secondary health consequences, including body weight changes. These remain poorly understood but can lead to metabolic disorders including obesity and diabetes. Energy balance is a function of the equation: energy balance = energy intake – energy expenditure; an imbalance to this equation results in body weight changes. Currently, in the clinical setting, changes to food intake (energy intake) are considered as the primary mediator of body weight changes related to substance abuse, reflected in the current treatment focus on nutritional intervention. The influence of substance abuse on energy expenditure receives less attention. The aim of this think-piece is to consider potential causes of body weight changes during active substance abuse and abstinence, by focussing on the components of the energy balance equation.
Methods: We discuss both human and animal studies on the effects of substance abuse on energy balance, with particular focus on animal models utilising pair-feeding, which enable investigation of energy balance whilst controlling for the effects of altered food intake.
Results: We demonstrate that whilst some drugs of abuse affect food intake, this effect is inconsistent. Furthermore, body weight changes do not match food intake changes.
Conclusion: We provide evidence that drugs of abuse can affect both energy intake and energy expenditure; contributing to the observed body weight changes. This think-piece highlights that treatment strategies for body weight changes related to substance abuse cannot focus solely on nutritional interventions, but should consider the impact of broader disruptions to energy balance.
... 2). [2][3][4][5]. Wywiad (młody wiek, brak dolegliwości bólowych w klatce piersiowej, niskie ryzyko zmian miażdżycowych), badanie przedmiotowe oraz wyniki badań laboratoryjnych pozwoliły na wykluczenie ostrego zespołu wieńcowego, natomiast rozpoznano uszkodzenie mięśnia lewej komory na tle niedoborów żywieniowych. W badaniu Mont i wsp. ...
... and 2.0% of men, respectively (Hudson, Hiripi, Pope, & Kessler, 2007), engagement in subclinical levels of disordered eating (e.g., skipping meals, use of weight loss pills or extreme diets, subthreshold levels of binge eating/purging, etc.) is alarmingly common in both males and females (Mintz & Betz, 1988;Mond et al., 2014). Eating disorders and disordered eating place individuals at risk for a number of negative health outcomes (Fairburn, Cooper, & Waller, 2008;Mehler, Birmingham, Crow, & Jahraus, 2010;Sharp & Freeman, 1993) and are associated with significant psychosocial impairment, high rates of comorbid psychopathology, and elevated mortality rates O'Brien & Vincent, 2003). As current intervention approaches are limited in their efficacy (Berkman et al., 2006;Keel & Haedt, 2008), identification of factors that may contribute to or maintain disturbed eating patterns represents an important area of inquiry with significant implications for intervention. ...
Objective:
Objectification theory posits that self-objectification increases risk for disordered eating.
Method:
The current study sought to examine the relationship between self-objectification and disordered eating using meta-analytic techniques.
Results:
Data from 53 cross-sectional studies (73 effect sizes) revealed a significant moderate positive overall effect (r = .39), which was moderated by gender, ethnicity, sexual orientation, and measurement of self-objectification. Specifically, larger effect sizes were associated with female samples and the Objectified Body Consciousness Scale. Effect sizes were smaller among heterosexual men and African American samples. Age, body mass index, country of origin, measurement of disordered eating, sample type and publication type were not significant moderators.
Discussion:
Overall, results from the first meta-analysis to examine the relationship between self-objectification and disordered eating provide support for one of the major tenets of objectification theory and suggest that self-objectification may be a meaningful target in eating disorder interventions, though further work is needed to establish temporal and causal relationships. Findings highlight current gaps in the literature (e.g., limited representation of males, and ethnic and sexual minorities) with implications for guiding future research.
... In a 12-year longitudinal study of 84 female adolescent and young adult patients (median age 20.7 years), NL was found in 5% of patients [4]. Several factors have been hypothesized to contribute to stone formation in patients with AN including: (1) low urinary output and an increase in urinary ammonium output accompanying a prolonged state of hypophosphaturia, (2) the state of chronic volume depletion in fluid-restricting patients leading to urinary saturation of uric acid, oxalate and calcium and (3) the hyperchloremic acidosis seen in patients presenting with diarrhea and laxative abuse [5]. ...
Nephrocalcinosis (NC) has been described as a long-term complication of anorexia nervosa (AN). This is the first report of this complication in an adolescent male patient. We describe the case of a 12-year-old male with AN who presented with acute food restriction and excessive exercising leading to three inpatient admissions. The patient experienced an isolated episode of dysuria and hematuria while on calcium and vitamin D supplementation. Investigations revealed hypophosphatemia, hypercalciuria and mild NC. Follow-up confirmed the presence of NC and possible nephrolithiasis (NL). We discuss the pathophysiology and risk factors of NC and NL in the context of an early presentation of AN. We suggest fluid intake should be liberalized under observation and calcium and vitamin D supplementation should be initiated with caution in patients presenting with AN and risk factors for NC and NL.
... While most of the deaths attributed to AN are related to starvation or medical complications of the disorder, it is alarming that 20% of deaths are due to suicide [3]. Medical complications are typical during the acute phase of an eating disorder [7,8] and persist among those not successfully treated [9], leading to a wide range of physical and emotional disorders into early adulthood [10]. There is still considerable debate concerning the criteria for recovery [11,12] with quality of life remaining poor for many [13] and the costs of treatment being substantial [14]. ...
... Studies of the early 90s already indicated that AN as the third chronic disease most common among girls aged 15 to 19 years [8]. It is also associated with severe medical complications and its mortality rate exceeds the expected incidence of death from all causes in women between 15 and 24 years [9,10]. BN shows lower mortality rates [11,12,13] indubitably of Public Health interest for the teenagers [14]. ...
... However, recently, a multifactorial etiology has been hypothesized. Hepatocellular injuries associated with non-alcoholic fatty liver disease have been regarded as a cause of elevated liver enzymes in patients with AN and those recovering from malnutrition [3,5,6]. Some reports have presented the relationship between low body mass index (BMI) and hepatocellular injuries [7][8][9][10][11]. ...
Background
There are few previous reports regarding the cause and evolution of liver injury in patients with anorexia nervosa (AN) during the refeeding process, and its management remains controversial. This study aimed to determine the risk factors for elevated liver enzymes during refeeding and their effect on the therapeutic process in severely malnourished patients with eating disorders. Methods
In a retrospective cohort study of 167 female inpatients in a single hospital from January 2004 to March 2015, 67 who had normal alanine aminotransferase (ALT) levels on admission were divided into two groups according to the presence or absence of elevated ALT levels during refeeding, and then compared. ResultsThe median age and body mass index (BMI) of the patients on admission were 22 [interquartile range (IQR), 16–33] years and 12.2 (IQR, 11.1–13.0) kg/m2, respectively. Compared with their cohorts, significantly more patients in the early onset age group (<15 years old) had elevated ALT levels during refeeding (67% vs. 33%, p = 0.033), as did patients with longer median time to nadir BMI (3.0 vs. 0 days, p = 0.03). In addition, onset age [odds ratio (OR): 0.274; 95% confidence interval (CI): 0.077–0.981; p = 0.047] and time to nadir BMI (OR: 1.271; 95% CI: 1.035–1.56; p = 0.022) were significantly associated with the odds of elevated ALT levels during refeeding. Conclusions
The results of this study suggest that early age at onset may be a potential risk factor for elevated ALT levels during refeeding in severely malnourished patients with eating disorders. Furthermore, elevated ALT levels during refeeding were significantly associated with delay in the start of weight gain. No significant relationship was found between the amount of initial prescribed calories and elevated ALT levels during refeeding. The median time to maximum ALT was 27 (IQR, 21–38) days after the refeeding process started.
... Approximately one third of deaths of anorexia nervosa patients are due to cardiac complications but pronounced hypotension, bradycardia or also tachycardia are often not considered [29][30][31]. However eating orders in general lead to changes in electrolyte content and associated whole-body organ dysfunction including the heart. Hypotension and sinus bradycardia is common in AN [9]. ...
Background: Eating disorders such as anorexia nervosa present with a significant cardiovascular associated risk of sudden cardiac death. Bradycardia is a serious complication of eating disorders.
Methods: Eating Disorder (ED) patients were admitted to a 6-week treatment program and assessed for of heart rate variability (HRV) at entrance to the program and at discharge from hospital. Linear heart rate variability measures were determined using Kubios software from Lead 3 ECG recordings following a 5-minute rest period. Nonparametric statistics were applied and significance set at p < 0.05.
Results: No significant differences in HRV parameters were noted for the control group following the 6-week treatment program. For the ED group, mean RR interval length decreased significantly following treatment compared (median ± IQR; -64 ± 76; p = 0.002). Sympathovagal function was abnormal in the ED group on admission but improved following treatment, showing a decrease in RMSSD (median ± IQR; -9 ± 18; p = 0.048) and SD1 (median ± IQR; -6 ± 13; p = 0.048). Sample entropy, a, measure of heart rate complexity did not change significantly.
Conclusion: At admission to hospital the ED group was more parasympathetic during rest compared to controls, but they became more sympathetic after the intervention and approached the HRV measures of the controls.
... Approximately one third of deaths of AN patients are due to cardiac complications [17][18][19]. A lowered body mass index (BMI) is often cited as the main factor for the increased risk of cardiac morbidity and mortality due to arrhythmia and related to vagal overdrive as a response to low BMI [4,15,16] and Heart rate and heart rate variability as an independent predictor for cardiac morbidity and mortality was established by [20][21][22]. ...
Eating Disorder (ED) patients who were admitted to an eating disorders program for a 6-week treatment and were assessed for changes in heart rate variability (HRV). Linear heart rate variability measures (HRV) were determined using Kubios software from 20 minute, Lead 3 ECG recordings following a 5-minute rest period. Eighteen patients and 31 controls were included in the analysis. Results were deemed significant if p<0.05. No significant differences in HRV parameters were noted for the control group between Pre- and Post-treatment. For the ED group, mean RR interval length decreased significantly compared to the control group (p=0.006). HF peak frequency increased significantly in the ED group (p=0.001). High frequency (HF) peak indicated that the respiratory frequency increased from Pre to Post measurement. RMSSD tended to decrease (p=0.047) in the ED group. Hence at admission to hospital the ED group was more parasympathetic during rest compared to controls, but they became more sympathetic after the intervention and thus approached the HRV measures of the controls suggesting improvement in ANS modulation of the heart.
... While most of the deaths attributed to AN are related to starvation or medical complications of the disorder, it is alarming that 20% of deaths are due to suicide [3]. Medical complications are typical during the acute phase of an eating disorder [7,8] and persist among those not successfully treated [9], leading to a wide range of physical and emotional disorders into early adulthood [10]. There is still considerable debate concerning the criteria for recovery [11,12] with quality of life remaining poor for many [13] and the costs of treatment being substantial [14]. ...
A major problem plaguing the discussion of insurance reimbursement for the treatment of anorexia nervosa is the apparent gap between research on variables associated with outcome and the formulas used for reimbursement.
... The reported serious cardiac abnormalities in patients with anorexia nervosa include dysrhythmias, some of which may be secondary to hypokalaemia (Sharp & Freeman, 1993;Bonne et al., 1993). Screening and monitoring patients with anorexia nervosa for cardiac risk factors and dysfunction is important, and this should include asking patients whether they purge or have histories of hypokalaemia and/or purging behaviours. ...
... The estimated prevalence of AN in the general population is1 % [4] and it is sex-biased, with an estimated female to male ratio of 10:1 [1,3] and many patients being young women. Common comorbid psychiatric disorders include major depression disorder and anxiety disorders [5][6][7][8][9]. Among all psychiatric disorders, AN has one of the highest mortality rates [10][11][12][13][14][15][16]. ...
Background:
Anorexia nervosa (AN) is a complex psychiatric disease with a moderate to strong genetic contribution. In addition to conventional genome wide association (GWA) studies, researchers have been using machine learning methods in conjunction with genomic data to predict risk of diseases in which genetics play an important role.
Methods:
In this study, we collected whole genome genotyping data on 3940 AN cases and 9266 controls from the Genetic Consortium for Anorexia Nervosa (GCAN), the Wellcome Trust Case Control Consortium 3 (WTCCC3), Price Foundation Collaborative Group and the Children's Hospital of Philadelphia (CHOP), and applied machine learning methods for predicting AN disease risk. The prediction performance is measured by area under the receiver operating characteristic curve (AUC), indicating how well the model distinguishes cases from unaffected control subjects.
Results:
Logistic regression model with the lasso penalty technique generated an AUC of 0.693, while Support Vector Machines and Gradient Boosted Trees reached AUC's of 0.691 and 0.623, respectively. Using different sample sizes, our results suggest that larger datasets are required to optimize the machine learning models and achieve higher AUC values.
Conclusions:
To our knowledge, this is the first attempt to assess AN risk based on genome wide genotype level data. Future integration of genomic, environmental and family-based information is likely to improve the AN risk evaluation process, eventually benefitting AN patients and families in the clinical setting.
... One possible explanation for these puzzling results is that Prrxl1 À/À mice may have decreased gastric motility as a side effect of starvation (Robinson et al. 1988;Sharp and Freeman 1993), such that WT and Het mice may have consumed significantly more milk, but also urinated and defecated significantly more due to higher gastric motility. This could result in a difference in ingestion being invisible to the current measurement technique. ...
Ingestive behaviors in mice are dependent on orosensory cues transmitted via the trigeminal nerve, as confirmed by transection studies. However, these studies cannot differentiate between deficits caused by the loss of the lemniscal pathway vs. the parallel paralemniscal pathway. The paired-like homeodomain protein Prrxl1 is expressed widely in the brain and spinal cord, including the trigeminal system. A knockout of Prrxl1 abolishes somatotopic barrellette patterning in the lemniscal brainstem nucleus, but not in the parallel paralemniscal nucleus. Null animals are significantly smaller than littermates by postnatal day 5, but reach developmental landmarks at appropriate times, and survive to adulthood on liquid diet. A careful analysis of infant and adult ingestive behavior reveals subtle impairments in suckling, increases in time spent feeding and the duration of feeding bouts, feeding during inappropriate times of the day, and difficulties in the mechanics of feeding. During liquid diet feeding, null mice display abnormal behaviors including extensive use of the paws to move food into the mouth, submerging the snout in the diet, changes in licking, and also have difficulty consuming solid chow pellets. We suggest that our Prrxl1(-/-) animal is a valuable model system for examining the genetic assembly and functional role of trigeminal lemniscal circuits in the normal control of eating in mammals and for understanding feeding abnormalities in humans resulting from the abnormal development of these circuits.
Feeding and eating disorders (FEDs) are psychological disorders that are characterized by abnormal eating, dysfunctional relationships with food, and a preoccupation with one’s weight and shape. Among others, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes two specific FEDs: anorexia nervosa (AN) and bulimia nervosa (BN), although there are subtypes associated with each. The DSM-5 and the International Classification of Diseases (ICD-10) have different criteria for diagnosing AN and BN. Early identification of a FED is associated with shorter duration and fewer medical complications. Yet it is estimated that only about 33% of AN patients and 6% of BN are receiving proper treatment for their illnesses. Gastrointestinal upset, fluid, and electrolyte imbalances are common with AN and may lead to complications such as, pernicious anemia, osteoporosis, and heart disease. On the other hand, BN can cause adverse effects, such as erosion of the teeth, enlargement of the parotid salivary glands, and acidic stomachs leading to heartburn. Long-term adverse effects caused by BN are gynecological problems, hormonal disturbances, hypercholesterolemia, and hypertension. Successful treatment of FEDs should be managed with a team-based approach including the physician, psychologist, and registered dietitian.
Eating disorders are common and have a high morbidity and mortality rates. They present with a range of comorbid features and require specialized treatment to achieve a positive outcome. The literature on eating disorders has expanded rapidly in the past 20 years and this article reviews diagnostic and defining features, assessment, etiology, comorbidities and treatment options. Recent advances in the understanding and treatment of eating disorders can be expected to produce positive outcomes in most cases.
Anorexia nervosa (AN) is a kind of malnutrition resulting from chronic self-induced starvation. The reported associated endocrine changes (adaptive and non-adaptive) include hypothalamic amenorrhea, a nutritionally acquired growth hormone resistance with low insulin-like growth factor-1 (IGF-1) secretion, relative hypercortisolemia, decreased leptin and insulin concentrations, and increased ghrelin, Peptide YY (PYY), and adiponectin secretion. The combined effect of malnutrition and endocrinopathy may have deleterious effects on multi-organs including bone, gonads, thyroid gland, and brain (neurocognition, anxiety, depression, and other psychopathologies). The mammalian target of rapamycin (mTOR) is a kinase that in humans is encoded by the mTOR gene. Recent studies suggest an important role of the mTOR complex in the integration of nutrient and hormone signals to adjust energy homeostasis. In this review, we tried to elucidate the role/s of mTOR as a critical mediator of the cellular response in anorexia nervosa. (www.actabiomedica.it)
Objective
DSM-5 Atypical Anorexia Nervosa (AAN), a new eating disorder diagnosis, presents similarly to Anorexia Nervosa (AN) in the absence of severe underweight. The prevalence of AAN and other DSM-5 eating disorders was estimated in a sample of Veterans. Sociodemographic, mental health, and eating behavior correlates were examined.
Method
Iraq and Afghanistan war era Veterans (N = 1137, 51.6% female) completed the Eating Disorder Diagnostic Scale-5 for probable AAN diagnosis and validated measures of eating pathology and mental health between February 2016 and October 2019. Multivariate analyses compared Veterans with AAN to those with and without any DSM-5 eating disorder.
Results
Among completers, 9.3% of the sample met criteria for probable AAN and 16.6% for another eating disorder. Veterans with AAN were 74% female and 89% White. Mean age was 41 years, and on average BMIs were classified as overweight (BMI = 28.8, SD = 5.6) despite being at least 10% lower than their lifetime highest weight. Two-thirds reported dietary restraint on more than half the days in the past month. On measures of mental health, the AAN group had worse functioning than the no eating disorder group, similar functioning to Veterans with Binge Eating Disorder (BED), and better functioning than Veterans with Bulimia Nervosa (BN).
Discussion
Results support AAN as a highly prevalent and clinically significant diagnosis. Findings highlight the need to identify and address eating disorders, particularly other specified eating disorders not meeting criteria for AN, BN, or BED, in the military and Veteran populations, and other high-risk and underserved populations.
Eating disorders affect a significant number of individuals across the life span and are found among all demographic groups (including all genders, socioeconomic statuses, and ethnicities). They can cause malnutrition, which can have significant effects on every organ system in the body. Cardiovascular complications are particularly dangerous and cause eating disorders to have the highest mortality rate of all mental illnesses. This article outlines the medical assessment and treatment of malnutrition due to disordered eating.
Eating disorders are increasingly problematic in the United States. Magazines, television, movies, certain athletes, etc., all promote an unrealistic image of very thin people. Eating disorders, which primarily affect women, carry a high morbidity and the highest rate of mortality of any psychiatric illness. It has been estimated that more than 3% of young women have these disorders and probably twice that number have a clinically important variant.¹ Males have these conditions as well, but in much smaller numbers. This chapter will focus on anorexia nervosa (AN) and bulimia nervosa (BN), as virtually all research on eating disorders (ED) has focused on one or both of these conditions. Other known ED conditions - not-otherwise-specified and binge-eating disorder - will not be reviewed because of the limited research in these areas.
Anorexia nervosa (AN) is an eating disorder that most frequently afflicts females in adolescence. In these subjects, cardiovascular complications are the main cause of morbidity and mortality. Aim of this review is to analyze the hemodynamic, pro-arrhythmic and structural changes occurring during all phases of this illness, including re-feeding. A systematic literature search was performed on studies in the MEDLINE database, from its inception until September 2017, with PUBMED interface focusing on AN and cardiovascular disease. This review demonstrated that the most common cardiac abnormalities in AN are bradycardia and QT interval prolongation, which may occasionally degenerate into ventricular arrhythmias such as Torsades des Pointes or ventricular fibrillation. As these arrhythmias may be the substrate of sudden cardiac death (SCD), they require cardiac monitoring in hospital. In addition, reduced cardiac mass, with smaller volumes and decreased cardiac output, may be found. Furthermore, mitral prolapse and a mild pericardial effusion may occur, the latter due to protein deficiency and low levels of thyroid hormone. In anorectic patients, some cases of hypercholesterolemia may be present; however, conclusive evidence that AN is an atherogenic condition is still lacking, although a few cases of myocardial infarction have been reported. Finally, refeeding syndrome (RFS), which occurs during the first days of refeeding, may engender a critically increased risk of acute, life-threatening cardiac complications.
Essstörungen imponieren vor allem durch die Fixierung auf Figur, Gewicht und Essen und gehen mit einer starken Verzerrung des Körperbildes einher. Unterschiede zwischen beiden Essstörungsdiagnosen bestehen vor allem im tatsächlichen Körpergewicht. Trotz im Vergleich zu anderen psychischen Störungen geringerer Auftretenshäufigkeit (je nach Störung von 1–3 %) sind Essstörungen, insbesondere die Anorexia nervosa aufgrund ihrer schwerwiegenden körperlichen Komorbiditäten nicht zu vernachlässigen. Die Entstehung der Störung ist multifaktoriell bedingt. Der Verlauf trotz Behandlung in zirka einem Drittel der Fälle intermittierend bis chronisch.
Background. Patients with anorexia nervosa (AN) run a high risk of becoming chronically ill and of dying. In the acute phase of their illness they present with numerous physical and laboratory abnormalities. However, little is known about the long-term prognostic value of these findings or about the medical morbidity in large samples of consecutively treated patients in the long-term.
Methods:
A comprehensive literature review on cardiac changes in anorexia nervosa was carried out.
Results:
There are structural, functional, and rhythm-type changes that occur in patients with anorexia nervosa. These become progressively significant as ongoing weight loss occurs.
Conclusion:
Cardiac changes are inherent to anorexia nervosa and they become more life-threatening and serious as the anorexia nervosa becomes increasingly severe. Weight restoration and attention to these cardiac changes are crucial for a successful treatment outcome.
Objective. To establish the range and extent of psychological improvement during the course of inpatient treatment for anorexia nervosa. Design. A prospective study, measuring change along specific parameters of psychological functioning and nutritional status over time. Setting. A specialist inpatient facility for the treatment of eating disorders. Subjects. 15 randomly selected patients, diagnosed with anorexia nervosa, who completed the programme. Outcome measures. Body mass index (BMI); Eating Disorders Inventory (EDI); Beck Depression Inventory (BDI). Results. Significant improvement was achieved in respect of nutritional status, as well as psychological and emotional functioning. Change in nutritional status was not specifically correlated with these improvements. However, discharge nutritional status was significantly correlated with a number of psychological and behavioural characteristics associated with anorexia as measured by the EDI. It was also found that discharge nutritional status was positively correlated with mood status as measured by the BDI. Conclusions. The study highlights the broad range of parameters that improve within the context of a cognitivebehavioural inpatient treatment programme. Inpatient treatment should not be regarded purely as a weightrestoring process.
Biological susceptibility to eating psychopathology influences the onset, course, and maintenance of eating disorders across the life-span. Consequently, a developmental lens is imperative to understand the expression of eating disorders and to identify key risk factors and windows for prevention for women at each stage of life. As early as puberty, the associated neuroendocrine changes that occur may trigger expression of an eating disorder for those with a genetic predisposition. Subsequently, this has a potentially deleterious effect on later reproductive physical and mental health. Eating disorders often impact pregnancy and birth outcomes as well as increase vulnerability to perinatal mood and anxiety disorders. Additionally, perinatal issues such as anxiety, weight retention, and difficulty with child feeding can have an intergenerational effect, increasing the risk of onset in successive generations. This chapter explores the dynamic interplay between women's physical development, eating disorder symptoms, and overall mental health. © 2014 Springer International Publishing Switzerland. All rights reserved.
IntroductionBulimia NervosaBinge Eating Disorder (Bed)Anorexia NervosaReferences
Ego development, independence, and self-concept are psychosocial issues which play an enormous role in the successful passage of youth through adolescence. This is a time of uncertainty and upheaval for the healthy teen. The onset of a chronic disease such as insulin dependent diabetes mellitus (IDDM) during this tumultuous period of development can disrupt the adolescent, and psychological problems and/or disorders such as depression, poor body image, and eating disorders can develop. A review of the literature tends to implicate stringent dietary restrictions and weight gain as predisposing factors in the incidence of eating disorders within this population. Also, low self-esteem, depression, and the struggle between autonomy and dependence are commonly associated with IDDM, as well as eating disorders. Although the association between diabetes mellitus and eating disorders is controversial, the magnitude of serious complications arising from the combination warrants further research. Eating disorders within the IDDM population interfere with glycemic control, in a population already hormonally tenuous in achieving this control, and predisposes the young individual to the many serious complications which arise from poor metabolic functioning. In order to adequately care for adolescents with IDDM, caregivers must look at the disease in a multidisciplined approach and consider the possibility of low self-esteem, depression, and/or an eating disorder.
Eating disorders, including anorexia nervosa and bulimia nervosa, are complex psychiatric diseases characterized by severe disturbances in eating behavior, often resulting in dramatic consequences for the physical health of patients. Even though appearing after the beginning of an eating disorder and therefore not representing their primary cause, physical impairments play an important role in the development of psychopathology, its course and prognosis, and in the most severe cases may also represent a significant threat to the patient's life. They contribute, together with suicide, to the high mortality of patients with eating disorders. Indeed, anorexia nervosa has the highest mortality of any psychiatric diagnosis, estimated at 10% within 10 years of diagnosis, while mortality for bulimia nervosa is lower, occurring at approximately 1% within 10 years of diagnosis. With a few exceptions, the physical complications resolve with the recovery of body weight and the discontinuation of aberrant eating and purging behaviors. The burden of physical complications demands prompt clinical consideration and appropriate treatment.
The relation between reduced nutritional intake, with consequent weight loss, and sleep disturbance was studied by comparing certain sleep encephalogram patterns in a group of inpatients with anorexia nervosa before, during, and after a regimen of refeeding with a normal diet to a matched population mean weight. At low body weights patients had less sleep and more restlessness, especially in the last four hours of the night. During refeeding and weight gain slow-wave sleep initially increased and then tended to decrease during the final stage of restoration of weight back to matched population mean levels. With the overall weight gain, however, there was a significant increase in length of sleep and rapid eye movement sleep, the latter increasing especially during the later stages of weight gain. These results reaffirm that insomnia, and especially early morning waking, is associated with low body weight in anorexia nervosa, and their implications are discussed with particular reference to a hypothetical association between various anabolic profiles and the need for differing components of sleep.
The carpal bones of 18 anorexia nervosa patients were radiographed and the X-ray age assessed by 2 different standard methods.
The study demonstrates that skeletal development in anorexia nervosa patients is delayed such that there is no association between radiological assessment of age and chronological age. It is strongly suggested that bony development actually ceases when body weight falls sufficiently to stop menstruation. There was a highly significant (P = 0.001) linear relationship between radiological age and the sum of the age of onset of the illness plus any period(s) of re-feeding. Weight gain seems to re-kindle the bone maturing mechanisms: the role of weight thresholds and associated hormone activity being discussed.
The findings of this study strongly support the existing evidence that the anorexia nervosa patient is biologically and psychologically immature.
Seventeen anorexia nervosa patients were examined dentally and their dietary histories and eating habits studied. Analysis of the data confirmed earlier observations dental deterioration associated with anorexia nervosa. The deterioration included a pattern of enamel dissolution in cases of vomiting, regurgitation, and/or the consumption of large amounts of citrus fruits; and an altered caries response due to abnormal carbohydrate consumption. Despite the patient's probably insistent denial of 'anorectic' eating habits, the general practitioner should consider the existence of anorexia nervosa in the presence of such abnormal features, especially in young women. The relationship of these findings to larger populations with similar eating habits is discussed.
The digestion, absorption and intramucosal metabolism and transport of vitamin A and beta carotene are reviewed. The major pathways of dietary vitamin A consist of micellar absorption of retinol, intra mucosal esterification and lymphatic transport. Most of the ingested beta carotene is cleaved into 2 molecules of retinal by a specific dioxygenase and then reduced to retinol. Low fat and low protein intakes interfere with many of the physiological processes in the intestine. Dietary factors or a deficiency of intra mucosal enzymes may be resonsible for the hypercarotenemia observed in certain clinical conditions.
The development of the ovary that begins during embryonic life continues throughout childhood. Follicular growth and degeneration occur continuously and concomitantly during childhood. Although more follicles apparently start growth early in childhood than later, more follicles reach later antral sizes as age advances during childhood. An increase in the number and size of antral follicles, which do not yet come to ovulation but degenerate, contribute to the gradual increase in the size of the ovary. Gonadotrophins are also necessary for normal follicular growth during childhood as, in their absence, antral follicles do not form. The two ovaries of a child look similar and contain many distended follicles. When ovulation starts, the two ovaries often differ in their overall appearance, which is an expression of differing hormonal microenvironments in the two organs. Examination of the ovaries of young mature women revealed some healthy antral follicles present in some ovaries during the luteal phase. The question is raised whether such follicles might come to ovulation at other times than the midcycle period, and whether reflex ovulation occurs in the human. It is argued that recent findings of LH action on non-ovulatory antral follicles and the continued presence of healthy, non-ovulatory follicles at the periovulatory period suggest that reflex ovulation can occur in the human female.
100 females with anorexia nervosa were followed up 4-8 years after first presentation. All but 12 had had refeeding and/or psychotherapy. 48 had a good outcome (weight at least near normal, regular menstruation, largely satisfactory mental state and psychosexual and psychosocial adjustments) but outcome was intermediate in 30, and poor in 20 patients. 2 had died. Poor outcome could be positively associated with clinical data such as longer duration of illness, older age of onset and presentation, lower weight during illness and at presentation, presence of symptoms such as bulimia, vomiting, and anxiety when eating with others, poor childhood social adjustment, and poor parental relationships.
In Reply.—
Drs Silverman and Wolff challenge the statement in our article that acanthocytosis is a feature of anorexia nervosa and state that none of their 88 cases were found to have acanthocytosis. On review of the literature referenced in our article, seven patients with anorexia nervosa and acanthocytosis were described.1,2 In addition, we have subsequently seen a second case of anorexia nervosa with acanthocytosis.We are convinced that acanthocytosis is associated with some cases of anorexia nervosa. Mant and Faragher2 state that acanthocytosis is transient and disappears after therapy is started. Perhaps the failure to report the finding in the series by Silverman and Wolff is due to the presence of mild disease or ongoing treatment.
WE RECENTLY encountered a patient with anorexia nervosa who demonstrated pancytopenia, a hypoplastic bone marrow, and notable acanthocytosis. Although this constellation of findings has been reported in anorexia nervosa, to our knowledge, it is not fully described in major textbooks of hematology and has not previously been reported in the American medical literature. In addition, we have further verified the association of acanthocytosis and low levels of β-lipoproteins in a patient with anorexia nervosa.Report of a Case
An 18-year-old woman had been examined for weight loss and amenorrhea in 1975 and had the diagnosis of anorexia nervosa since that time. She had been hospitalized one week before admission because of worsening anorexia and cachexia. At that time the hematocrit value was 40%, and the WBC count was 3,400/cu mm, with a normal differential cell count. No comment was made about an abnormal RBC morphological condition.Following 12 hours of
Twelve patients with anorexia nervosa and weight loss ranging from 25% to 44% of total body weight were studied with respect to aberrations in serum carotene levels. Hypercarotenemia was found in nine of the 12. Hypercarotenemia apparently has not been previously described in other forms of human starvation. Other conditions which may lead to disturbances in lipid metabolism and which have been associated with hypercarotenemia were ruled out. An abnormality in lipid metabolism in anorexia nervosa is suggested by these findings.
Women with anorexia nervosa have reduced skeletal mass. Both anorexia and osteopenia are less common in men. We describe a 22-year-old man with anorexia nervosa and severe osteopenia involving both cortical and trabecular bone who developed a pelvic fracture and multiple vertebral compression fractures. He was found to have secondary hypogonadotropic hypogonadism that was reversible with weight gain. This case illustrates the need to consider osteopenia as a potential complication of anorexia nervosa in males as well as females.
(JAMA 1986;256:385-388)
• Clinically significant hypoglycemia is an unusual complication of anorexia nervosa. We describe a 44-year-old woman with a 5-year history of anorexia nervosa who presented with hypoglycemic coma and eventually experienced sudden death. Biochemical studies showed suppressed levels of insulin, C peptide, and proinsulin during hypoglycemia; appropriate elevations of growth hormone and cortisol levels were observed, suggesting that the hypoglycemia was related to severe malnutrition. Nine previously reported cases of severe hypoglycemia in anorexia nervosa are reviewed (six of the patients involved also died). The presence of severe hypoglycemia in anorexia nervosa implies a grave prognosis and mandates aggressive medical and nutritional therapy to improve the chance of survival.
(Arch Intern Med. 1990;150:894-895)
• The dermatologic changes in anorexia nervosa and bulimia nervosa may be the first signs to give the clinician a clue that an eating disorder is present, as many of these patients either deny their symptoms or secretly refuse to comply with treatment. The dermatologic signs are a result of (1) starvation or malnutrition, eg, lanugolike body hair, asteatotic skin, brittle hair and nails, and carotenodermia; (2) self-induced vomiting, eg, hand calluses, dental enamel erosion, gingivitis, and a Sjögrenlike syndrome; (3) use of laxatives, diuretics, or emetics and their dermatologic side effects; and (4) other concomitant psychiatric illness, eg, hand dermatitis from compulsive handwashing. Further, as most of the cutaneous signs are not specific to anorexia nervosa and bulimia nervosa, failure to include eating disorders in the differential diagnosis may lead to misdiagnosis of the cutaneous symptoms.
(Arch Dermatol 1987;123:1386-1390)
Of twelve patients consecutively admitted to the Maudsley Hospital Eating Disorders Unit, four had neuromuscular abnormality, eight haematological abnormality, and four no abnormality. All those having neuromuscular signs had concomitant haematological dysfunction. Vomiting, and food restriction with vegetarianism, appeared more likely to lead to complications than either food restriction alone or laxative abuse. The physical status of severely underweight patients admitted for refeeding needs to be carefully monitored.
Synopsis
It is suggested that chlorosis, or the ‘green-sickness’, was not a single disease entity, but a name applied to at least two distinct conditions affecting young females in the past. The first (‘chloro-anaemia’) was a form of hypochromic anaemia possibly associated with gastric ulceration and poor diet. This form predominated in the late nineteenth and early twentieth centuries. The second (‘chloro-anorexia’) was a disorder of psychogenic origin resembling, but not identical to, anorexia nervosa. The latter form predominated in earlier periods but also occurred throughout the nineteenth century; it was also known as ‘the virgin's disease’ or ‘febris amatoria’. The ‘green’ of‘;green-sickness’ may originally have indicated innocence rather than a green colour of the skin.
Historical and clinical data collected over a 15-year period from the study of 100 young inpatients with anorexia nervosa are presented. A clinical management program with zero mortality is described.
To study the pathophysiology of hypercortisolism in patients with anorexia nervosa, we examined plasma ACTH and cortisol responses to ovine corticotropin-releasing hormone before and after correction of weight loss. We also studied patients with bulimia whose weight was normal, since this disorder has been suspected to be a variant of anorexia nervosa. Before their weight loss was corrected, the anorexic patients had marked hypercortisolism but normal basal plasma ACTH. The hypercortisolism was associated with a marked reduction in the plasma ACTH response to corticotropin-releasing hormone. When these patients were studied three to four weeks after their body weight had been restored to normal, the hypercortisolism had resolved but the abnormal response to corticotropin-releasing hormone remained unchanged. On the other hand, at least six months after correction of weight loss their responses were normal. The bulimic patients whose weight was normal also had a normal response to corticotropin-releasing hormone. We conclude that in underweight anorexics, the pituitary responds appropriately to corticotropin-releasing hormone, being restrained in its response by the elevated levels of cortisol. This suggests that hypercortisolism in anorexics reflects a defect at or above the hypothalamus. The return to eucortisolism soon after correction of the weight loss indicates resolution of this central defect despite persistence of abnormalities in adrenal function.
To determine whether patients with anorexia nervosa (AN) and leukopenia have an increased risk of infection, we reviewed the incidence of leukopenia and infection in 68 cases of AN and studied the mechanism of profound neutropenia in one. Compared with controls, patients with AN had substantially lower total leukocyte counts and absolute neutrophil, lymphocyte, and monocyte counts. Despite frequent and often severe panleukopenia, the patients with AN had no more infections than did the control subjects. The patient with severe neutropenia had a hypocellular bone marrow biopsy specimen showing relative myeloid hyperplasia, normal distribution of neutrophils between the marginal and circulating pools, and normal bone marrow neutrophil reserves as estimated by response to hydrocortisone sodium succinate. We conclude that patients with AN and associated leukopenia do not have increased infection propensity.(Arch Intern Med 138:1520-1523, 1978)
• Anorexia nervosa is a common psychiatric disorder predominantly affecting young women, associated with significant morbidity and mortality, much involving the cardiovascular system. In contrast, protein-calorie malnutrition, while not strictly analogous to the protein-sparing characteristics often noted in anorexia nervosa, is a problem of global stature. Physiologic consequences of anorexia nervosa include rhythm disturbances, mitral valve prolapse, plus both systolic and diastolic ventricular dysfunction. Diminished exercise capacity occurs in both states, with marked blunting of the heart rate and blood pressure response. Congestive heart failure may appear, especially during refeeding. In addition to the myofibrillar destruction associated with protein-calorie malnutrition, hypophosphatemia, particularly when exacerbated by unrestricted glucose-rich refeedings or hyperalimentation, may be one additional cause of ventricular dysfunction. A high level of suspicion for cardiovascular complications is, therefore, warranted in the evaluation and therapy of weight loss conditions such as starvation and anorexia nervosa.
(Arch Intern Med 1989;149:877-881)
SYNOPSIS
The frequencies of various forms of eating-related behaviour (such as vomiting and laxative abuse) are reported for a series of non-anorectic bulimia patients seen for evaluation in an eating disorders clinic. The results of serum electrolyte, glucose and other screening tests in these patients are presented. Electrolyte abnormalities were found in 82 of the 168 patients (48·8%) who were diagnosed as having either bulimia or atypical eating disorder. The most common abnormality was metabolic alkalosis (27·4%); hypochloremia (23·8%) and hypokalemia (13·7%) were also commonly seen. No significant blood sugar abnormalities were encountered. An elevated serum amylase level was found to be associated with frequent binge-eating and vomiting behaviour. The pathophysiology of electrolyte abnormalities in this patient group is briefly reviewed.
A raised serum cholesterol level in a group of patients with anorexia nervosa has been confirmed in a comparative study of 37 patients and 37 normal subjects, matched individually with the patients for age and sex. However, wide scatter of serum cholesterol levels in the patient group continues to be evident. Serum cholesterol levels in the patient group were found to be unrelated to thyroid function as determined by protein bound iodine levels, 24-hour uptake of I131, B.M.R. and response to TS.H. In 7 patients undergoing treatment (involving restoration of weight to normal levels), additional parameters of fat metabolism have been investigated; namely, plasma total lipids, plasma triglycerides, lipid phosphorus, blood ketones, free fatty acids, and urinary estimations of fat mobilizing substance. The outstanding features in the results are the wide variability in levels between patients and the great lability in each patient during treatment.
Cortisol metabolism and the pituitary adrenal axis were investigated in 10 adult patients with protein calorie malnutrition in Calcutta, India. Control studies were performed on all patients after complete recovery. Plasma cortisol was elevated in malnutrition, and urinary cortisol was high in relation to creatinine clearance. Metabolic clearance rate and plasma production rate were reduced, and urinary 17 hydroxycorticosteroid excretion was reduced to a greater degree than cortisol production. Plasma ACTH was maintained, in spite of the elevated plasma cortisol. Testing with ACTH and metyrapone produced appropriate adrenal and pituitary responses. Dexamethasone administration failed to suppress plasma cortisol to a normal degree. Dextrose infusion produced similar decreases in plasma cortisol in malnutrition and after refeeding. It is concluded that cortisol metabolism is reduced in rate in protein calorie malnutrition and is altered such that production of the chloroform extractable 17 hydroxycorticosteroid metabolites is disproportionately small. The pituitary adrenal axis is intact, and ACTH secretion is maintained by an unidentified stimulus so as to produce elevated levels of plasma cortisol. The stimulus for ACTH secretion is not blocked by dexamethasone and is not hypoglycemia.
From this study it is concluded that the self-induced caloric restriction seen in anorexia nervosa results in considerable changes in body composition and circulatory and renal functions. From the clinical point of view it is important to be aware of the adaptations that follow weight loss in these patients. The loss of weight was not due solely to a loss of body fat, but could also be ascribed to a decrease in soft fat-free tissue. The reductions in heart volume, blood volume and total body potassium were found to be proportional to the weight loss. The findings of low body temperature and loss of body fat suggest a potential risk of hypothermia. This is of particular importance when the patients are exposed to a cold environment. It should be emphasized that these patients have a very low aerobic capacity, despite their often marked hyperactive behavior. This implies that the AN patients during daily life, when activities often require an oxygen uptake of around 11/min, work close to their maximal capacity. The renal dysfunction found in this study is probably of minor importance in daily life. However, during abnormal situations, such as gastroenteritis or intravenous treatment, it is necessary to consider the altered renal homeostasis and the adapted circulatory dimensions. The edema sometimes found in anorexia nervosa is consistent with the presence of a reduced GFR and a possibly generalized decrease in membrance permeability. When water production is increased, these factors contribute to fluid retention. The somewhat broad criteria for AN in this study may be open to criticism. Nevertheless, an early recognition of the syndrome is important for the prognosis. This may justify a broad definition of the disease.
In a retrospective study of case notes a number of experiential and psychological factors were discerned of possible importance to the psychogenesis of anorexia nervosa. These factors included issues of dependence and independence, sexual challenge, concern about obesity, and a variety of other, less specific stresses.
Attempts to confirm the findings by means of a prospective study were impeded by difficulties in defining the onset of the illness. While in some patients the occurrence of anorexic type behaviour led immediately to weight loss, in others there was a significant delay between the onset of behavioural change and consequent emaciation.
Primary anorexia nervosa (PAN) is an important psychiatric disease with a 7--21% mortality rate. Although altered gastrointestinal function may be an important aspect of its pathophysiology, no information is available concerning gastric emptying and secretion in those patients. During fasting, fractional emptying rates and hydrogen ion (H+) output were decreased twofold in PAN, as compared with healthy controls, and fluid output was slightly but not significantly decreased. Pentagastrin-induced peak stimulation of H+ output in PAN was 64% of that found in controls (P less than 0.05). Peak gastric fluid output was also significantly less in PAN patients, but suppression of fractional emptying produced by pentagastrin was of the same magnitude in both groups. Following a 250-ml water load, the magnitude and the duration of both the emptying and secretory responses were less in PAN patients than in controls. As a result, the initial increase of intragastric volume was greater in PAN patients than in controls, and the gradual return to fasting volume was delayed in those patients. Follow weight gain, fractional emptying tended to return toward control values, but was still significantly less than in controls following the water load. Gastric H+ and fluid output were not significantly modified following weight gain.
Measurements of serum thyroid hormones were compared in 22 patients with typical anorexia nervosa and 22 euthyroid control subjects. Serum total triiodothyronine (T3) was (mean +/- (SE) 62.1 +/- 7.1 ng/100 ml in anorexia patients and 115.2 +/- 8.4 ng/100 ml in control subjects (P less than 0.001). Serum adjusted thyroxine (T4Adj) was significantly different in the anorexia (7.1 +/- 0.4) and control (8.2 +/- 0.4) groups. Serum T3 was subnormal in 63% and T4Adj subnormal in 36% of the 22 anorexia patients. The mean serum T4/T3 in anorexia patients (158 +/- 19) was higher than that in the control subjects (88 +/- 5.5, P less than 0.005) or in 18 patients with hypothalamic or pituitary hypothyroidism (77.9 +/- 10.1, P less than 0.001). Following weight gain in 6 anorexia patients, there was a significant rise in serum T3 without change in T4Adj concentration. The Achilles reflex half-relaxation time (ART) in 38 anorexia patients was 348.6 +/- 10 msec compared with 280 +/- 30 msec in 168 normal age-matched subjects (P less than 0.001), and was prolonged (greater than 340 msec) in 65% of these 38 patients. In 18 anorexia patients with measured ART, T3 and T4Adj, the mean ART was longer 376.1 +/- 20 msec) in 10 with subnormal T3 than in 8 patients with a normal T3 (294.7 +/- 13.2 msec, P less than 0.01). There was no significant difference in the mean ART between patients with a normal or low serum T4Adj. Administeration of oral T3 40 mug/day for 4 weeks to 11 anorexia patients caused a significant reduction (P less than 0.001) in mean ART of 108.7 +/- 9.6 msec compared with 17.7 +/- 3.3 msec in 18 normal subjects. There was a normal peak serum TSH and a rise in mean total serum T3 of 47 +/- 12 ng/100 ml (range 11-100 ng/ml) in 7 of 8 patients following 200 mug of iv thyrotropin releasing hormone (TRH). The fall in serum TSH was delayed in 6 patients. Assessment of hypothalamic control of thyroid function in 3 patients using the method of thyroidal iodide release (TIR) showed impairment of the normal diurnal variation and response to administered glucocorticoids. In the absence of a space-occupying pituitary lesion, the TRH and TIR data suggest a central inhibition of thyroid function, possibly by impairment of hypothalamic TRH release. In addition, a probable decrease of peripheral T4 to T3 conversion leads to low serum T3 concentrations. The prolonged basal ART and the marked ART reduction in response to T3 administration is attributed to correction of tissue thyroid hormone deficiency in the anorexia patients.
The literature on anorexia nervosa largely ignores the acid-base and electrolyte disturbances that may accompany this condition. In an attempt to assess the magnitude of these disturbances in anorexia nervosa the authors reviewed the laboratory profiles of 7 patients with the disease who were consecutively admitted to a hospital over a period of 8 years. Several acid-base and electrolyte disturbances were observed; the most frequent was chloride-responsive metabolic alkalosis. The authors suggest that all patients with anorexia nervosa receive diagnostic studies for these disturbances, including ECG and urinary electrolytes when necessary, so that abnormalities can be diagnosed and treated appropriately.
Synopsis
Thirty patients were selected for a prospective study according to two criteria: (i) an irresistible urge to overeat (bulimia nervosa), followed by self-induced vomiting or purging; (ii) a morbid fear of becoming fat. The majority of the patients had a previous history of true or cryptic anorexia nervosa. Self-induced vomiting and purging are secondary devices used by the patients to counteract the effects of overeating and prevent a gain in weight. These devices are dangerous for they are habit-forming and lead to potassium loss and other physical complications. In common with true anorexia nervosa, the patients were determined to keep their weight below a self-imposed threshold. Its level was set below the patient‘s healthy weight, defined as the weight reached before the onset of the eating disorder. In contrast with true anorexia nervosa, the patients tended to be heavier, more active sexually, and more likely to menstruate regularly and remain fertile. Depressive symptoms were often severe and distressing and led to a high risk of suicide.
A theoretical model is described to emphasize the interdependence of the various symptoms and the role of self-perpetuating mechanisms in the maintenance of the disorder. The main aims of treatment are (i) to interrupt the vicious circle of overeating and self-induced vomiting (or purging), (ii) to persuade the patients to accept a higher weight. Prognosis appears less favourable than in uncomplicated anorexia nervosa.
The endocrine dysfunctions that occur in anorexia nervosa are secondary phenomena, resulting from the disturbance in behaviour. Their presentation is different from that of any primary endocrine disease, and their occurrence should not lead to difficulties in differential diagnosis. The current practice of submitting anorexia nervosa patients, who present with amenorrhoea and 'unexplained' weight loss, to exhaustive endocrine investigations, appears unwarrented. Anorexia nervosa is a clinical diagnosis which can usually be made by careful attention to history taking and physical examination and there is usually little need for laboratory tests of endocrine function. If such tests are performed and yield positive results of the type outlined above, they should be interpreted as evidence supporting the diagnosis rather than as a justification for further investigation. The patient should be referred for appropriate psychiatric treatment at the earliest opportunity and should not be confirmed in a medical sick role by unnecessary concentration on the endocrinological sequelae of weight loss.
Summary A case of acute pancreatitis and gastric dilatation in refeeding after anorexia nervosa is presented. The aetiology of this
condition is discussed.
This study was undertaken to examine hematologic findings in a sample of 34 patients with established anorexia nervosa compared with a carefully selected control group. The mean hemoglobin, hematocrit, and white blood cell count are significantly lower in the anorectic patients than in the controls. The shift in the differential count from neutrophils to lymphocytes is also statistically significant and suggests that the leukopenia of the anorectic patients is due primarily to a reduction in circulating neutrophils.
To determine whether patients with anorexia nervosa (AN) and leukopenia have an increased risk of infection, we reviewed the incidence of leukopenia and infection in 68 cases of AN and studied the mechanism of profound neutropenia in one. Compared with controls, patients with AN had substantially lower total leukocyte counts and absolute neutrophil, lymphocyte, and monocyte counts. Despite frequent and often severe panleukopenia, the patients with AN had no more infections than did the control subjects. The patient with severe neutropenia ahd a hypocellular bone marrow biopsy specimen showing relative myeloid hyperplasia, normal distribution of neutrophils between the marginal and circulating pools, and normal bone marrow neutrophil reserves as estimated by response to hydrocortisone sodium succinate. We conclude that patients uith AN and associated leukopenia do not have increased infection propensity.
In previous studies we had established that emaciated women with active primary anorexia nervosa (AN) had immature 24-hr luteinizing hormone (LH) secretory patterns. In this study, we have examined the circadian LH patterns of eight women with AN who had partially or fully recovered their ideal weights. Three of the women were studied before and after weight gain and five women were studied only after the appearance of binge-eating and consequent weight gain (by history). Our findings are: (1) The adult (mature) circadian LH secretory pattern was not present in women who had partially or totally achieved ideal weight but who otherwise remained symptomatic; (2) those women who showed both weight gain and normalization of LH pattern were also symptomatically improved in other respects; (3) the degree of immaturity of pattern did not correlate reliably with the duration of illness, the degree of fatness, or the extent of deficit from ideal weight; (4) the mode of illness onset and the type of secretory pattern were not related; and (5) the return of menses did not show a simple relationship to weight, fatness, or maturity of LH pattern.
Patients with anorexia nervosa can demonstrate clinical and/or laboratory findings suggestive of reduced thyroid hormone secretion. In this study, the thyroxine (T4) and triiodothyronine (T3) serum concentrations, and thyrotropin (TSH) response to intravenous administration of thyrotropin releasing hormone (TRH) were determined in 6 patients (aged 9 to 15 yr) with anorexia nervosa and the results compared to those found in a group of 15 normal subjects. The mean basal TSH concentration and mean maximum increase in TSH after TRH were comparable to those in the normal subjects. The mean T4 concentration (7.2 mug/100 ml) in the anorexia nerovsa group was slightly but significantly lower than in the normal group (9.5 mug/100 ml). Five of the 6 patients had serum T3 concentrations below the lower limits of normal and the mean T3 concentrations (49.7 ng/100 ml) was significantly lower than in the normal group (106 ng/100 ml). The extremely low serum levels of T3 in these patients with anorexia nervosa suggest that peripheral conversion of T4 to T3 is impaired during chronic starvation.
Fifteen women with anorexia nervosa were studied before and after weight gain. Basal plasma thyroid stimulating hormone (TSH) and prolactin (PRL), and the responses of both these hormones to thyrotropin releasing hormone (TRH), were normal. Basal plasma luteinizing hormone (LH) and follicle stimulating hormone (FSH) were low in patients who were emaciated, and their responses to gonadotropin releasing hormone (GnRH) were impaired. Both basal and stimulated levels of LH and FSH rose with weight gain, with a linear correlation between gonadotropin levels and body weight expressed as a percentage of standard. The FSH response became greater than normal in patients who had regained weight to more than 70% of standard, while the LH response to GnRH was exaggerated in those who had regained weight to more than 80%. Basal plasma estradiol (E2) levels were low at first, but returned to within the normal range in patients over 80% of standard. Menstruation resumed in some patients after they had regained weight. The relationship between body weight and gonadotropin levels appears to be an important feature of the menstrual disturbance in anorexia nervosa. The restoration of a normal body weight is a prerequisite for the resumption of menstruation in this condition, but other as yet unidentified factors may also be involved.
We studied cortisol secretion and metabolism in 10 women with anorexia nervosa. The 24-hour mean plasma cortisol concentration was 8.9 mug per deciliter (controls, 4.9) (P less than 0.01). Secretory patterns showed normal circadian rhythms. Cortisol half-life was prolonged from 60 to 78 minutes (P less than 0.01), and metabolic clearance rate was decreased from 359 to 177 liters per day (P less than 0.001). Cortisol production was normal (19.4 mg per day). Urinary cortisol was slightly elevated in two of five patients. These findings, as well as the increased tetrahydrocortisol/tetrahydrocortisone ratio (1.2 vs 0.65, P less than 0.01), also appear in hypothyroid patients. Thyroid-function studies showed normal total and free thyroxine and thyrotropin, but low plasma tri-iodothyronine levels (52.7+/-13.2 vs. 137.8+/-24.1 ng per deciliter in the controls, P less than 0.001). In five additional patients with anorexia nervosa studied before and after short-term tri-iodothyronine administration, metabolic abnormalities decreased as plasma tri-iodothyronine levels rose to or above normal.
The metabolism of 14C-testosterone was studied in 8 severely underweight young women with anorexia nervosa. The urinary androsterone/etiocholanolone (A/E) ratio was uniformly low, in a range characteristic of hypothyroidism; the patients also showed low plasma concentrations of triiodothyronine (T3). Clinical remission as manifested by weight gain was accompanied by concomitant increases of the A/E ratio and the plasma T3 concentration to or toward normal. The administration of T3 also resulted in a shift of the A/E ratio toward normal. These data demonstrate that the low plasma T3 concentrations in patients with anorexia nervosa may be related to the development of one of the characteristic biochemical abnormalities found in clinical hypothyroidism, namely a decreased A/E ratio. These data suggest that the "low T3 syndrome" may be associated with biochemical hypothyroidism.