A Standard Test Meal to Assess Treatment Response in Anorexia Nervosa Patients

This report describes a clinical experience of quantitative and qualitative observations of eating behavior in 19 anorexia nervosa patients before and after a standardized meal prior to treatment, compared to a similar observation at the end of a comprehensive, integrative treatment program. Prior to treatment, patients demonstrated a consistent low intake of food energy, especially fats, with report via analog scale of low hunger and high fullness, as well as distress in mood overall. After treatment, patients more than doubled their food intake, doubled their fat intake, and significantly increased the rate of calories per minute ingested. They reported more robust hunger and less inappropriate fullness before a meal. While still symptomatic, they showed overall significant decreases in anxiety, guilt, depression, and fear of fatness at the time of discharge. This report suggests that clinical observation and documentation of eating behavior, hunger, satiety, and mood prior to treatment is simple, cost-effective, and a powerful means of documenting the effect of treatment when repeated prior to discharge.     

Neurological complications of prolonged hunger strike

We investigated neurological findings in 41 prisoners (mean age: 28.6) who participated in a hunger strike between 2000 and 2002. All cases were evaluated using neuropsychological, neuroradiological, and electrophysiological methods. The total duration of fasting ranged from 130 to 324 days (mean 199 days). All cases had 200–600 mg/day thiamine orally for 60–294 days (mean 156) during the hunger strike, and had neurological findings consistent with Wernicke–Korsakoff syndrome. All 41 patients exhibited altered consciousness which lasted from 3 to 31 days. All patients also presented gaze-evoked horizontal nystagmus and truncal ataxia. Paralysis of lateral rectus muscles was found in 14. Amnesia was apparent in all cases. Abnormal nerve conduction study parameters were not found in the patient group, but the amplitude of compound muscle action potential of the median and fibular nerves and sensory nerve action potential amplitude of the sural nerve were lower than the control group, and distal motor latency of the posterior tibial nerve was significantly prolonged as compared with the control group. The latency of visual evoked potential was prolonged in 22 cases. Somatosensory evoked potential (P37) was prolonged but not statistically significant. Our most significant finding was that the effect of hunger was more prominent on the central nervous system than on the neuromuscular system, despite the fact that all patients were taking thiamine. In our opinion, partial recovery of neurological, and neurocognitive signs in prolonged hunger could be a result of permanent neurological injury.     

New Dimensions for the Dietitian in the Treatment of Patients with Eating Disorders

Abstract

This report describes a clinical experience of quantitative and qualitative observations of eating behavior in 19 anorexia nervosa patients before and after a standardized meal prior to treatment, compared to a similar observation at the end of a comprehensive, integrative treatment program. Prior to treatment, patients demonstrated a consistent low intake of food energy, especially fats, with report via analog scale of low hunger and high fullness, as well as distress in mood overall. After treatment, patients more than doubled their food intake, doubled their fat intake, and significantly increased the rate of calories per minute ingested. They reported more robust hunger and less inappropriate fullness before a meal. While still symptomatic, they showed overall significant decreases in anxiety, guilt, depression, and fear of fatness at the time of discharge. This report suggests that clinical observation and documentation of eating behavior, hunger, satiety, and mood prior to treatment is simple, cost-effective, and a powerful means of documenting the effect of treatment when repeated prior to discharge.     

Effects of isradipine, a dihydropyridine-class calcium channel antagonist, on d-methamphetamine-induced reduction in hunger

1. The authors studied the effects of isradipine, a dihydropyridine-class calcium channel antagonist, on d-methamphetamine-induced changes in somatic and psychological perceptions of hunger state using a placebo-controlled, double-blind, Latin Square, cross-over design in 18 healthy volunteers. 2. D-methamphetamine significantly decreased these subjective ratings of hunger, presumably by increasing monoaminergic turnover. 3. Effects on hunger are hypothesized to be mediated by norepinephrine primarily, while dopamine plays only a modest role. Isradipine alone, an inhibitor of dopamine release, had no significant effect on the hunger measures. Additionally, isradipine pretreatment did not significantly alter d-methamphetamine's anorexic effects. 4. Isradipine may, therefore, not significantly modify the control of hunger in humans.     

Artificial gastric distention and neonatal feeding and hunger reflexes

This paper reports on an experiment, using a gastric balloon, to determine whether the hunger and feeding reflexes would be affected by artificial distention of the gastric walls in newborn infants. The hunger reflex was terminated when the gastric walls were distended by increased air volume in the gastric balloon, and the feeding reflex was initiated by this. Removing the air from the gastric balloon led to cessation of the feeding reflex and the induction of the hunger reflex. The experiment confirms that the human newborn's feeding and hunger reflexes are present from birth and mirror its state of satiation or hunger, respectively.The author wishes to thank Dr. Shelley Jones, Pediatric Resident, and Mr. Patrick R. Joffery, Psysiology Instructor, Louisiana State University Medical Center, New Orleans, Louisiana, for the assistance in this study.     

The ontogeny of salt hunger in the rat.

Salt hunger is the behaviour of an animal suffering sodium deficiency. It is characterised by an increased motivation to seek and ingest sodium, and the ability to distinguish between sodium and other salts. Here I review the development of salt hunger in the rat. Salt hunger develops rapidly between birth and weaning. It can first be demonstrated 72 h postnatally when an intracerebroventricular injection of renin elicits greater swallowing of NaCl solution than water and greater mouthing of solid fragments of NaCl than of an artificial sweetener. However, sodium deficit per se cannot arouse the hunger at this age, and first elicits increased intake of NaCl only at 12 days-of-age. The next landmark is at 17 days-of-age when the hormonal synergy of aldosterone and central angiotensin II first elicits salt hunger, as it does in the adult. The specificity of the hunger for the sodium ion also develops postnatally: the 72 h-old sodium-hungry neonate does not distinguish between NaCl and other mono- and di-valent chloride salts but, increasingly during development, the sodium hungry pup distinguishes salts and by weaning age NaCl is clearly preferred to other salts almost as it is in adults. Early development may also be a sensitive period for determining lifelong preferences, and indeed, acute perinatal sodium depletion induces a lifelong enhancement of salt intake. Taken together, these findings demonstrate how a behaviour develops precociously and how, when the behaviour becomes important at weaning, the rat pup is competent to meet its sodium requirements, and may be adapted to anticipate sodium deficit.     

Satiety responses in eating disorders

Appetite and satiety responses in a test meal paradigm were studied in six anorexia nervosa patients (four had bingeing and purging behaviors) and in nine normal control women. The anorexic patients were distinguished from normal controls by the amounts of food taken and by the pattern of the hunger and fullness responses to the test meal. Possible explanations for these findings are discussed.     

Clinical, psychopathological and personality correlates of interoceptive awareness in anorexia nervosa, bulimia nervosa and obesity

OBJECTIVE: To determine the levels of interoceptive awareness (IA), which measures the ability of an individual to discriminate between sensations and feelings, and between the sensations of hunger and satiety, in eating disorder patients and to identify the clinical, psychopathological and personal variables correlated with IA. SAMPLING AND METHODS: Sixty-one restrictor anorectics, 61 binge-purging anorectics, 104 purging bulimics, 49 obese subjects with binge eating disorder (BED) and 47 obese subjects without BED were compared. They were assessed with the Eating Disorder Inventory-2, the Temperament and Character Inventory, and the Beck Depression Inventory, and their clinical and sociodemographic features were recorded. RESULTS: In all patients, the levels of IA were higher than the 'normal' ones; in bulimia nervosa, they were higher than in anorexia nervosa and obesity. Similar personal features and eating attitudes are shared by patients with bulimia nervosa and BED. In the total sample, the following variables independently correlate with IA: the Beck Depression Inventory, self- directedness and persistence. CONCLUSIONS: The importance of an altered IA in eating disorders is supported. Both depression and a perfectionist and poorly self-directive personality can lead to greater difficulties in discriminating hunger and satiety.     

Eating behavior of women with bulimia

To obtain objective information about binge- and non-binge-eating behavior, 12 women with bulimia and ten women without eating problems (controls) were asked to eat four meals in a structured laboratory setting, on separate nonconsecutive days. The same instructions were given to both groups. On two days, they were asked to eat a normal amount, and on two days, they were asked to eat as much as they could, ie, to binge. For each type of instruction, they were given a single- and a multiple-course meal. The patients ate significantly more than the controls when asked to binge, both on the multiple-course meals that they rated as typical of binges and on the single-course meals. When they were asked to eat normally, there was no significant difference in intake between patients and controls on either single- or multiple-course meals. After all meals, hunger ratings of patients were significantly higher than hunger ratings of controls. There was also a significant positive correlation between intakes of single- and multiple-course binge meals and an inverse correlation between intake of multiple-course binge meals in bulimic patients and their rating of how well they controlled their eating. Thus, a structured laboratory eating situation can be used to reveal differences between bulimic and normal individuals and has the potential for assessing clinical status and exploring mechanisms responsible for binge eating.     

The pervasive effect of youth self-report of hunger on depression over 6 years of follow up

Purpose

We used longitudinal data to clarify the association between self-report of hunger and subsequent depression risk among youth and young adults, accounting for other risk factors.

Methods

Youth self-report of ever experiencing hunger data were collected from cycles 4–6 of the National Longitudinal Survey of Children and Youth cohort of Canadian youth 16 years and older (n?=?4139). Data on depressive symptoms (CES-D 12) were collected over three cycles (2004–2009, cycles 6–8). We used multivariable regression based on generalized estimating equations (GEE) to examine prior youth hunger on later depression risk, adjusting for time-stable, time-varying, and lagged variables (e.g., depressive symptoms in previous cycle), thereby clarifying the temporal relationship.

Results

The prevalence of youth hunger experience and depression risk reached 5.9 and 15.0%, respectively. The adjusted odds ratio of depression for participants reporting hunger was 2.31 (95% CI 1.54, 3.46) and changed little [2.17 (95% CI 1.29, 3.67)] after accounting for previous CES-D 12 scores, suggesting a temporal relationship in which hunger contributes to depression risk. Unlike never-hungry youth, depression in ever-hungry youth remained comparatively elevated over time.

Conclusions

Our models support an independent and temporal relationship between youth self-report of hunger and depression in adolescence and young adulthood.

     

Force-feeding: the physician's dilemma

The right to treatment and the right to refuse treatment are parallel legal rights which, when in opposition, pose a dilemma. In this paper the issues surrounding the possible force-feeding of a hunger striker are examined together with the pertinent legal precedents and possible courses of action. Although the discussion is particularly relevant to hunger strikers, the principles may be applicable to other circumstances.     

Effects of gustatory stimulation on brain activity during hunger and satiety in females with restricting-type anorexia nervosa: An fMRI study

Background

Previous research has demonstrated altered neuronal responses to visual stimulation with food in anorexia nervosa, varying with the motivational state of hunger or satiety. The aim of the present fMRI study was to assess hunger- and satiety-dependent alterations in the gustatory processing of stimulation with food in anorexia nervosa.

Methods

After food abstention (hunger condition) and after eating bread rolls with cheese (satiety condition), 12 females with restricting-type anorexia nervosa and 12 healthy females drank chocolate milk and water via a tube in a blocked design during image acquisition. Additionally, heart rate was registered during the measurements, and subjective ratings of hunger/satiety and of the valence of chocolate milk were assessed using a Likert scale.

Results

In participants with anorexia nervosa, drinking chocolate milk in the hunger condition induced significant activations in the right amygdala and in the left medial temporal gyrus relative to healthy controls. When contrasting neuronal responses to drinking chocolate milk during satiety with those evoked during hunger, a significant activation was found in the left insula in healthy controls, whereas in participants with anorexia nervosa, neuronal activity in the inferior temporal gyrus, covering the extrastriate body area, was observed.

Conclusions

Neuronal responses evoked by gustatory stimulation differ depending on hunger and satiety. Activations located in the amygdala and in the extrastriate body area might reflect fear of weight gain, representing one of the core symptoms of anorexia nervosa.     

From sensory circumventricular organs to cerebral cortex: Neural pathways controlling thirst and hunger

Much progress has been made during the past 30 years with respect to elucidating the neural and endocrine pathways by which bodily needs for water and energy are brought to conscious awareness through the generation of thirst and hunger. One way that circulating hormones influence thirst and hunger is by acting on neurones within sensory circumventricular organs (CVOs). This is possible because the subfornical organ and organum vasculosum of the lamina terminalis (OVLT), the sensory CVOs in the forebrain, and the area postrema in the hindbrain lack a normal blood‐brain barrier such that neurones within them are exposed to blood‐borne agents. The neural signals generated by hormonal action in these sensory CVOs are relayed to several sites in the cerebral cortex to stimulate or inhibit thirst or hunger. The subfornical organ and OVLT respond to circulating angiotensin II, relaxin and hypertonicity to drive thirst‐related neural pathways, whereas circulating amylin, leptin and possibly glucagon‐like peptide‐1 act at the area postrema to influence neural pathways inhibiting food intake. As a result of investigations using functional brain imaging techniques, the insula and anterior cingulate cortex, as well as several other cortical sites, have been implicated in the conscious perception of thirst and hunger in humans. Viral tracing techniques show that the anterior cingulate cortex and insula receive neural inputs from thirst‐related neurones in the subfornical organ and OVLT, with hunger‐related neurones in the area postrema having polysynaptic efferent connections to these cortical regions. For thirst, initially, the median preoptic nucleus and, subsequently, the thalamic paraventricular nucleus and lateral hypothalamus have been identified as likely sites of synaptic links in pathways from the subfornical organ and OVLT to the cortex. The challenge remains to identify the links in the neural pathways that relay signals originating in sensory CVOs to cortical sites subserving either thirst or hunger.     

Noradrenergic hypothesis in anorexia nervosa: prospective study using beta-stimulant therapy

We assumed for this study that beta-stimulants could efficient for the treatment of anorexia nervosa not with direct action upon the center of hunger or upon the secretion of insulin but by stimulating the norepinephrine way which is characterized by a function hypotrophy as it is the case in some affective disorder. This experiment was homogenously performed with seven patients. It then presents an encouraging prospective value.     

Symptoms of tobacco withdrawal. A replication and extension

Smokers (n = 315) who wished to quit were randomly assigned in a double-blind manner to groups using either nicotine or placebo gum. Self-reported and observed symptoms of tobacco withdrawal were collected before cessation and at follow-ups of 1 to 2 weeks, 1 month, and 6 months. Self-reported and/or observed anger, anxiety, craving, difficulty concentrating, hunger, impatience, and restlessness were the most prominent symptoms of tobacco withdrawal. These symptoms had returned to precessation levels by 1 month except increased weight, hunger, and craving continued for 6 months in many smokers. Nicotine gum decreased most symptoms, including craving and hunger but not weight. Abstinent smokers with more intense withdrawal were not more likely to relapse. Abstinent smokers who gained more weight were less likely to relapse.     

Potentiation of reward by hunger is opioid mediated

In tests of frequency threshold for brain stimulation-induced feeding, naloxone (s.c.) did not affect the first in a brief series of threshold estimates but elevated subsequent estimates progressively. It was demonstrated that neither the time-course of drug action nor any cumulative disruptive effect of brain stimulation itself, accounts for the progressive elevation of threshold. Self-stimulation in ‘feeding’ electrodes was therefore studied, in combination with hunger manipulations, to inferentially evaluate naloxone's effect on feeding mechanisms. Results suggest naloxone's anoretic effect does not reflect heightened responsiveness of a satiety mechanism. Reversal by naloxone of the potentiating effect of hunger on self-stimulation, however, suggests the anoretic effect is due to blockade of an opioid process associated with hunger that otherwise enhances the reward value of food.     

Mood and food: an analysis of bulimic episodes

The present study examined those factors which differentially lead to normal eating and binge eating. Twenty-one bulimic subjects and comparison subjects monitored their mood, hunger, and food intake hourly over a number of days. The bulimic sample ate fewer meals and had lower overall mood. Positive mood, food abstinence combined with intensified hunger, and being in the company of another person preceded normal eating (i.e. retained meal). Negative mood, recent consumption of food, and being alone preceded bulimic episodes.     

Reward for food odors: an fMRI study of liking and wanting as a function of metabolic state and BMI

Brain reward systems mediate liking and wanting for food reward. Here, we explore the differential involvement of the following structures for these two components: the ventral and dorsal striatopallidal area, orbitofrontal cortex (OFC), anterior insula and anterior cingulate. Twelve healthy female participants were asked to rate pleasantness (liking of food and non-food odors) and the desire to eat (wanting of odor-evoked food) during event-related functional magnetic resonance imaging (fMRI). The subjective ratings and fMRI were performed in hunger and satiety states. Activations of regions of interest were compared as a function of task (liking vs wanting), odor category (food vs non-food) and metabolic state (hunger vs satiety). We found that the nucleus accumbens and ventral pallidum were differentially involved in liking or wanting during the hunger state, which suggests a reciprocal inhibitory influence between these structures. Neural activation of OFC subregions was correlated with either liking or wanting ratings, suggesting an OFC role in reward processing magnitude. Finally, during the hunger state, participants with a high body mass index exhibited less activation in neural structures underlying food reward processing. Our results suggest that food liking and wanting are two separable psychological constructs and may be functionally segregated within the cortico-striatopallidal circuit.     

Serum leptin concentrations and satiety in Parkinson's disease patients with and without weight loss.

We compared serum leptin and satiety measures in 18 Parkinson's disease (PD) patients with unintended weight loss (WL) and 18 PD patients whose weight was stable (WS). Mean serum leptin concentrations tended to be lower in WL than WS patients, but this did not reach statistical significance. Body mass index correlated with serum leptin concentrations. Ratings of hunger, satiety, fullness, and thirst did not differ between groups. However, the mean sensation of fullness before meals correlated with serum leptin in the entire cohort of patients, particularly in the WL group. The results indicate that unintended weight loss in PD patients is unlikely to be due to abnormal serum leptin concentrations.     

Visceral perceptions and gastric myoelectrical activity in healthy women and in patients with bulimia nervosa

Bulimia nervosa remains a common eating disorder in young women. Little is known about upper gastrointestinal symptoms or gastric motility in patients with bulimia nervosa. The aim of this study was to measure gastric myoelectrical activity and hunger/satiety and stomach emptiness/fullness before and after a non-nutrient water load and solid-phase gastric emptying in hospitalized patients with bulimia nervosa (n = 12) and in healthy women (n = 13). Gastric myoelectrical activity was measured by means of cutaneous electrodes; visual analogue scales were used to measure perceptions of hunger/satiety and stomach emptiness/fullness. Before and after a standard water load the bulimia patients reported significantly greater stomach fullness and satiety compared with control subjects (P < 0.01). The percentage of gastric myoelectrical power in the normal 3 cpm range was significantly less in bulimics compared with controls. Power in the 1–2 cpm bradygastria range was significantly greater in bulimia patients before and after the water load compared with the control subjects (P < 0.05). Solid-phase gastric emptying studies using radio-isotope-labelled scrambled eggs showed the lag phase was shortened in the bulimic patients (16 ± 4 min vs 31 ± 4 min in controls, P < 0.01), but the percentage of meal emptied at 2 h was similar to control values. In conclusion: bulimia patients had exaggerated perceptions of stomach fullness and satiety in response to water; and abnormal gastric myoelectrical activity and accelerated lag phase of gastric emptying were objective stomach abnormalities detected in hospitalized patients with bulimia nervosa.