Seasonal BMI differences between restrictive and purging anorexia nervosa subtypes

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Seasonal and subtype differences in body mass index at admission in inpatients with anorexia nervosa

OBJECTIVE

In the general population, body weight is-on average-higher in the winter than in the summer. In patients with anorexia nervosa (AN), however, the opposite pattern has been reported. Yet, only a handful of studies exist to date that suffer from small sample sizes and inconsistent results. Therefore, the current study examined seasonal effects on body weight in a large sample of patients with AN to dissolve previous inconsistencies.

METHOD

Clinical records of N = 606 inpatients (95.4% female) who received AN treatment at the Schoen Clinic Roseneck (Prien am Chiemsee, Germany) between 2014 and 2019 were analyzed.

RESULTS

Patients with restrictive type AN had lower body mass index at admission in the winter than in the summer. This difference was not found for patients with binge/purge type AN and patients with atypical AN.

DISCUSSION

Individuals with restrictive type AN show seasonal variations in body weight that are opposite to seasonal variations in body weight in individuals without AN. These seasonal effects are specific to the restrictive subtype and cannot be found for the binge/purge or atypical subtypes. Future studies that replicate this effect in other cultures or latitudes and that examine the mediating mechanisms are needed.

Hypothesis: Clues From Mammalian Hibernation for Treating Patients With Anorexia Nervosa

This hypothesis is that anorexia nervosa (AN) is a biologically driven disorder, and mammalian hibernation may offer clues to its pathogenesis. Using this approach, this hypothesis offers suggestions for employing heart rate variability as an early diagnostic test for AN; employing the ketogenic diet for refeeding patients, attending to omega 3:6 ratio of polyunsaturated fatty acids (PUFAs) in the refeeding diet; and exploring clinical trials of the endocannabinoid-like agent, palmitoylethanolamde for patients with AN. This hypothesis also explores the role of lipids and autoimmune phenomena in AN, and suggest a lipodomics study to search for antibodies in the serum on patients with AN.

Seasonal variation of BMI at admission in German adolescents with anorexia nervosa

Objective

Recent preliminary studies indicated a seasonal association of BMI at admission to inpatient treatment for anorexia nervosa (AN), indicating lower BMI in the cold season for restrictive AN. An impaired thermoregulation was proposed as the causal factor, based on findings in animal models of AN. However, findings regarding seasonality of BMI and physical activity levels in the general population indicate lower BMI and higher physical activity in summer than in winter. Therefore, we aimed to thoroughly replicate the findings regarding seasonality of BMI at admission in patients with AN in this study.

Method

AN subtype, age- and gender-standardized BMI scores (BMI-SDS) at admission, mean daily sunshine duration and ambient temperature at the residency of 304 adolescent inpatients with AN of the multi-center German AN registry were analyzed.

Results

A main effect of DSM-5 AN subtype was found (F(2,298) = 6.630, p = .002), indicating differences in BMI-SDS at admission between restrictive, binge/purge and subclinical AN. No main effect of season on BMI-SDS at admission was found (F(1,298) = 4.723, p = .025), but an interaction effect of DSM-5 subtype and season was obtained (F(2,298) = 6.625, p = .001). Post-hoc group analyses revealed a lower BMI-SDS in the warm season for restrictive AN with a non-significant small effect size (t(203.16) = 2.140, p = .033; Hedges′g = 0.28). Small correlations of mean ambient temperature (r = −.16) and daily sunshine duration (r = −.22) with BMI-SDS in restrictive AN were found. However, the data were widely scattered.

Conclusions

Our findings are contrary to previous studies and question the thermoregulatory hypothesis, indicating that seasonality in AN is more complex and might be subject to other biological or psychological factors, for example physical activity or body dissatisfaction. Our results indicate only a small clinical relevance of seasonal associations of BMI-SDS merely at admission. Longitudinal studies investigating within-subject seasonal changes might be more promising to assess seasonality in AN and of higher clinical relevance.

Evaluation of the DSM-5 severity ratings for anorexia nervosa in a clinical sample

We examined the validity and utility of the DSM-5 severity ratings for anorexia nervosa (AN) in a clinical (treatment-seeking) sample (N = 273; 95.6% women). Participants classified with mild, moderate, severe, and extreme severity of AN based on their measured body mass index, differed significantly from each other in eating disorder features, putative maintenance factors, and illness-specific functional impairment (medium effect sizes). However, they were statistically indistinguishable in psychiatric-disorder comorbidity and distress, demographics, and age-of-AN onset. The implications of our findings, providing limited support for the DSM-5 severity ratings for AN, and directions for future research are outlined.

Mortality in Women With Anorexia Nervosa: The Role of Comorbid Psychiatric Disorders

OBJECTIVE

To investigate mortality in anorexia nervosa (AN) with a psychiatric comorbidity.

METHODS

Using Swedish registers, data for 8069 female inpatients with AN were retrospectively collected for 1973-2010. Mortality patterns were assessed using standardized mortality ratios (SMRs), Cox regression-derived hazard ratios, and incidence rate ratios. A control cohort of 76,995 women was used.

RESULTS

Patients with AN and a psychiatric comorbidity had higher mortality rates did than those without a comorbidity. The SMRs for patients with AN and a psychiatric comorbidity were 5.4 (95% confidence interval [CI] = 4.6-6.4) and 18.1 (95% CI = 15.2-21.3) for natural and unnatural causes of death, respectively. The SMRs for patients with AN without a comorbidity were 2.8 (95% CI = 2.3-3.5) and 3.1 (95% CI = 2.2-4.1) for natural and unnatural causes of death, respectively. The adjusted hazard ratios for mortality from natural or unnatural causes were 2.0 (95% CI = 1.5-2.7) and 5.7 (95% CI = 3.9-8.2), respectively. Incidence rate ratios comparing patients with AN and controls, both with psychiatric comorbidities, suggest a negative synergistic effect of comorbid AN and psychiatric disorder on mortality, which was greater for unnatural causes of death.

CONCLUSIONS

Mortality in patients with AN was greater in the presence of a psychiatric comorbidity, and even more pronounced for unnatural causes of death and suicides. Substance abuse, especially alcohol use disorder, increased mortality from natural causes of death. These findings highlight the need for early detection and treatment of psychiatric comorbidity in AN, to potentially improve long-term outcomes.

Anorexia nervosa, seasonality, and polyunsaturated fatty acids

Anorexia nervosa is a serious neurobehavioral disorder marked by semistarvation, extreme fear of weight gain, frequently hyperactivity, and low body temperature. The etiology remains unknown. We present a speculation that a primary causative factor is that polyunsaturated fatty acids are skewed to prevent oxidative damage in phospholipid membranes. This causes a change in the trade off of oxidation protection vs homeoviscous adaptation to lower temperatures, which sets off a metabolic cascade that leads to the rogue state of anorexia nervosa.

First results of a refeeding program in a psychiatric intensive care unit for patients with extreme anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with a high mortality rate. This study describes a compulsory re-feeding program established in Munich for extremely underweight patients.

METHODS

The contract between the patient and the therapeutic team included mandatory inpatient status, establishment of guardianship and compulsory re-feeding with a percutaneous gastric feeding tube, as indicated. The predefined target was a body mass index (BMI) of 17 kg/m(2). Data on the first 68 patients with AN are presented.

RESULTS

65 (95.6%) patients were female and mean age at admission was 26.5 ± 8.5 years. BMI increased from 12.3 ± 1.4 kg/m(2) at admission to 16.7 ± 1.7 kg/m(2) at discharge. Thirty-two (47.1%) patients had the restrictive subtype (ANR) and 36 (52.9%) had the binging and purging subtype (ANBP). Duration of illness before admission (p = .004), days of treatment until discharge (p = .001) and weight increase (p = .02) were significantly different between subgroups in favor of patients with ANR. Also, seasonal differences could be found. Comparison of feeding methods showed that percutaneous tube feeding was superior. Almost half of the patients were treated with psychotropic medication. To date, however, the number of patients included in this program is too small to assess rare complications of this acute treatment program and long term outcomes of AN.

CONCLUSIONS

An intensive care program for severely ill AN patients has been successfully established. Besides averting physical harm in the short term, this program was designed to enable these patients to participate in more sophisticated psychotherapeutic programs afterwards. To our knowledge, this is the first such program that regularly uses percutaneous feeding tubes.