Non-fat-phobic anorexia nervosa in British South Asian adolescents

OBJECTIVE: The current study investigated the clinical features of British South Asian adolescent females presenting with low weight in the absence of organic disease. METHODS: The authors performed a retrospective case note study of South Asian British female adolescents presenting with weight loss/anorexia nervosa to psychiatric clinics and matched White English peers presenting with low weight. RESULTS: South Asian patients presented more frequently with loss of appetite (p = .01) and less frequently with fat phobia (p = .032) and weight preoccupation (p = .001). South Asians also had significantly more satisfactory relationships with their nuclear family and peers (p = .03). DISCUSSION: Differing symptom profiles for anorexia nervosa need to be taken into account when assessing patients from different cultures. South Asian adolescents may present with a non-fat-phobic form of anorexia nervosa. This has clinical and epidemiologic implications. Further investigation is warranted to assess the nosologic status of this group.     

Fasting and Electrolytes (Anorexia Nervosa)

Patients with anorexia nervosa show a low serum potassium level (especially with excessive weight loss) accompanied by reduced levels of sodium and chloride and elevated levels of carbon dioxide. High intakes of potassium overcome these abnormalities.     

Metabolic abnormalities associated with skeletal myopathy in severe anorexia nervosa

The aim of this study was to characterize the metabolic disturbance associated with the skeletal myopathy resulting from extreme weight loss in anorexia nervosa. Muscle function was examined in eight female patients with severe (40%) weight loss due to anorexia nervosa and histologically confirmed myopathy. A wide range of biochemical and hematologic investigations were carried out, including serum enzymes and the response of plasma lactate to ischemic exercise of forearm muscles. All patients showed proximal muscular weakness. A diminished lactate response to ischemic exercise was a consistent finding, and a reduction of serum carnosinase activity was also found. There were no other consistent biochemical or hematologic abnormalities apart from lymphopenia of no clinical consequence. These findings contribute to our understanding of severe protein-energy malnutrition on the musculoskeletal system. The resulting disorder is a metabolic myopathy from which the patients recover rapidly as their nutrition improves. Although the patients admitted to a variety of abnormal eating behaviors, no correlation was found between a specific type of abnormal eating behavior and subsequent biochemical abnormalities. Reinstating appropriate eating behavior will treat the myopathy.     

Electrocardiographic abnormalities in anorexia nervosa

Electrocardiograms, biochemical parameters, and drug histories were reviewed in 37 patients with anorexia nervosa. Prolongation of the Q-T interval was identified in 24%, sinus bradycardia in 41%, and low voltage in 11% of our study population. Hypocalcemia was identified in none of our patients, hypomagnesemia in one, and hypokalemia in nine. Hypokalemia was more frequent (67%) and marked in patients with Q-T prolongation than in those with normal Q-T intervals (11%). Bulimic tendencies were more frequent in anorexics with Q-T prolongation and were associated with hypokalemia. Q-T prolongation when present was usually mild. One patient had documented ventricular fibrillation associated with hypokalemia and the longest Q-T interval encountered in our group (G-Q_c = 0.54 seconds). Patients with severe anorexia nervosa should be screened for hypokalemia and Q-T prolongation, particularly if bulimic tendencies are present. Although Q-T prolongation associated with weight loss due to dieting, starvation, and gastroplasty is not commonly associated with hypokalemia, such may not be the case with anorexia nervosa.     

以低钾血症起病的神经性厌食症探讨分析

目的:探讨易于漏诊的表现为低钾血症的神经性厌食症患者的临床特点。方法:对我院2003年-2010年以低钾血症原因待查入院而最终诊断为神经性厌食症的4例患者临床资料进行回顾性分析。结果:4例患者体形消瘦,BMI在12.5 kg/m2～16.4 kg/m2之间,体温、血压均偏低,血钾水平变化无规律,均经反复询问病史与仔细观察后获得关键病史得以诊断。结论:对于血钾水平无规律的重度消瘦患者,需要考虑神经性厌食症的可能。     

Muscle metabolic changes in severe malnutrition — Effect of total parenteral nutrition

Severe malnutrition with extreme loss of muscle mass and body fat can be seen in anorexia nervosa. Seven otherwise healthy girls with anorexia nervosa with a weight loss of 25–40% of their premorbid weight were studied. Because of their critical condition and unsuccessful refeeding, total parenteral nutrition (TPN for 3–5 weeks) was indicated. The TPN was administered via a tunnelated silicon catheter. Their weight gain was about 2.5 kg/week. Muscle biopsies were taken from the quadriceps femoris muscle at admission and after TPN for analysis of energy substrates and electrolytes. Initially ATP, phosphocreatine, glycogen, magnesium and potassium were decreased compared to controls. The values returned to normal with 3–5 weeks of TPN. Total muscle water was increased at admission and was not significantly affected by the TPN. No serious complications were observed during the nutritional treatement. These findings emphasized the importance of nutritional supply to patients with severe anorexia nervosa who do not have any known disturbances in the metabolic pathways of the cell.     

Total body potassium,intracellular potassium and body composition in patients with anorexia nervosa during refeeding

The total body potassium content and the potassium concentration in serum and erythrocytes was measured in 16 patient with anorexia nervosa (8 “vomiters” and 8 “restricters”). The data were compared with results obtained for 11 normal controls, whose body weight was 99.6% ± 4.99% of ideal body weight (IBW). Patients were studied before treatment (IBW 72.8 ± 6.3%) and after an average weight gain of 19%. Serum potassium was not significantly different between groups, but potassium concentration was significantly reduced (p < 0.01) in both groups at the time of the first study. Total body potassium—as measured by the potassium-40 method—was significantly lower in both “vomiters” and “restricters” than in controls and was normalized during weight gain. Cell body mass and fat mass were calculated from the potassium-40 measurement. Both body compartments were significantly increased during weight gain; cell mass was normalized, but fat mass remained significantly below normal values.     

Clinical and personality correlates of body size overestimation in anorexia nervosa and bulimia nervosa

A video camera technique was used to assess perceived actual and ideal size in patients with a restricting type of anorexia nervosa (n = 17), bulimia nervosa patients with previous anorexia (n = 23), bulimia nervosa patients with no previous anorexia (n = 24), phobic controls (n = 18), and normals (n = 33). Bulimic patients with previous anorexia demonstrated a significantly greater tendency to overestimate their actual body size (p <.05) than subjects in the restricting anorexic or control groups. Previously anorexic bulimics also demonstrated more overall clinical and personality disturbance than any of the other groups (p <.01). Body size overestimation and dissatisfaction were strongly associated with the duration and severity of the eating disturbance in previously anorexic bulimics but there were no clear relationships between clinical or personality disturbances and body size distortions in the restricting anorexic or never-anorexic bulimic groups. Results are discussed with respect to the importance of refining diagnostic criteria for subtypes of anorexia and bulimia nervosa. Multitrait-multimethod methodologies are recommended for purposes of elucidating “body image disturbance” and its importance in the etiology and maintenance of eating disorders.     

Weight gain and nutritional efficacy in anorexia nervosa

To evaluate the usefulness of interval weight change in assessing nutritional support efficacy, we studied four anorexia nervosa patients (52% ideal body weight) requiring long-term total parenteral nutrition (TPN) for 63 +/- 18 days. Fluid and electrolyte deficits were corrected before the initiation of nutritional support. Resting energy expenditure was measured before the initiation of TPN and weekly thereafter, using indirect calorimetry. Daily caloric expenditure was estimated at 1.1 X resting energy expenditure, based on previous studies of continuous heart rate monitoring in this patient population. Daily excess calories were calculated as caloric intake minus caloric expenditure. Each patient was weighed daily and linear regression analysis (excess calories versus weight change) was performed for individual patients and the group over intervals of varying length. There was no individual or group correlation between excess calories and weight gain on a daily or weekly interval basis. Cumulative weight changes over the long-term course of TPN correlated significantly with cumulative excess calories for each patient and the whole group (r = +0.82, p less than 0.01). The excess calories required to gain a kilogram body weight ranged from 5569 to 15619 kcal/kg with a mean of 9768. Cumulative long-term weight changes during nutritional repletion in anorexia nervosa are meaningful indicators of caloric balance, but short interval weight changes (daily, weekly) are not. The caloric cost of weight gain is variable in this population.     

The hypothalamic-pituitary-ovarian axis in anorexia and bulimia nervosa. An Appraisal

In anorexia nervosa, the combination of low levels of plasma estradiol and serum gonadotropins, and the age-inappropriate Orcadian patterns of LH and FSH can be ascribed to a functional reversion to prepuberty or puberty. The causes of this reversion are unknown: weight and body fat loss and/or malnutrition do not fully account for them, nor, seemingly, does increased physical activity. But a combination of weight recovery and symptom remission normalizes the circadian patterns. Estradiol is metabolized differently in anorexia nervosa, being shifted preferentially toward 2-OH estrone. This shift is a consequence of chronic illness or weight loss which produces a nonspecific state: the low T3 syndrome. 2-OH estrone has antiestrogen properties and inhibits the release of LH by ethynyl estradiol but its increased production is a consequence of the illness and cannot account for initiating the changes in LH levels or patterns. It could, however, sustain them and also the changes in the HPO axis that characterize anorexia nervosa. It is likely that in anorexia nervosa there is a functional anterior hypothalamic disturbance of unknown origin that may persist even after weight recovery, as evidenced by the absence of positive feedback effect on LH and presumably on LHRH by estradiol. No defect in the release of LH and FSH from the pituitary gland by LHRH is present in anorexia nervosa as long as LHRH is pulsed rather than injected as a bolus into anorexia nervosa patients.     

Relationship of serum leptin levels and selected nutritional parameters in patients with protein-caloric malnutrition

Leptin is a protein hormone produced by adipocytes that reflects the body fat content, i.e., its serum concentration in healthy individuals positively correlates with the body mass index and body fat content. Serum leptin levels are lower in both patients with anorexia nervosa and protein-caloric malnutrition caused by chronic non-malignant illnesses. The aim of the present study was to compare serum leptin levels and selected, routinely used nutritional parameters in women with anorexia nervosa (n = 17), severely malnourished patients with short bowel syndrome (n = 13), and control non-obese healthy women (n = 17) to clarify the relation between selected nutritional parameters and serum leptin levels. We found that serum leptin levels in the anorexia nervosa and short bowel syndrome groups were significantly lower than those in the control group (in ng/mL: 3.63 +/- 1.64 and 2.59 +/- 1.17 versus 12.06 +/- 7.59, respectively). Protein malnutrition expressed by decrease in serum concentrations of total protein, albumin, and prealbumin was more pronounced in the short bowel syndrome group. Triceps skin fold, arm muscle circumference, and body mass index were significantly lower in the patient group than in the control group and did not significantly differ between the short bowel syndrome and anorexia nervosa groups. No significant difference in serum leptin concentration between the short bowel syndrome and anorexia nervosa groups was found. Serum leptin levels correlated positively with body mass index and triceps skin fold in the control and anorexia nervosa groups but not in the short bowel syndrome group. We conclude that serum leptin levels in patients with anorexia nervosa and short bowel syndrome are significantly lower than in healthy individuals and have no statistically significant relation to serum total protein, abumin, and prealbumin.     

Amenorrhea in anorexia nervosa neuroendocrine control of hypothalamic dysfunction

Amenorrhea is one of the cardinal features of anorexia nervosa and is associated with hypothalamic dysfunction. Earlier theories of weight loss, decreased body fat, or exercise do not fully explain the etiology of amenorrhea in anorexia nervosa. Disturbances in central dopaminergic and opioid activity have been described in anorexia nervosa and both these substances are known to modulate gonadotropin-releasing hormone (GnRH)-mediated luteinizing hormone (LH) release. Serum LH, folliclestimulating hormone (FSH), estradiol, and prolactin levels were measured at baseline and after administration of metoclopramide (a central D-2 dopamine receptor blocker) in 10 newly diagnosed women with anorexia nervosa and in 10 healthy age-matched controls. Basal prolactin levels and the prolactin response to metoclopramide were significantly impaired in the group with anorexia nervosa. Metoclopramide did not induce a significant rise in LH levels in either the anorexic or the control groups. Neurotransmitter abnormalities may influence hypothalamic dysfunction in anorexia nervosa but the exact mechanism remains to be determined. © 1994 by John Wiley & Sons, Inc.     

Severe neutropenia with gelatinous bone marrow transformation in anorexia nervosa: a case report

A 28-year-old woman with a history of anorexia nervosa was admitted with excessive weight loss, edema, and amenorrhea. She had lost 34% of her previous body weight within 2 years, and her body mass index was 12.3 kg/m(2). The leukocyte count on admission was 2150/microl and gradually decreased to 980/microl (neutrophils; 276/microl). Bone marrow biopsy disclosed gelatinous transformation with hypocellularity. After the patient was treated with intravenous nutritional support, the severe neutropenia improved to the level on admission. Hematological abnormalities seem to be common in anorexia nervosa, but severe neutropenia with gelatinous bone marrow transformation has rarely been reported.     

Changes in regional fat redistribution and the effects of estrogen during spontaneous weight gain in women with anorexia nervosa

BACKGROUND: Anorexia nervosa is a disease of severe acquired undernutrition with a high and increasing prevalence among young women in the United States. OBJECTIVE: The objective was to investigate the effects of spontaneous outpatient weight recovery and estrogen administration on fat distribution in patients with anorexia nervosa. DESIGN: Twenty-seven amenorrheic women aged 26.6 +/- 1.2 y with anorexia nervosa were identified through an outpatient study of bone loss and were randomly assigned to receive or not receive estrogen without any dietary intervention other than calcium and multivitamin supplements. Body composition was measured at baseline and at 6 and 9 mo and was compared with cross-sectional values obtained in 20 healthy, eumenorrheic, age-matched (25.4 +/- 0.5 y) control subjects. RESULTS: Twenty of the 27 patients with anorexia aged 27.0 +/- 1.3 y spontaneously gained weight (4.1 +/- 0.9 kg); body mass index (in kg/m(2)) increased from 16.1 +/- 0.3 to 17.5 +/- 0.4. Fat mass and lean mass accounted for 68% and 32% of the gain in total body mass, respectively. With spontaneous weight gain, there was a significant increase in the percentage of trunk fat from 32.4 +/- 1.3% at baseline to 36.5 +/- 1.0% at 9 mo (P = 0.03), which correlated with urinary free cortisol (r = 0.66, P = 0.003). Estrogen treatment was not protective against the gain in trunk fat with spontaneous weight gain. CONCLUSIONS: In women with anorexia nervosa, spontaneous weight gain is associated with a significant increase in trunk adiposity, and estrogen administration may not protect against the accumulation of central fat with weight gain.     

Predictors of weight maintenance after hospital discharge in adolescent anorexia nervosa

OBJECTIVE: To analyze variables that predict weight maintenance in adolescent anorexia nervosa. METHOD: The Eating Attitudes Test, the Beck Depression Inventory, the Leyton Obsessional Inventory, the State and Trait Anxiety Inventory, and the Anorexia Nervosa Stages of Change Questionnaire were administered to 49 anorexia nervosa patients (mean age 14.3 years, SD 1.7) consecutively admitted to an eating disorder unit. They were evaluated at admission, at discharge, and after nine months follow-up. RESULTS: At discharge, patients had improved in body mass index (p < .001), eating attitudes (p = .002), depressive symptomatology (p = .001), and motivation to change (p < .001). Patients with good weight maintenance at follow-up had higher body mass index (p = .017) at admission, lower abnormal eating attitudes (p = .035), depressive symptomatology (p = .026), and higher motivation to change (p = .004) at discharge. Logistic regression analysis showed a high motivation to change at discharge and a high body mass index at admission to be predictors of weight maintenance. CONCLUSION: High motivation to change, low abnormal eating attitudes, depressive symptomatology at discharge, and high body mass index at admission are associated with weight maintenance in adolescent anorexia nervosa.     

Eating disorders: a role for dipeptidyl peptidase IV in nutritional control

Dipeptidyl peptidase IV (DPP IV), a serine protease with broad tissue distribution and known activity in serum, has been postulated to modulate nutrition control by modification or inactivation of peptide hormones operating in the enteroinsular axis. We hypothesized that changes of DPP IV activity in serum are related to the nutrition status of patients with eating disorders. Serum DPP IV activity was measured in 52 patients (28 with anorexia nervosa and 24 with bulimia nervosa) in four consecutive weekly analyses. Simultaneously, the number of CD26 (DPP IV)-positive peripheral blood lymphocytes was counted. The same analyses were carried out in 28 healthy female volunteers. In week 1 and throughout the observation period, DPP IV activity in the sera of patients with anorexia nervosa and, to a lesser extent, those with bulimia nervosa was elevated in comparison to that of healthy controls (week 1: means = 92.8 U/L for anorexia-nervosa patients and 89.3 U/L for bulimia-nervosa patients versus 74.7 U/L for healthy control subjects, P = 0.014; weeks 1-4: 91.8 U/L for anorexia-nervosa patients and 86.2 U/L for bulimia-nervosa patients versus 77.6 U/L for healthy controls, P < 0.001). We assume that the increase in DPP IV serum activity will increase the turnover of distinct peptide hormones with known effects on nutrition control and susceptibility to degradation by DPP IV. The potential impact of an increase in DPP IV activity in serum on satiety and nutrition control contributes to previously reported implications for immune function.     

Body cell mass in cancer-bearing and anorexic patients

We used a sensitive whole body counter which measures potassium-40 (40K) to determine total body potassium and to estimate body cell mass (BCM) in 104 previously untreated patients with upper gastrointestinal malignancies, 233 normal volunteers, and 18 patients with anorexia nervosa. BCM was greater in normal males than in females. In both normal males and females, the BCM tended to decrease with age, both as an absolute measure and as a percentage of body weight. Anorexia nervosa patients experienced marked weight loss (30.5%), and had significant depletion of absolute BCM, but exhibited relative sparing of BCM as indicated by a rise in BCM as a percentage of body weight. This may reflect a normal adaptation and predominant fat utilization in chronic malnutrition. The cancer patients, on the other hand, had significant weight loss (12.7% for females, 13.9% for males) and demonstrated a proportional decline in BCM, with no change in BCM as a percentage of body weight. These findings support the contention that, in the cancer-bearing patient, weight loss consists of a significant depletion of both fat and BCM. The challenge to the clinicians caring for cancer patients is repletion of this supremely functional body compartment.     

Common physiological changes in anorexia nervosa

A variety of physiological abnormalities are associated with the disorder, anorexia nervosa. In this study 40 anorexia patients were studied for hematological, electrolyte, lipid, and serum enzyme aberrations when they entered a treatment study in the emaciated state and again after nutritional rehabilitation. This article discusses all those metabolic aberrations which revert to normal with nutritional rehabilitation and those aberrations which occur in the course of weight gain.     

Primary anorexia nervosa: Gastric emptying and antral motor activity in 53 patients

In 53 consecutive patients with primary anorexia nervosa, gastric emptying of a semisolid meal was significantly slower than in 24 healthy subjects. Slow emptying tended to be associated with low serum potassium, low body weight, and long illness duration. Antral contraction amplitudes were lower than in healthy subjects and failed to increase postcibally, whereas contraction frequency and rhythmicity seemed unaffected. After the gastric prokinetic agent, cisapride, 8 mg intravenously administered double-blind, emptying was significantly faster than after placebo. The recognition of impaired gastric motility may be important in the management of anorexia nervosa.     

Body composition in adolescents with anorexia nervosa.

BACKGROUND: Malnourished patients with anorexia nervosa have altered body composition characterized by depletion of fat and fat-free mass. OBJECTIVES: The objectives of this study were to assess the body composition of adolescents with anorexia nervosa compared with that of control subjects and to investigate the relation between simple anthropometric measures and reference techniques for measuring body composition. DESIGN: Twenty-three adolescent females with anorexia nervosa aged 15.46 +/- 1.34 y (x +/- SD) were studied. Body composition was measured by anthropometry, dual-energy X-ray absorptiometry (DXA) (for body fat), and prompt gamma in vivo neutron activation analysis [for total body nitrogen (TBN)]. Twenty-five female subjects provided the control DXA data. TBN measurements were compared with prediction equations based on sex, height, age, and weight. RESULTS: Anorexia nervosa patients had significantly lower weight (40.2 +/- 4.6 kg), body mass index (in kg/m(2): 15.3 +/- 1.2), percentage of body fat (DXA) (13.8 +/- 5.8%), percentage of TBN predicted for age (73 +/- 10%), trunk fat (2.1 +/- 1.0 kg), leg fat (2.6 +/- 1.1 kg), and trunk-to-leg fat ratio than did control subjects (P < 0.05). In anorexia nervosa patients, significant correlations were found between triceps skinfold thickness and percentage of body fat (r = 0.83), body mass index and percentage of body fat (r = 0.46), and body weight and TBN (r = 0.84, P < 0.05). CONCLUSIONS: Hospitalized adolescent females with anorexia nervosa are depleted of total body fat and protein. We identified 3 simple anthropometric measures (triceps skinfold thickness, BMI, and body weight) that can be used to assess body composition and nutritional status in malnourished adolescents with anorexia nervosa.