Composantes neurosensorielles et hormonales dans l’anorexie mentale

Anorexia nervosa (AN) is often considered a multifactorial illness of unknown pathophysiology. Family and twin studies have consistently demonstrated that AN is strongly related to genetic factors. The probability of some genetic origin is 92%, genetic factors explaining around 20% of the variance. It must be remembered that 95% of the AN patients were girls or women, suggesting a role for gonadal hormonal systems and their effects on the brain and on cognitive functions. Most studies focused on the serotonin system, but other candidate genes have been suggested. At the present time, we have no evidence that women who develop AN have an adipose, metabolic, gonadal, pituitary, hypothalamic or some other dysfunctions that predispose them for the illness. It is suggested on the contrary that the symptoms of AN are physiological responses to starvation or to the response to altered body image and self-satisfaction. If this eating disorder is related to the fear of the alimentary desire of the patients, it will be easy to understand the plasma level of adiponectin, ghrelin and better understand a role for the low leptin level in the enhanced hunger. If we remember that almost 60% of these patients are engaged in a physical and mental hyperactivity, the abnormality in plasma level of cortisol, ACTH, and CRH. The decease in fat mass could explain why leptin level was low and low leptin level may explain the amenorrhea and the fall in LH, FSH, and LH–RH secretion. Moreover, anxiety, obsessive compulsive disorders and physical hyperactivity may be three interrelated factors, which could be related to serotonin and dopamine systems and in turn inhibit food intake.     

Bilan somatique et critères de gravité dans l’anorexie mentale

Anorexia nervosa is a serious syndrome that can kill patients due to malnutrition complications by muscular weakness, especially cardiac and/or diaphragmatic failure, and infections. Clinical gravity criteria, linked to body mass index and visceral impairment symptoms must be known. Major biological gravity criteria are severe and symptomatic hypokaliemia, hypophosphoremia and hypoglycaemia. Renutrition must absolutely be careful to prevent the refeeding syndrome, the major risk of severe anorexia that can cause multivisceral organ failure.     

Thérapies comportementales et cognitives de l’anorexie mentale

To lead a behavioral and cognitive therapy supposes that the patient wishes to change his behavior and that he asks to the therapist to help him by an information, a support and instructions there. This initiative is rarely voluntary at the patient's suffering from anorexia nervosa. These therapies were thus adapted to this pathology. The practice of aspirational interviews is also lawful on an extrapolation from investigations concerning the other pathologies, a priori close. The clinical impression shared by the practitioners formed in these methods is the one of a facilitation of the behavior of the treatment and an intensification of what we call the therapeutic alliance. Problems posed by the particularities of the anorexia nervosa however have the effect of stimulating the evolution of the behavioral therapies. This pathology confronts the therapists with the firm reality of the contradictions and the irrational logics, which are inherent in fact to the human thought.     

Conséquences digestives de l’anorexie mentale

Gastrointestinal disorders are almost a constant finding in patients with anorexia nervosa and induce a major functional burden as well as obstacles to refeeding. All the parts of the gastrointestinal tract may be involved: benching, delayed gastric emptying, abdominal distension and bloating, delayed transit or terminal constipation. Anorectic patients often refer for gastrointestinal disorders which may delay the diagnosis of the eating disorder because of repeated gastroenterological investigations and also because eating disorders are poorly acknowledged by gastroenterologists. The pathophysiology of gastrointestinal disorders during anorexia nervosa is still poorly understood; it may involve the consequences of malnutrition, altered neuropeptidergic regulation associated with the eating disorder or immunological alterations. Gastrointestinal symptoms must be systematically looked for in anorectic patients and actively treated to ease the implication of the patient to the oral refeeding program or to enteral nutrition. Conversely, eating disorders should be suspected in case of severe dyspepsia or irritable bowel syndrome with weight loss.     

Approche psychanalytique de l’anorexie mentale

The essential difficulty of these adolescents suffering of anorexia nervosa lies within their personalities and their incapacity to deal with conflict. The relationships of these patients to others are similar to their relationships to food: both are often characterized by a paradoxical aspect: an alternating between a great eagerness for relationships and a capacity for isolation and withdrawal, with intolerance for loneliness; a great awareness of the attitude and the opinion of others; difficulties in regulating relationships and in finding optimal distancing; oscillation between an anxiety due to fear of separation and an anxiety due to fear of intrusion; the coexistence of exacerbated expectations concerning important people, along with the ability to be easily influenced, but at the same time a large capacity for opposition and an obstinate refusal of change. Globally these characteristics find a common ground in the concept of dependency. In all these patients there is a predisposition towards an exaggerated dependency on certain people in the outside world, especially parents with a lack of autonomy. The psychopathological significance of these conducts; its stakes, and its therapeutical consequences are discussed.     

Conséquences métaboliques de l’anorexie mentale

In anorexia nervosa, weight loss and malnutrition are responsible for metabolic, hormonal and behavioural consequences. An important decrease in energy expenditure (EE) is observed during fasting states of the disease, but the refeeding and the weight gain induce on the contrary a marked increase in EE, including an increase in resting EE, in diet-induced thermogenesis and in EE related to physical activity. There is also a dramatic fall in protein catabolism and glucose disposal during the fasting stages of the disease. During renutrition, these profiles are normalized long time before normalisation of body weight. Malnutrition and slimming diet induce some alterations in muscles mass and function, which lead difficult the refeeding, for example by slowing gastric emptying. As showed in rats, the restrictive diet together with the access to physical activity, which is secondary to anorectic thought, are responsible to increase the cognitive restrictive diet and to enhance mental and physical hyperactivity as well. Energy and nutrients deficiencies are the consequence to fear of becoming obese, but could also induce, in one third of the cases, binge-eating and thus purging. Recent studies have provided no evidence that anorexia nervosa is caused by neural, hormonal or metabolic factors and/or damages. But these metabolic and cognitive changes, which are mainly the consequence of the starvation, could explain some symptoms or behaviour observed in anorexia nervosa, i.e. those related to the compulsive needs to remain thin and to the fear to being fat.     

Prise en charge nutritionnelle intégrée de l’anorexie mentale

The therapeutic problem in the particular clinical situation, that is anorexia nervosa, is described. It is about a situation in which somatic medical aspects and psychological troubles are mixed. Treatments are actually going to apply to all these therapeutic targets, nutritional support, biological abnormalities correction, normal weight recovering, behaviour disorders treatment, improvement of psychological conditions and anxiety linked with weight gain and with distortions of body self-perception. It is in an integrated care program associating nutritional, behavioural and psychotherapeutic actions that we can hope for satisfactory improvement of these patients. This hospital model does not resolve the problem of relapse still present in this type of trouble, but allows the patients to find better physiological and psychological conditions.     

État nutritionnel des patients avec maladies du foie : épidémiologie et pronostic

Malnutrition is generally defined as protein-energy malnutrition (PEM) in patients with chronic liver disease, because the depletion of muscle mass and body fat is associated with protein depletion. Deficiencies of vitamins and minerals often coexist. PEM represents a common complication of advanced liver disease, both of alcoholic and nonalcoholic etiology. It is related to the severity of the liver disease more than to its etiology.Malnutrition negatively affects liver function, complications of the liver disease, and survival. Malnourished patients have an increased surgical risk and decreased survival after liver transplantation. The assessment of nutritional status in patients with chronic liver disease may be helpful in providing better prognostic information and more precise targeting of potential nutrition intervention.     

Consommation de produits laitiers et facteurs de risque cardiovasculaire dans l′étude MONICA

The aim of this study was to assess the associations between dairy products and cardiovascular risk factors in a representative sample of the French population. A sample of 912 men aged 45-64 years was randomly selected from the general population in Northern (Lille), Eastern (Strasbourg) and South-Western (Toulouse) regions of France. Risk factors were evaluated in each participant who completed a three-consecutive-day food record. In statistical analysis, subjects were separated according to quintiles of daily dairy product consumption. From the lowest quintile to the highest quintile of dairy product consumption and after adjustment for center, age, energy intake, alcohol, sodium, magnesium, and antihypertensive and antidiabetic treatments, systolic blood pressure significantly decreased. The prevalence of the metabolic syndrome decreased significantly from 32.6% to 25.0%, 21.8%, 18.3% and 19.9% (p=0.02 after adjustment for center, age, energy intake, alcohol, sodium, magnesium, and antihypertensive and antidiabetic treatments). In conclusion, high consumption of dairy products is associated with lower levels of blood pressure and a lower prevalence of the metabolic syndrome.     

Physiopathologie de l’anorexie liée à l’âge

A relative reduction in food intake in older versus younger individuals is commonly present in the general population and is often referred to as anorexia of aging. In most cases, anorexia of aging represents a normal physiological phenomenon, but sometimes it may underlie vulnerability for the frailty syndrome and increased mortality. However, the mechanisms responsible for anorexia of aging are not completely understood. In this review, we focused on the biological mechanisms which may trigger development in older subjects and experimental animals a resistance to anabolic and orexigenic peptide messengers including neuropeptide Y, ghrelin and growth hormone. The putative role of the aging gut, microbial intestinal contamination and the immune system are also discussed.     

Évaluation de l’état nutritionnel péri-opératoire

In surgical patients, malnutrition is associated with an increase in morbidity, mortality, length of stay and health care costs, and has an impact on quality of life. Before surgery, the risk of malnutrition is depending on patient-related factors (age, associated diseases, on-going symptoms, duration of pre-operative hospital stay), surgical procedure, and medical treatment (radiotherapy, chemotherapy, corticoid treatment). The early screening and management of malnutrition are mandatory during the peri-operative period, with the aim to improve post-operative prognosis and clinical outcome. The nutritional assessment is based on the research of weight loss, the calculation of body mass index and the research of an hypoalbuminemia, all of them having a negative impact on postoperative prognosis. The Nutritional Risk Index (NRI) is also of strong prognostic value. We propose a stratification of the nutritional risk indicating several levels of surgical risk. The organization, the planning and the traceability in the medical record of the nutritional assessment should allow optimizing the management and the clinical outcome of surgical patients. The pre-operative consultation of anaesthesia could be the privileged time to perform the screening of malnutrition and to plan its management, if they were not previously performed by the medico-surgical team.     

Place de l’alpha-cétoglutarate d’ornithine dans le traitement de la sarcopénie

Sarcopenia is defined as the loss of muscle mass and function during ageing. Despite its important metabolic and functional consequences, the underlying mechanisms of sarcopenia are poorly understood. A blunted anabolic response to food intake together with a reduction in the peripheral availability of amino acid associated with a greater use by the splanchnic bed likely participate in this phenomenon. In this context, ornithine α-ketoglutarate (OKG), which stimulates the secretion of insulin and growth hormone and the production of amino acids with anabolic function and/or low splanchnic extraction could improve the mechanical and metabolic capacities of muscle in older individuals. If so, the ultimate goal of such treatment should be to improve muscle contractile function and limit the loss of mobility in the elderly.     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.     

Facteurs trophiques : perspectives thérapeutiques de l'utilisation des facteurs de croissance et pharmaconutriments dans l'insuffisance intestinale

During intestinal insufficiency, improving intestinal functions may limit the needs for prolonged parenteral nutrition. Gut trophicity is supported by the intake of nutrients, polyamines, and nitrogenous pharmaconutrients such as glutamine, arginine and ornithine oxoglurate, but also growth factors acting as hormones or locally. Intestinal cell proliferation is stimulated by growth hormone and glucagonlike peptide-2, as well as by the insulin growth factor, epidermal growth factor, transforming growth factor-alpha, while it is inhibited by transforming growth factor-beta. The evaluation of combined therapies with glutamine, growth hormone and a specialized diet in short bowel patients has yielded conflicting results. The clinical use of GLP-2, alone or in combination, looks promising but need to be evaluated. The knowledge about intestinal growth factors and pharmaconutrients is increasing rapidly and should lead to innovative therapeutic strategies of intestinal insufficiency.     

Mécanismes de l’action antidiabétique des thiazolidinediones

The range of therapeutic modalities to treat type 2 diabetes mellitus has broadened in recent years. Thiazolidinediones (TZD) are currently available classe of anti-hyperglycemic agents with insulin-sensitizing properties. TZD improve insulin resistance. TZD act as agonists of peroxisome proliferator-activated receptor-gamma (PPARγ) primarily in adipose tissue. PPAR-gamma receptor activation by TZD improves insulin sensitivity by promoting fatty acid uptake into adipose tissue, increasing production of adiponectin and reducing levels of inflammatory mediators such as tumour necrosis factor-alpha (TNF-alpha), plasminogen activator inhibitor-1(PAI-1) and interleukin-6 (IL-6).     

Impact de l’athérome carotidien sur le risque cardiovasculaire chez l’hypertendu Mauritanien

Aim: To determine the prevalence of carotid atheroma in hypertensive patients and assess the levels of cardiovascular risk. Methods: This is a prospective study that took place in the outpatient department of the National Cardiology Center of Nouakchott over a period of 6 months (October 2019 to March 2020). Patients with hypertension without complications were included. Patients lost to follow-up and those whose records were incomplete were excluded from the study. Results: Out of a total of 171 patients, a total of 93 patients (54.38%) was collected, of which 54.8% were women, 55.9% of the patients in the series were over 50 years old.The associated cardiovascular risk factors were dominated by dyslipidemia (27.9%), diabetes (20.4%), smoking (26.8%). hypertension was grade 2 in 47.3% of patients and grade 3 in 52.7% of patients. Left ventricular hypertrophy was noted in 77.4% of patients. Echo-Doppler of the supra-aortic trunks revealed atherosclerotic plaques in 63.4% of patients. Conclusion: The prevalence of carotid atheroma in hypertensive patients at high cardiovascular risk level was frequent in our series, it follows from this to recommend early detection for optimal management.     

Allaitement maternel et lait maternel : quels bénéfices pour la santé de l’enfant

Breastfeeding has been shown to be beneficial for the health of neonates infants, mainly for the prevention of infectious diseases. Other beneficial effects such as prevention of atopic diseases or prevention of obesity has been also suggested. The optimal breastfeeding duration is still a matter of debate. Most of the beneficial effects were reported systematically for a duration of three months or more. However, there is a dose-dependent effect and breastfeeding, even for a short duration is beneficial for infants. Exclusive breastfeeding is presently recommended for six months, with introduction of complementary feeding at that time.