Anorexia nervosa and cancer risk

Low risk of some common cancers in women with anorexia nervosa: Evidence from a national record-linkage study

BACKGROUND

Some studies report that women with anorexia nervosa (AN) have lower risk than others of breast cancer, but increased risk of cancers of other sites. No work has been done to quantify the risk in the English population.

METHODS

Retrospective cohort study using a national linked dataset of Hospital Episode Statistics for 1999-2021. We selected individuals with a hospital admission for AN, and compared their relative risk (RR) of developing site-specific cancers, with that in a reference cohort.

RESULTS

We identified 75 cancers in 15,029 women hospitalised with AN. There was a low RR of all cancers combined at 0.75 (95%CI 0.59-0.94), and, notably, low RR for breast cancer 0.43 (0.20-0.81), cancers of secondary and ill-defined sites 0.52 (0.26-0.93). The RR for parotid gland cancer was 4.4 (1.4-10.6) within a year of first recorded diagnosis of AN. In men, we found 12 cancers in 1413 individuals hospitalised with AN, but no increased risks beyond the first year of diagnosis of AN.

CONCLUSIONS

This is the first report on the association between AN and cancers in the all-England population. The study showed low rates of breast cancer, and of all cancers combined, in women hospitalised with AN. It is possible that some of the metabolic or hormonal changes observed in AN could work as a protective factor for breast cancer. More experimental work is needed to identify and explain these factors. The new finding on the higher risk of salivary gland tumours could inform clinicians caring for patients with AN.

Relationship between irregular diet and risk of esophageal cancer: A meta-analysis

Background: Associations between irregular diet and the risk of esophageal cancer remain unclear. The current meta-analysis was performed to determine whether the presence of irregular diet increases the risk of esophageal cancer.

Methods: The data from PubMed, Cochrane Libraries, and Embase up to 23 January 2022 were included in our analysis to identify studies that investigated associations between irregular diet and the risk of esophageal cancer. Summary relative risk (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model.

Results: Five cohort studies and one case-control study investigating associations between irregular diet and the risk of esophageal cancer were included. None of the articles demonstrated publication bias. The summary RR was 4.181 (95% CI 2.196–7.960, I² = 66.1%, p = 0.011). In the subgroup analysis, we found significant heterogeneity in the Non-disease-causing group, nurse group and Asian group. The above three that produce heterogeneity may be the source of heterogeneity in the results of this study.

Conclusion: The current meta-analysis indicates that irregular diet increase the risk of esophageal cancer.

Trial registration: (https://www.crd.york.ac.uk/prospero/), (PROSPERO, CRD42022306407)

Bulimia Nervosa Leading to Squamous Cell Carcinoma of the Esophagus in a Young Adult

Bulimia nervosa is an eating disorder which is defined as binge eating which is followed by purging and inappropriately increased concern about one’s weight and body shape. We report a case of a 20 year old female who presented with a history of a dysphagia since 2 months. She had a history of binge eating disorder followed by a ritual of purging activity since six years. She also gave a history of increased concern about her weight and body shape. On endoscopy, a growth was seen on the esophagus, which upon biopsy showed features of squamous cell carcinoma.Thus, even in a young female, a simple psychological eating disorder might manifest as a malignancy. This emphasizes the need of early diagnosis and treatment of such innocent looking eating disorders to prevent serious complications in the future.

Eating disorders and the risk of developing cancer: a systematic review

PURPOSE

Evidence concerning eating disorders as risk toward developing cancer is sparse. Energy restriction might be cancer protective, while malnutrition, vomiting, laxative and substance use might stimulate cancer development. We examined whether individuals with an eating disorder (not restricted to anorexia nervosa) had a different risk of developing cancer.

METHODS

A systematic search on Medline and Embase until 28th April 2020 identified relevant human original research publications, including all populations and all cancer types.

RESULTS

From 990 records, 6 case reports and 9 cohorts were included. Some cohorts found a decreased breast (3/5 studies) or cervical (1/2) cancer risk, while an increased esophageal (2/3), liver (1/1), brain (1/1 in men) and respiratory (2/4) cancer risk, but other cancer risks were non-significant, and an increased mortality overall (1/2), from breast (1/1), female genital (1/1) and skin (1/1) cancer in eating disorder patients. The case reports further described esophageal cancer and leukemia. No clear statistical differences in cancer risk were found depending on eating disorder type, perhaps due to the small sample size (n = 1783 for other than anorexia nervosa).

CONCLUSIONS

The literature on eating disorders and cancer risk is sparse with many gaps. Hormonal changes, sexual activity, nutritional status, vomiting and concomitant tobacco/alcohol abuse may explain increased/decreased cancer risk. Future large studies (now 1-366 cancer cases) that also include men (now 4.7%), bulimia nervosa (now 3.8%) and several cancer sites (now mainly breast cancer) are needed and should foresee longer follow-up time (now 5.4-15.2 years) and extensive confounder adjustment (now only age and sex).

LEVEL OF EVIDENCE

Level I, systematic review.

Is Host Metabolism the Missing Link to Improving Cancer Outcomes?

For the past 100 years, oncologists have relentlessly pursued the destruction of tumor cells by surgical, chemotherapeutic or radiation oncological means. Consistent with this focus, treatment plans are typically based on key characteristics of the tumor itself such as disease site, histology and staging based on local, regional and systemic dissemination. Precision medicine is similarly built on the premise that detailed knowledge of molecular alterations of tumor cells themselves enables better and more effective tumor cell destruction. Recently, host factors within the tumor microenvironment including the vasculature and immune systems have been recognized as modifiers of disease progression and are being targeted for therapeutic gain. In this review, we argue that—to optimize the impact of old and new treatment options—we need to take account of an epidemic that occurs independently of—but has major impact on—the development and treatment of malignant diseases. This is the rapidly increasing number of patients with excess weight and its’ attendant metabolic consequences, commonly described as metabolic syndrome. It is well established that patients with altered metabolism manifesting as obesity, metabolic syndrome and chronic inflammation have an increased incidence of cancer. Here, we focus on evidence that these patients also respond differently to cancer therapy including radiation and provide a perspective how exercise, diet or pharmacological agents may be harnessed to improve therapeutic responses in this patient population.

Association of Anorexia Nervosa With Risk of Cancer: A Systematic Review and Meta-analysis

IMPORTANCE

Anorexia nervosa is recognized as an important cause of morbidity in young people. However, the risk of cancer in people with anorexia nervosa remains uncertain.

OBJECTIVE

To evaluate the association of anorexia nervosa with the risk of developing or dying of cancer.

DATA SOURCES

MEDLINE, Scopus, Embase, and Web of Science from database inception to January 9, 2019.

STUDY SELECTION

Published observational studies in humans examining the risk of cancer in people with anorexia nervosa compared with the general population or those without anorexia nervosa. Studies needed to report incidence or mortality rate ratios (RRs).

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction, and methodological quality assessment were performed by at least 2 researchers independently. A random-effects model was used to synthesize individual studies. Heterogeneity (I2) was assessed and 95% prediction intervals (PIs) were calculated.

MAIN OUTCOMES AND MEASURES

All cancer incidence and cancer mortality associated with anorexia nervosa. Secondary outcomes were site-specific cancer incidence and mortality.

RESULTS

Seven cohort studies published in 10 articles (42 602 participants with anorexia nervosa) were included. Anorexia nervosa was not associated with risk of developing any cancer (4 studies in women; RR, 0.97; 95% CI, 0.89-1.06; P = .53; I2, 0%; 95% PI, 0.80-1.18; moderate confidence). Anorexia nervosa was associated with decreased breast cancer incidence (5 studies in women; RR, 0.60; 95% CI, 0.50-0.80; P < .001; I2, 0%; 95% PI, 0.44-0.83; high confidence). Conversely, anorexia nervosa was associated with increased risk of developing lung cancer (3 studies in women; RR, 1.50; 95% CI, 1.06-2.12; P = .001; I2, 0%; 95% PI, 0.19-16.46; low confidence) and esophageal cancer (2 studies in women; RR, 6.10; 95% CI, 2.30-16.18; P < .001; I2, 0%; low confidence).

CONCLUSIONS AND RELEVANCE

Among people with anorexia nervosa, risk of developing cancer did not differ compared with the general population, but a significantly reduced risk of breast cancer was observed. Understanding the mechanisms underlying these associations could have important preventive potential.

Chemically induced carcinogenesis in rodent models of aging: assessing organismal resilience to genotoxic stressors in geroscience research

There is significant overlap between the cellular and molecular mechanisms of aging and pathways contributing to carcinogenesis, including the role of genome maintenance pathways. In the field of geroscience analysis of novel genetic mouse models with either a shortened, or an extended, lifespan provides a unique opportunity to evaluate the synergistic roles of longevity assurance pathways in cancer resistance and regulation of lifespan and to develop novel targets for interventions that both delay aging and prevent carcinogenesis. There is a growing need for robust assays to assess the susceptibility of cancer in these models. The present review focuses on a well-characterized method frequently used in cancer research, which can be adapted to study resilience to genotoxic stress and susceptibility to genotoxic stress-induced carcinogenesis in geroscience research namely, chemical carcinogenesis induced by treatment with 7,12-dimethylbenz(a)anthracene (DMBA). Recent progress in understanding how longer-living mice may achieve resistance to chemical carcinogenesis and how these pathways are modulated by anti-aging interventions is reviewed. Strain-specific differences in sensitivity to DMBA-induced carcinogenesis are also explored and contrasted with mouse lifespan. The clinical relevance of inhibition of DMBA-induced carcinogenesis for the pathogenesis of mammary adenocarcinomas in older human subjects is discussed. Finally, the potential role of insulin-like growth factor-1 (IGF-1) in the regulation of pathways responsible for cellular resilience to DMBA-induced mutagenesis is discussed.

Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States

OBJECTIVE

To examine psychiatric and somatic correlates of DSM-5 eating disorders (EDs)-anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED)-in a nationally representative sample of adults in the United States.

METHOD

A national sample of 36,309 adult participants in the national epidemiologic survey on alcohol and related conditions III (NESARC-III) completed structured diagnostic interviews (AUDADIS-5) to determine psychiatric disorders, including EDs, and reported 12-month diagnosis of chronic somatic conditions. Prevalence of lifetime psychiatric disorders and somatic conditions were calculated across the AN, BN, and BED groups and a fourth group without specific ED; multiple logistic regression models compared the likelihood of psychiatric/somatic conditions with each specific ED relative to the no-specific ED group.

RESULTS

All three EDs were associated significantly with lifetime mood disorders, anxiety disorders, alcohol and drug use disorders, and personality disorders. In all three EDs, major depressive disorder was the most prevalent, followed by alcohol use disorder. AN was associated significantly with fibromyalgia, cancer, anemia, and osteoporosis, and BED with diabetes, hypertension, high cholesterol, and triglycerides. BN was not associated significantly with any somatic conditions.

CONCLUSIONS

This study examined lifetime psychiatric and somatic correlates of DSM-5 AN, BN, and BED in a large representative sample of U.S. adults. Our findings on significant associations with other psychiatric disorders and with current chronic somatic conditions indicate the serious burdens of EDs. Our findings suggest important differences across specific EDs and indicate some similarities and differences to previous smaller studies based on earlier diagnostic criteria.

Extreme population-level events: Do they have an impact on cancer?

The report by Sadetzki and colleagues in this issue showcases the impact of a horrendous event—the Holocaust—on subsequent health decades after the occurrence. Two additional calamities—country‐wide famines and population‐level discrimination—are provided as examples of this phenomenon to add evidence to the causal pathway identified by Sadetzki et al.

See also pages 3335‐45.

Anorexia nervosa and cancer: a protocol for a systematic review and meta-analysis of observational studies

BACKGROUND

Anorexia nervosa is characterized by a severe restriction of caloric intake, low body weight, fear of gaining weight or of becoming fat, and disturbance of body image. Pathogenesis of the disorder may include genetic predisposition, hormonal changes and a combination of environmental, psychosocial, and cultural factors. Cancer is the second leading cause of death worldwide. At present, no systematic reviews and meta-analyses have evaluated the risk of cancer in people with anorexia nervosa. The objective of this study will be to evaluate the association between anorexia nervosa and the risk of developing or dying from cancer.

METHODS/DESIGN

This study protocol is part of a systematic collection and assessment of multiple systematic reviews and meta-analyses (umbrella review) evaluating the association of cancer and multiple central nervous system disorders. We designed a specific protocol for a new systematic review and meta-analysis of observational studies of anorexia nervosa with risk of developing or dying from any cancer. Data sources will be PubMed, Embase, Scopus, Web of Science, and manual screening of references. Observational studies (case-control and cohort) in humans that examined the association between anorexia nervosa and risk of developing or dying from cancer will be sought. The primary outcomes will be cancer incidence and cancer mortality in association with anorexia nervosa. Secondary outcomes will be site-specific cancer incidence and mortality, respectively. Screening of abstracts and full texts, and data abstraction will be performed by two team members independently. Conflicts at all levels of screening and abstraction will be resolved through discussion. The quality of studies will be assessed by using the Ottawa-Newcastle scale by two team members independently. Random effects models will be conducted where appropriate. Subgroup and additional analyses will be conducted to explore the potential sources of heterogeneity. The World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for cancer outcomes.

DISCUSSION

Findings from this systematic review will inform an ongoing umbrella review on cancer and central nervous system disorders. Our systematic review and meta-analysis of observational studies will establish the extent of the epidemiological evidence underlying the association between anorexia nervosa and cancer.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017067462.

Eating Disorders and Breast Cancer

BACKGROUND

Eating disorders such as anorexia nervosa and bulimia nervosa affect overall and reproductive health and may also affect breast cancer risk. We studied the association between self-reported eating disorders and breast cancer risk in a prospective cohort study.

METHODS

In 2003-2009, the Sister Study enrolled women ages 35-74 years who had a sister with breast cancer but had never had it themselves. Using data from 47,813 women, we estimated adjusted HRs and 95% confidence intervals (CI) for the association between eating disorders and invasive breast cancer over a median of 5.4 years of follow-up.

RESULTS

Three percent (n = 1,569) of participants reported a history of an eating disorder. Compared with women who never had an eating disorder, women who reported eating disorders in the past had reduced breast cancer risk (HR = 0.62; 95% CI, 0.42-0.92).

CONCLUSIONS

In this large prospective, observational cohort study, we observed an inverse association between having a history of an eating disorder and invasive breast cancer.

IMPACT

Historical eating disorders may be associated with a long-term reduction in breast cancer risk. Cancer Epidemiol Biomarkers Prev; 26(2); 206-11. ©2016 AACR.

Cancer Incidence among Patients with Anorexia Nervosa from Sweden, Denmark and Finland

A diet with restricted energy content reduces the occurrence of cancer in animal experiments. It is not known if the underlying mechanism also exists in human beings. To determine whether cancer incidence is reduced among patients with anorexia nervosa who tend to have a low intake of energy, we carried out a retrospective cohort study of 22 654 women and 1678 men diagnosed with anorexia nervosa at ages 10-50 years during 1968-2010 according to National Hospital Registers in Sweden, Denmark and Finland. The comparison group consisted of randomly selected persons from population registers who were similar to the anorexia nervosa patients in respect to sex, year of birth and place of residence. Patients and population comparisons were followed for cancer by linkage to Cancer Registries. Incidence rate ratios (IRR) were estimated using Poisson models. In total, 366 cases of cancer (excluding non-melanoma skin cancer) were seen among women with anorexia nervosa, and the IRR for all cancer sites was 0.97 (95% CI = 0.87-1.08) adjusted for age, parity and age at first child. There were 76 breast cancers corresponding to an adjusted IRR of 0.61 (95% CI = 0.49-0.77). Significantly increased IRRs were observed for esophageal, lung, and liver cancer. Among men with anorexia nervosa, there were 23 cases of cancer (age-adjusted IRR = 1.08; 95% CI = 0.71-1.66). There seems to be no general reduction in cancer occurrence among patients with anorexia nervosa, giving little support to the energy restriction hypothesis.

Risk of oesophageal cancer among patients previously hospitalised with eating disorder

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There are case reports of oesophageal cancer in patients with eating disorders.

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We followed up a cohort of patients hospitalised previously with eating disorders.

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These patients were at significantly increased risk of oesophageal cancer.

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All cancers were squamous cell carcinomas in females with prior anorexia nervosa.

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Indirect evidence suggests confounding by established risk factors.

Background

It has been suggested that the risk of oesophageal adenocarcinoma might be increased in patients with a history of eating disorders due to acidic damage to oesophageal mucosa caused by self-induced vomiting practiced as a method of weight control. Eating disorders have also been associated with risk factors for squamous cell carcinoma of the oesophagus, including alcohol use disorders, as well as smoking and nutritional deficiencies, which have been associated with both main sub-types of oesophageal cancer. There have been several case reports of oesophageal cancer (both main sub-types) arising in patients with a history of eating disorders.

Methods

We used linked records of hospitalisation, cancer registration and mortality in Scotland spanning 1981–2012 to investigate the risk of oesophageal cancer among patients with a prior history of hospitalisation with eating disorder. The cohort was restricted to patients aged ≥10 years and <60 years at the date of first admission with eating disorder. Disregarding the first year of follow-up, we calculated indirectly standardised incidence ratios using the general population as the reference group to generate expected numbers of cases (based on age-, sex-, socio-economic deprivation category-, and calendar period-specific rates of disease).

Results

After exclusions, the cohort consisted of 3617 individuals contributing 52,455 person-years at risk. The median duration of follow-up was 13.9 years. Seven oesophageal cancers were identified, as compared with 1.14 expected, yielding a standardised incidence ratio of 6.1 (95% confidence interval: 2.5–12.6). All were squamous cell carcinomas arising in females with a prior history of anorexia nervosa.

Conclusions

Patients hospitalised previously with eating disorders are at increased risk of developing oesophageal cancer. Confounding by established risk factors (alcohol, smoking, and nutritional deficiency) seems a more likely explanation than acidic damage through self-induced vomiting because none of the incident cases of oesophageal cancer were adenocarcinomas, and because the study cohort had higher than background rates of hospitalisation with alcohol-related conditions and chronic obstructive pulmonary disease.

Long-term consequences of anorexia nervosa

Anorexia nervosa (AN) is a psychiatric disorder that occurs mainly in female adolescents and young women. The obsessive fear of weight gain, critically limited food intake and neuroendocrine aberrations characteristic of AN have both short- and long-term consequences for the reproductive, cardiovascular, gastrointestinal and skeletal systems. Neuroendocrine changes include impairment of gonadotropin releasing-hormone (GnRH) pulsatile secretion and changes in neuropeptide activity at the hypothalamic level, which cause profound hypoestrogenism. AN is related to a decrease in bone mass density, which can lead to osteopenia and osteoporosis and a significant increase in fracture risk in later life. Rates of birth complications and low birth weight may be higher in women with previous AN. The condition is associated with fertility problems, unplanned pregnancies and generally negative attitudes to pregnancy. During pregnancy, women with the condition have higher rates of hyperemesis gravidarum, anaemia and obstetric complications, as well as impaired weight gain and compromised intrauterine foetal growth. It is reported that 80% of AN patients are affected by a cardiac complications such as sinus bradycardia, a prolonged QT interval on electrocardiography, arrythmias, myocardial mass modification and hypotension. A decrease in bone mineral density (BMD) is one of the most important medical consequences of AN. Reduced BMD may subsequently lead to a three- to seven-fold increased risk of spontaneous fractures. Untreated AN is associated with a significant increase in the risk of death. Better detection and sophisticated therapy should prevent the long-term consequences of this disorder. The aims of treatment are not only recovery but also prophylaxis and relief of the long-term effects of this disorder. Further investigations of the long-term disease risk are needed.

The protective effect of intermittent calorie restriction on mammary tumorigenesis is not compromised by consumption of a high fat diet during refeeding

Previously we reported that intermittent calorie restriction (ICR) provided greater prevention of mammary tumors (MTs) than chronic calorie restriction (CCR). Here the impact of increased fat intake during refeeding in an ICR protocol was evaluated. MMTV-TGF-α female mice were assigned to one of three groups: ad libitum (AL) fed (n = 45) with free access to a moderately high fat diet (22 % fat calories); ICR (n = 45) 50 % calorie restricted for 3-week intervals followed by 3 weeks of 100 % of AL intake; and CCR (n = 45) fed 75 % of AL mice, matching each 6-week cycle of ICR mice. ICR mice were further designated as ICR-Restricted or ICR-Refed for data obtained during these intervals. All mice consumed the same absolute amount of dietary fat. Mice were followed to assess MT incidence, body weight and serum IGF-1, IGFBP3, leptin and adiponectin levels until 79 (end of final 3-week restriction) or 82 (end of final 3-weeks refeeding) weeks of age. Age of MT detection was significantly extended for CCR (74 weeks) and ICR (82 weeks) mice, compared to 57.5 weeks for AL mice. MT incidence for AL, ICR and CCR mice was 66.7, 4.4, and 52.3 %, respectively. Mammary and fat pad weights were reduced significantly following 50 % calorie restriction in ICR-Restricted mice compared to AL, CCR and ICR-Refed mice. IGF-1 and leptin levels also tended to be reduced in ICR-Restricted mice over the course of the study while adiponectin was not compared to AL, CCR, and ICR-Refed mice. The adiponectin:leptin ratio was consistently higher following 50 % restriction in ICR-Restricted mice. There was no relationship of IGF-1, leptin, or adiponectin with the presence of MTs in any groups. Thus the manner in which calories are restricted impacts the protective effect of calorie restriction independently of high fat intake.

Nutrient restriction and radiation therapy for cancer treatment: when less is more

Calorie restriction (CR), or a diet modification aiming to reduce the total intake of calories by 20%-40%, has been shown to increase longevity across multiple species. Recently, there has been growing interest in investigating the potential role of CR as a treatment intervention for age-related diseases, such as cancer, because an increasing body of literature has demonstrated a metabolic component to both carcinogenesis and tumor progression. In fact, many of the molecular pathways that are altered with CR are also known to be altered in cancer. Therefore, manipulation of these pathways using CR can render cancer cells, and most notably breast cancer cells, more susceptible to standard cytotoxic treatment with radiation and chemotherapy. In this review article we demonstrate the laboratory and clinical evidence that exists for CR and show compelling evidence through the molecular pathways CR induces about how it may be used as a treatment in tandem with radiation therapy to improve our rates of disease control.

Insights into the beneficial effect of caloric/ dietary restriction for a healthy and prolonged life

Over the last several years, new evidence has kept pouring in about the remarkable effect of caloric restriction (CR) on the conspicuous bedfellows- aging and cancer. Through the use of various animal models, it is now well established that by reducing calorie intake one can not only increase life span but, also, lower the risk of various age related diseases such as cancer. Cancer cells are believed to be more dependent on glycolysis for their energy requirements than normal cells and, therefore, can be easily targeted by alteration in the energy-metabolic pathways, a hallmark of CR. Apart from inhibiting the growth of transplantable tumors, CR has been also shown to inhibit the development of spontaneous, radiation, and chemically induced tumors. The question regarding the potentiality of the anti-tumor effect of CR in humans has been in part answered by the resistance of a cohort of women, who had suffered from anorexia in their early life, to breast cancer. However, human research on the beneficial effect of CR is still at an early stage and needs further validation. Though the complete mechanism of the anti-tumor effect of CR is far from clear, the plausible involvement of nutrient sensing pathways or IGF-1 pathways proposed for its anti-aging action cannot be overruled. In fact, cancer cell lines, mutant for proteins involved in IGF-1 pathways, failed to respond to CR. In addition, CR decreases the levels of many growth factors, anabolic hormones, inflammatory cytokines, and oxidative markers that are deregulated in several cancers. In this review, we discuss the anti-tumor effect of CR, describing experiments done in vitro in tumor models and in vivo in mouse models in which the tumor was induced by means of radiation or chemical exposure, expressing oncogenes or deleting tumor suppression genes. We also discuss the proposed mechanisms of CR anti-tumor action. Lastly, we argue the necessity of gene expression studies in cancerous versus normal cells upon CR.

Somatic problems and self-injurious behaviour 18 years after teenage-onset anorexia nervosa

The aim of this study was to study long-term outcome of physical health and self-injurious behaviour (SIB) in anorexia nervosa (AN). Fifty-one adolescent-onset AN cases, originally recruited after community screening, and 51 matched controls (COMP) were interviewed regarding somatic problems and SIB and physically examined 18 years after AN onset, at mean age 32 years. Six individuals had an eating disorder (ED). No one had died. The AN group weighed less than the COMP group. The frequency of somatic problems did not differ between groups. Dental enamel lesions and shorter than expected stature occurred only in the AN group. Dysdiadochokinesis was overrepresented in the AN group and age of AN onset was lower among those with the neurological deficit. Severe SIB occurred only in the AN group, predominantly during adolescence. To conclude, somatic problems were common in both groups. Most individuals in the AN group had recovered from their ED, but weight revealed a persistent restricted eating behaviour.

Energy restriction during childhood and early adulthood and ovarian cancer risk

Dietary energy restriction may protect against cancer. In parts of the Netherlands, mostly in larger cities, periods of chronically impaired nutrition and even severe famine (Hunger Winter 1944–1945) existed during the 1930s and World War II (1940–1945). We studied the association between energy restriction during childhood and early adulthood on the risk of ovarian cancer later in life. In 1986, the Netherlands Cohort Study was initiated. A self-administered questionnaire on dietary habits and other cancer risk factors was completed by 62,573 women aged 55–69 years at baseline. Follow-up for cancer was established by record linkage to the Netherlands Cancer Registry. After 16.3 years of follow-up, 364 invasive epithelial ovarian cancer cases and 2220 subcohort members (sampled from the total cohort directly after baseline) with complete information confounders were available for case-cohort analyses. In multivariable analysis, ovarian cancer risk was lower for participants with an unemployed father during the 1930s (Hazard Ratio (HR), 0.70; 95% Confidence Interval (CI), 0.47–1.06) compared to participants with an employed father as well as for participants living in a city during World War II (HR, 0.69; 95% CI, 0.54–0.90) compared to participants living in the country-side. Residence in a Western City during the famine (Hunger Winter) was not associated with a decreased risk. Our results show a relation between proxy variables for modest energy restriction over a longer period of time during childhood or early adulthood and a reduced ovarian cancer risk.

The manner in which calories are restricted impacts mammary tumor cancer prevention

Although treatments for breast cancer have improved and long-term survival after diagnosis is now common, prevention of the disease is the ultimate goal. Weight loss or weight maintenance is one approach that has been recommended to reduce the risk of breast cancer, particularly for peri/postmenopausal women. This approach is supported by decades of data indicating that calorie restriction prevents spontaneous and chemically induced mammary tumor development in rodents. In most cases, calorie restriction was implemented by a consistent daily reduction of calories, i.e. chronic calorie restriction (CCR). There have also been several studies where periods of reduced caloric intake were followed by periods of refeeding, i.e. intermittent calorie restriction (ICR), resulting in the prevention of spontaneous mammary tumorigenesis. In most of the early studies, there were no direct comparisons of CCR to ICR. One study using moderate calorie restriction in a chemically induced breast cancer rat model found a slight increase in mammary tumor incidence compared with ad libitum fed and CCR rats. However, recently, it has been demonstrated in several transgenic mouse models of breast cancer that ICR consistently provided a greater degree of protection than CCR. This review will provide a detailed comparison of ICR and CCR for breast cancer prevention. It will also examine potential mechanisms of action that may include periods of reduced IGF-I and leptin as well as an increase in the adiponectin:leptin ratio. Application of this approach to at-risk women may provide an approach to lower the risk of breast cancer in overweight/obese women.

Excess mortality, causes of death and prognostic factors in anorexia nervosa

BACKGROUND

Anorexia nervosa is a mental disorder with high mortality.

AIMS

To estimate standardised mortality ratios (SMRs) and to investigate potential prognostic factors.

METHOD

Six thousand and nine women who had in-patient treatment for anorexia nervosa were followed-up retrospectively using Swedish registers.

RESULTS

The overall SMR for anorexia nervosa was 6.2 (95% CI 5.5-7.0). Anorexia nervosa, psychoactive substance use and suicide had the highest SMR. The SMR was significantly increased for almost all natural and unnatural causes of death. The SMR 20 years or more after the first hospitalisation remained significantly high. Lower mortality was found during the last two decades. Younger age and longer hospital stay at first hospitalisation was associated with better outcome, and psychiatric and somatic comorbidity worsened the outcome.

CONCLUSIONS

Anorexia nervosa is characterised by high lifetime mortality from both natural and unnatural causes. Assessment and treatment of psychiatric comorbidity, especially alcohol misuse, may be a pathway to better long-term outcome.

Safety, tolerability and pharmacokinetics of intravenous ghrelin for cancer-related anorexia/cachexia: a randomised, placebo-controlled, double-blind, double-crossover study

Twenty-one adult patients were randomised to receive ghrelin on days 1 and 8 and placebo on days 4 and 11 or vice versa, given intravenously over a 60-min period before lunch: 10 received 2 μg kg⁻¹ (lower-dose) ghrelin; 11 received 8 μg kg⁻¹ (upper-dose) ghrelin. Active and total ghrelin, growth hormone (GH), and insulin-like growth factor 1 levels were monitored at baseline (4–5 days before day 1), during treatment days, and at end of study (day 17/18). Drug-related adverse events (assessed by NCI-CTC-toxicity criteria and cardiac examination) did not differ between ghrelin and placebo. No grade 3/4 toxicity or stimulation of tumour growth was observed. The peak increase of GH, a biological marker of ghrelin action, was 25 ng ml⁻¹ with lower-dose and 42 ng ml⁻¹ with upper-dose ghrelin. Morning fasting total ghrelin levels were higher (P<0.05) for upper-dose patients at end of study (3580 pg ml⁻¹) than at baseline (990 pg ml⁻¹). Insulin-like growth factor 1 levels did not change. At day 8, 81% of patients preferred ghrelin to placebo as against 63% at the end of study. Nutritional intake and eating-related symptoms, measured to explore preliminary efficacy, did not differ between ghrelin and placebo. Ghrelin is well tolerated and safe in patients with advanced cancer. For safety, tolerance, and patients' preference for treatment, no difference was observed between the lower- and upper-dose group.

The impact of the Occupation of Guernsey 1940-1945 on breast cancer risk factors and incidence

To examine the impact of the German Occupation of Guernsey (1940-1945) on breast cancer risk factors and incidence. Under study were 1019 women who stayed, or whose mothers had stayed, in Guernsey, and 1358 women evacuated or born to evacuated mothers. Amongst those born 1926-1934 who remained in Guernsey, the secular trend of earlier menarche disappeared: menarche was delayed by 12 months for those born in 1930. By March 2006, 97 breast cancers had been diagnosed, 37 in the occupied group. Unusually, higher age at menarche appeared to be associated with increased risk of breast cancer (>or=14 years vs. <or=13 years: HR = 1.52, 95% CI = 0.80-2.92). Separate analyses by birth cohort revealed a non-significantly higher incidence in the subgroup born from 1926 to 1934 (HR = 1.30, 95% CI = 0.62-2.76). Delay in menarche among women remaining in Guernsey during the Occupation, rather than being protective, was associated with an increased risk of breast cancer.

Transient caloric restriction and cancer risk (The Netherlands)

Over the past century, many animal experiments have shown that caloric restriction can reduce the risk of cancer, a finding that proved to be highly reproducible. Many papers have been published on its potential for human health, but until know little evidence is available on its actual effects in humans. In Utrecht, The Netherlands, we have been investigating the effects of the 1944–1945 Dutch famine on breast cancer risk factors and breast cancer risk, and paradoxically the relatively short-term famine seemed to be related to increased breast cancer risk in later life. One of the differences between the famine situation and the large body of evidence from animal experiments is the duration of caloric restriction. Almost all animal experiments investigated sustained caloric restriction and information on the effects of short-term transient caloric restriction is very scarce. A search in the literature identified some animal experiments on short-term transient caloric restriction and these seemed to be at least supportive to the famine findings. Because caloric restriction in humans for preventive health measures would be mostly short-term, it is important to extend animal research on short-term caloric restriction.

Energy balance and breast cancer risk: a prospective cohort study

While there is evidence that breast cancer risk is positively associated with body mass index (in postmenopausal women) and energy intake and inversely associated with physical activity, few studies have examined breast cancer risk in association with energy balance, the balance between energy intake and expenditure. Therefore, in the cohort study reported here, we studied the independent and combined associations of vigorous physical activity, energy consumption, and body mass index (BMI), with breast cancer risk. The investigation was conducted in 49,613 Canadian women who were participants in the National Breast Screening Study (NBSS) and who completed self-administered lifestyle and food frequency questionnaires between 1980 and 1985. Linkages to national mortality and cancer databases yielded data on deaths and cancer incidence, with follow-up ending between 1998 and 2000. During a mean 16.4 years of follow-up, we observed 2545 incident breast cancer cases. Due to exclusions for various reasons, the analyses were based on 40,318 subjects amongst whom there were 1673 incident cases of breast cancer. Participation in vigorous physical activity and body mass index were not independently associated with breast cancer risk in the total cohort. A statistically significant positive trend was observed, however, between energy intake and breast cancer risk (P (trend )= 0.01). Although there was some variation in risk associated with vigorous physical activity, and BMI when the analyses were stratified by menopausal status, these interactions were not statistically significant. The interaction between menopausal status and energy intake, however, was of borderline statistical significance (P (interaction )= 0.06), with a statistically significant increased risk of breast cancer associated with highest versus lowest quartile of energy intake among premenopausal women (Hazard Ratio [HR] = 1.45, 95% confidence interval [CI] = 1.13- 1.85, P (trend) = 0.001). There was evidence of an increased risk of breast cancer associated with a relatively high body mass index among postmenopausal women in the highest quartile level of energy intake (Hazard Ratio [HR] = 1.72, 95% confidence interval [CI] = 1.01- 2.93, P (trend) = 0.05). In addition, there was evidence of an increased risk of breast cancer among premenopausal, physically inactive, overweight/obese women who consumed > or =1972 kcal/day compared to physically active normal weight women who consumed <1972 kcal/day (HR = 1.60, 95% CI = 1.08-2.37). Our data suggest that obese premenopausal women with relatively high energy intake may be at increased risk of breast cancer. In addition, energy imbalance, represented by a relatively high energy intake, lack of participation in vigorous physical activity, and a relatively high body mass index, may be associated with increased breast cancer risk, particularly among premenopausal women.

The 1944-1945 Dutch famine and subsequent overall cancer incidence

Caloric restriction seems to be the most potent dietary intervention to protect against a variety of cancers in animals. We investigated whether overall cancer risk is affected in humans after exposure to a brief famine, followed by a period of abundance. We used data of approximately 15,000 women who were exposed at various degrees to the 1944-1945 Dutch famine at ages between 2 and 33 years. Between 1983 and 1986, these women were asked about their individual experiences of famine exposure ("absent," "moderate," or "severe exposure"). During follow-up until January 2000, 1,602 new cancer cases were identified by the regional cancer registry. We assessed the relation between famine and total cancer risk by weighted Cox regression models, in which a 15% random sample was used to represent person-years lived in the entire cohort. In these models, we adjusted for potential confounders. Overall cancer risk was increased in women having been severely famine exposed compared with women having been unexposed (hazard ratio, 1.25; 95% confidence interval, 1.01-1.55). Exclusion of breast cancer cases from our analyses showed that this increase in risk was largely driven by the previously reported increase in breast cancer risk: women who were severely exposed to the famine were at a 1.12 (95% confidence interval, 0.87-1.43) times increased risk of non-breast cancer compared with the unexposed. In conclusion, we found no indications that this brief famine has affected overall cancer risk, exclusive of breast cancer. Counteracting increased caloric intake following the famine, however, may have obscured any relation.

Phobic memory and somatic vulnerabilities in anorexia nervosa: a necessary unity?

Anorexia nervosa is a clinically significant illness that may be associated with permanent medical complications involving almost every organ system. The paper raises a question whether some of them are associated with premorbid vulnerability such as subcellular ion channel abnormalities ('channelopathy') that determines the clinical expression of the bodily response to self-imposed malnutrition. Aberrant channels emerge as a tempting, if rather speculative alternative to the notion of cognitively-driven neurotransmitter modulation deficit in anorexia nervosa. The concept of channelopathies is in keeping with some characteristics of anorexia nervosa, such as a genetically-based predisposition to hypophagia, early onset, cardiac abnormalities, an appetite-enhancing efficacy of some antiepileptic drugs, and others. The purpose of this article is to stimulate further basic research of ion channel biophysics in relation to restrictive anorexia.

Breast cancer and the brain: a neurodevelopmental hypothesis to explain the opposing effects of caloric deprivation during the Dutch famine of 1944-1945 on breast cancer and its risk factors

Most studies on calorie deprivation and cancer risk in rodents show reductions in tumor occurrence. However, the few human studies on calorie restriction are conflicting. An overview is given of results in the DOM (diagnostic onderzoek mammacarcinoom) cohorts among women exposed to the Dutch Famine of 1944-1945. Opposing effects were found on risk factors (shortening of leg length, later menarche, and earlier menopause), whereas urinary estrogens and plasma insulin-like growth factor (IGF)-1 and IGF binding protein-3 were increased, as was breast cancer itself. Exposure between 2 and 10 y old was an unexpected window of susceptibility to the effects of calorie deprivation. The effects of famine exposure were most clearly seen in women who never gave birth. These opposing observations can be explained by a neurodevelopmental hypothesis on set-point shifts at the level of the diencephalons/hypothalamus, either directly or from rebound effects. Such a mechanism reflects old evolutionary adaptation systems in lower and higher organisms to cope with periods of stress and famine by adjusting, for example, reproductive functions. These effects in exposed women may later also affect their unexposed offspring. This hypothesis provides several testable, hormone-mediated corollaries on the relationships between the role of calories in a Westernized lifestyle and human cancer risk. The underlying developmental perspective, as opposed to a risk factor approach, can explain why certain ages, even before breast development, are especially sensitive to effects of large fluctuations in calories. The observations presented may have implications for preventive strategies such as promoting moderation of calorie intake to curb cancer risks.

Breast cancer risk after caloric restriction during the 1944-1945 Dutch famine

BACKGROUND

Data from animal models suggest that caloric restriction may reduce the risk of breast cancer, although not all dietary regimens produce similar effects. We examined whether caloric restriction imposed as a consequence of the 1944-1945 Dutch famine reduced the risk of breast cancer in women participating in a Dutch breast cancer screening program.

METHODS

Between 1983 and 1986, approximately 15 000 women, aged 2 to 33 years during the 1944-1945 Dutch famine, responded to a questionnaire about their famine experience. A famine exposure score, graded as absent, moderate, or severe exposure, was derived from answers regarding hunger, cold, and weight loss. During follow-up until January 2000, 585 women with incident breast cancer were identified by the regional cancer registry. The relationship between famine exposure and breast cancer risk was assessed by weighted Cox regression models, in which person-years lived for the entire cohort was extrapolated from data from a random sample of 15% of the cohort.

RESULTS

Women who were severely exposed to the famine had a statistically significantly higher risk of breast cancer (hazard ratio [HR] = 1.48, 95% confidence interval [CI] = 1.09 to 2.01) than women who were not exposed. Women who were moderately exposed to the famine had a 13% increased risk of breast cancer (HR = 1.13, 95% CI = 0.92 to 1.38; P(trend) = 0.016). The association between famine exposure and breast cancer risk was stronger for women who were exposed between the ages of 2 and 9 years (severely exposed versus unexposed: HR = 2.01, 95% CI = 0.92 to 4.41) than for women who were exposed at older ages.

CONCLUSIONS

The risk of breast cancer was increased in women who were severely exposed to a short but severe famine decades earlier. This result is compatible with data from the few animal studies investigating effects of short-term, transient caloric restriction.