The endocrine manifestations of anorexia nervosa: mechanisms and management

Associations between appetite loss and clinical features as well as inflammatory cytokines in adolescents with major depressive disorder

Background

Appetite loss is common in major depressive disorder (MDD). However, the psychosocial and biological mechanisms behind appetite loss remain unclear, particularly in the adolescent MDD population. Therefore, this study aimed to examine the links between appetite loss and clinical symptoms as well as inflammatory cytokines levels in this population.

Methods

Between January and December 2021, this study included 171 depressed adolescents. A range of scales were used to assess the patients' clinical symptoms, including depression severity, negative life events, insomnia, and alexithymia. Additionally, plasma inflammatory cytokines levels were measured, including interleukin (IL)-1β, IL-6, IL-10, IL-17A and tumor necrosis factor-α (TNF-α).

Results

The prevalence of appetite loss among adolescents with MDD was as high as 76.0%. Univariate analyses showed that patients with appetite loss had higher scores of the Hamilton Depression Scale (HAMD), interpersonal relationships, study pressure, punishment, sense of loss, the Insomnia Severity Index Scale (ISI) and difficulty identifying feelings, as well as higher levels of Log IL-6 (all p < 0.05) Furthermore, regression analyses revealed that appetite loss was independently associated with HAMD score (OR = 1.158, 95% CI = 1.091-1.229, p < 0.001), punishment score (OR = 1.117, 95% CI = 1.039-1.201, p = 0.003), and Log IL-6 level (OR = 5.041, 95% CI = 1.137-22.344, p = 0.033).

Conclusion

Adolescents with MDD face an elevated risk of appetite loss, which may correlate with clinical symptoms such as depression severity and negative life events, as well as elevated IL-6 level. Healthcare professionals should target these risk factors, including inflammation, to mitigate appetite loss.

Metabolic Signalling Peptides and Their Relation to Clinical and Demographic Characteristics in Acute and Recovered Females with Anorexia Nervosa

Background/Objectives: Recent research has established that metabolic factors may increase the vulnerability to develop anorexia nervosa (AN). The aim of this study was to explore the serum concentrations of leptin, insulin-like growth factor-1 (IGF-1), insulin and insulin receptor substrate (IRS-1) as possible state or trait biomarkers for AN in the acute and recovery (recAN) phases. Our secondary aim was to test associations between the tested markers and demographic and clinical characteristics. Methods: This cross-sectional study included data from 56 participants with AN, 24 recAN participants and 51 healthy controls (HCs). Enzyme-linked immunosorbent assays (ELISAs) were used to quantify serum concentrations of leptin, IGF-1, insulin and IRS-1. An analysis of covariance (ANCOVA) and linear regression models were utilised to test our results. Results: There were significant differences with a large effect size between the groups for serum leptin (p < 0.001; d = 0.80), whereby people with AN had lower leptin than those with recAN (p = 0.023; d = 0.35) and HCs (p < 0.001; d = 0.74). The between-group comparison of IGF-1 did not reach significance, although the effect size was moderate (d = 0.6) and was driven by lower levels of IGF-1 in people with acute AN compared to HCs (p = 0.036; d = 0.53). Serum insulin and IRS-1 did not differ between groups. Conclusions: Low leptin levels seen in individuals with AN may be due to starvation leading to fatty tissue depletion. Understanding the regulation of IGF-1 and insulin signalling over the course of the disorder requires further investigation.

The Effect of Preadmission Energy Balance on Short-Term Medical Outcomes: Findings From the Study of Refeeding to Optimize Inpatient Gains

PURPOSE

Caloric restriction and excessive exercise create an energy imbalance with medical sequelae in restrictive eating disorders. We examined the effect of acute and chronic energy imbalance on admission illness severity and refeeding outcomes in adolescents and young adults with anorexia nervosa (AN) and atypical AN.

METHODS

Secondary data analysis from the Study of Refeeding to Optimize Inpatient Gains, a multicenter randomized trial comparing higher- versus lower-calorie refeeding in 120 youth with AN or atypical AN hospitalized with medical instability. Vital signs were measured daily. Acute energy balance was calculated as caloric output (exercise recall plus estimated resting energy expenditure) subtracted from caloric input (dietary recall) before admission. Chronic energy imbalance variables included magnitude, rate, and duration of weight loss before admission. Regression analyses examined associations among energy balance, illness severity, and refeeding outcomes; dominance analyses examined the relative importance of energy balance.

RESULTS

Among 82 participants (91% female), admission mean (SD) age was 16.5 (2.5) years, %median body mass index was 85 (10) and acute energy balance was -898 (678) kilocalories. Those with more negative acute energy balance before admission required more days (-0.18, [95% CI, -0.35, -0.02] p = .03) and kilocalories to restore medical stability (-431.10, [95% CI, -857.06, -5.13] p = .047). Acute energy balance was a more important predictor than weight suppression in determining these outcomes.

DISCUSSION

More acute negative energy balance was associated with a need for more intensive refeeding, which supports the inclusion of preadmission dietary recall and exercise assessments, alongside weight history, to inform individualized refeeding protocols.

The lipocalin saga: Insights into its role in cancer-associated cachexia

Cancer-associated cachexia (CAC) is a debilitating condition, observed in patients with advanced stages of cancer. It is marked by ongoing weight loss, weakness, and nutritional impairment. Lower tolerance of chemotherapeutic agents and radiation therapy makes it difficult to treat CAC. Anorexia is a significant contributor to worsening CAC. Anorexia can be found in the early or advanced stages of cancer. Anorexia in cancer patients arises from a confluence of factors. Tumor-related inflammatory cytokines can directly impact the gastrointestinal tract, leading to dysphagia and compromised gut function. Additionally, increased serotonin and hormonal disruptions lead to early satiety, suppressing appetite. Due to the complexities in the pathogenesis of the disease, identifying druggable targets is a challenge. Research is ongoing to identify novel targets for the treatment of this condition. Recent research suggests a potential link between elevated levels of Lipocalin 2 (LCN2) and cachexia in cancer patients. LCN2, a glycoprotein primarily released by neutrophils, is implicated in numerous illnesses, including skin disorders, cancer, atherosclerosis, and type 2 diabetes. LCN2 suppresses hunger by binding to the melanocortin-4 receptors. Several in vitro, in vivo, and clinical studies indicate the association between LCN2 levels and appetite suppression. Further research should be explored emphasizing the significance of well-crafted clinical trials to confirm LCN2's usefulness as a therapeutic target and its ability to help cancer patients who are suffering from the fatal hallmark of cachexia. This review explores LCN2's function in the multifaceted dynamics of CAC and anorexia.

A scoping review of circulating peptides assessments in anorexia nervosa: Uncovering diversity and nuanced findings

Understanding biological mechanisms underlying anorexia nervosa (AN) is necessary to develop care strategies. Despite many articles dedicated to peptides assessment in AN, there is no systematic review. A scoping review of circulating peptides published in relation to AN, comparing their results with those of controls, was conducted. Embase and PubMed databases were search from 1966 to 2022 (PROSPERO CRD42022323716). All original English articles, assessing peptides in AN (except classical markers) were analyzed. 1151 studies for 207 peptides, in 486 published articles were selected, and evidences/trends in AN were compared to controls. Fifteen clusters of function gathering peptides covering physiopathological aspects of AN were identified. This scoping review revealed a large variety of circulating peptides explored in AN. Some peptides presented with convincing results and helped understanding pathophysiologic aspects. Other peptides presented with nuanced results, partly due to insufficient number of studies, multiple assay techniques, inadequate sampling time, and lack of phenotyping. Conversion from bench-to-bed remains difficult and may explain why peptides evaluations did not currently lead to specific international recommendations or tailored therapeutic/preventive strategies. Peptide evaluation in anorexia nervosa could explore secretion profiles, and test it in well-phenotyped patients with AN, to conclude for potential clinical use, and finally design therapeutic tests.

Gut-derived appetite regulating hormones across the anorexia nervosa spectrum

BACKGROUND

Appetite-regulating hormones are implicated in anorexia nervosa (AN) pathophysiology, however, data are limited for appetite-regulating hormones across the AN weight spectrum. We aimed to investigate fasting and post-prandial concentrations of appetite-regulating hormones - peptide YY (PYY), cholecystokinin (CCK), and ghrelin - among adolescent and young adult females across the AN weight spectrum, specifically those with AN and Atypical AN, and healthy controls (HC).

METHODS

Participants (N = 95; ages 11-22 years) included 33 with AN, 25 with Atypical AN, and 37 HC. AN was differentiated from Atypical AN by BMI < 10th percentile for age and sex (if <18 years) or < 18.5 kg/m2(if ≥18 years). Blood samples were collected fasting and 30, 60 and 120 minutes following a standardized meal to assess total PYY, CCK, and total ghrelin concentrations.

RESULTS

Median fasting and post-prandial PYY concentrations were significantly higher in AN vs. HC with medium differences (p = .001-.006, r = .34-.43). Atypical AN had significantly higher PYY concentrations compared to HC at T-0 (p = .027, r = .29) only, and did not significantly differ from concentrations in AN (p = .105-.413, r = .11-.22). Area under the curve (AUC; p = .001; r = .41) and peak PYY concentrations (p = .003; r = .41) were also significantly higher in AN vs. HC with medium differences. There were no significant differences in fasting (p = .885) or post-prandial (p = .846-.993) CCK concentrations across groups. AN and Atypical AN each had significantly higher ghrelin concentrations than HC with small to medium effect (AN vs HC p = .004-.025, r = .27-.36; Atypical AN vs HC p = .004-.033; r = .28-.28).

CONCLUSIONS

Higher peak postprandial concentrations of anorexigenic PYY in AN (compared to HC) may facilitate dietary restriction and contribute to maintenance of lower weight. Lack of CCK suppression in AN is maladaptive in the context of undernutrition. Despite continued restriction, ghrelin is adaptively higher in AN overall and may not be differentiated by weight status.

Brain network alterations in anorexia Nervosa: A Multi-Center structural connectivity study

Anorexia nervosa (AN) is a severe eating disorder characterized by intense fear of weight gain, distorted body image, and extreme food restriction. This research employed advanced diffusion MRI techniques including single-shell 3-tissue constrained spherical deconvolution, anatomically constrained tractography, and spherical deconvolution informed filtering of tractograms to analyze brain network alterations in AN. Diffusion MRI data from 81 AN patients and 98 healthy controls were obtained. The structural brain connectome was constructed based on nodes set in 84 brain regions, and graph theory analysis was conducted. Results showed that AN patients exhibited significantly higher clustering coefficient and local efficiency in several brain regions, including the left fusiform gyrus, bilateral orbitofrontal cortex, right entorhinal cortex, right lateral occipital gyrus, right superior temporal gyrus, and right insula. A trend towards higher global efficiency and small-worldness was also observed in AN patients, although not statistically significant. These findings suggest increased local connectivity and efficiency within regions associated with behavioral rigidity, emotional regulation, and disturbed body image among AN patients. This study contributes to the understanding of the neurological basis of AN by highlighting structural connectivity alterations in specific brain regions.

Blood Parameters in Children and Adolescents With Underweight and Atypical Anorexia Nervosa

OBJECTIVE

This study aimed to identify biochemical, hematological, and endocrinological abnormalities in a sample of children and adolescents with underweight AN and atypical AN and to compare these results between the two groups.

METHOD

Based on the 5th BMI-percentile admission, adolescents with underweight AN (n = 520) and atypical AN (n = 255) were included and medical records were reviewed.

RESULTS

Low prealbumin (35%) and neutropenia (39%), and several abnormalities in endocrinological parameters (50%) were the most common alterations found in the whole sample. Compared to the atypical AN group, the underweight AN group had significantly higher frequencies of elevated cholesterol (OR = 2.50; p < 0.001) and alanine aminotransferase (OR = 0.22; p = 0.005) and of reduced insulin-like growth (IGF) factor-1 (OR = 0.29; p < 0.001), T3 (OR = 0.46; p < 0.001), luteinizing hormone (OR = 0.24; p < 0.001), follicle stimulating hormone (OR = 0.58; p = 0.004), and 17b-estradiol (OR = 0.39; p < 0.001). However, other blood parameters showed similar alterations in both groups.

DISCUSSION

Both groups showed abnormalities in the same blood parameters, but some abnormal parameters were more common in the underweight AN group. These results suggest that atypical AN and underweight AN could present similar risks of certain medical complications.

Causal effects of gut microbiota, metabolites, immune cells, liposomes, and inflammatory proteins on anorexia nervosa: A mediation joint multi-omics Mendelian randomization analysis

BACKGROUND

Anorexia nervosa (AN) is a significant psychological disorder influenced by environmental and genetic elements. Emerging research highlights the pivotal role of the gut microbiome in the development of diverse mental health conditions. This study aims to explore the causal effects and interactions of the gut microbiome, metabolites, immune cells, lipids, and inflammatory proteins on the risk of anorexia nervosa through mediation and multi-omics Mendelian Randomization (MR) analysis.

METHODS

This study used data from the FinnGen genome-wide association study (GWAS) of AN (N = 402,625), integrated with GWAS data on 473 of gut microbiota (N = 5959), 233 metabolites (N = 136,016), 731 immune cells (N = 3757), 179 lipids (N = 7174), and 91 inflammatory proteins (N = 14,824). This study used the univariate MR (UVMR), mediation MR analysis, and sensitivity analysis to assess the potential causal associations between these biomarkers and AN.

RESULTS

The inverse variance weighted (IVW) results suggest that 25 gut microbiota have causal effects on AN. Firmicutes E (OR: 0.294, 95 % CI: 0.107-0.806, P = 0.017), RUG147 (OR: 0.386, 95 % CI: 0.151-0.990, P = 0.048), CAG-977 (OR: 0.562, 95 % CI: 0.378-0.837, P = 0.005), Desulfobacterota A (OR: 0.651, 95 % CI: 0.466-0.909, P = 0.012), CAG-269 sp002372935 (OR: 0.673, 95 % CI: 0.483-0.937, P = 0.019), Klebsiella (OR: 0.684, 95 % CI: 0.566-0.827, P = 0.00009), Desulfovibrionia (OR: 0.706, 95 % CI: 0.538-0.926, P = 0.012), Klebsiella pneumoniae (OR: 0.737, 95 % CI: 0.600-0.906, P = 0.004), Desulfovibrionales (OR: 0.786, 95 % CI: 0.631-0.979, P = 0.031), CAG-776 (OR: 0.787, 95 % CI: 0.632-0.980, P = 0.032), Desulfovibrionaceae (OR: 0.788, 95 % CI: 0.635-0.978, P = 0.030). 13 gut microbiota were risk factors for AN, including Parachlamydiales (OR: 3.134，95%CI: 1.185-8.287, P = 0.021), Paenibacillus J (OR: 2.366，95%CI: 1.305-4.29, P = 0.005), Gillisia (OR: 1.947，95%CI: 1.135-3.339, P = 0.016), UBA1191 (OR: 1.856，95%CI: 1.221-2.822, P = 0.004), UBA7703 (OR: 1.843，95%CI: 1.032-3.289, P = 0.039), Faecalicatena sp002161355 (OR: 1.788，95%CI: 1.114-2.870, P = 0.016), Johnsonella ignava (OR: 1.742，95%CI: 1.031-2.944, P = 0.038), Staphylococcus aureus (OR: 1.614, 95%CI: 1.007-2.588, P = 0.047), Comamonas (OR: 1.522，95%CI: 1.004-2.307, P = 0.048), Ruminococcus D (OR: 1.24，95%CI: 1.050-1.464, P = 0.011), CAG-349 (OR: 1.198，95%CI: 1.048-1.370, P = 0.008), Ruminococcus D bicirculans (OR: 1.175，95%CI: 1.001-1.379, P = 0.048), CAG-177 (OR: 1.272，95%CI: 1.077-1.503, P = 0.005). Reverse MR analysis showed that causal effect of AN on 18 gut microbiota, but to a lesser extent. 12 metabolites have causal effects on AN. There are 7 protective factors, including glucose levels (OR: 0.700, 95%CI: 0.550-0.893, P = 0.004), isoleucine levels (OR: 0.769, 95%CI: 0.602-0.983, P = 0.036), phospholipids in large VLDL (OR: 0.856, 95%CI: 0.736-0.996, P = 0.044), total lipids in large VLDL (OR: 0.860, 95%CI: 0.740-0.999, P = 0.049), total lipids in small VLDL (OR: 0.863, 95%CI: 0.751-0.992, P = 0.038), free cholesterol in small VLDL (OR: 0.86, 95%CI: 0.752-0.996, P = 0.044), and free cholesterol in medium VLDL (OR: 0.866, 95%CI: 0.752-0.998, P = 0.047). There are 5 risk factors, including estimated degree of unsaturation (OR: 1.174, 95%CI: 1.009-1.367, P = 0.039), free cholesterol to total lipids ratio in small VLDL (OR: 1.199, 95%CI: 1.017-1.414, P = 0.031), phospholipids to total lipids ratio in small VLDL (OR: 1.216, 95%CI: 1.008-1.467, P = 0.041), total cholesterol levels in small HDL (OR: 1.241, 95%CI: 1.008-1.530, P = 0.042), and phospholipids to total lipids ratio in medium VLDL (OR: 1.280, 95%CI: 1.055-1.553, P = 0.012). Reverse MR analysis showed that AN had a causal effect on 15 metabolites. Mediation analysis reveals that the estimated degree of unsaturation mediates 0.69 % of the effect of Klebsiella pneumoniae on AN. Total lipids in small VLDL mediate 0.358 % of the effect of CAG-177 on AN, with a mediated proportion of 1.490 %. The mediation proportions for Estimated degree of unsaturation and Total lipids in small VLDL are relatively small. 36 immune cells have causal effects on AN. There are 7 protective factors, including Switched memory B cells %B cell (OR: 0.892，95%CI: 0.801-0.994, P = 0.038), CD127-CD8+ T cell absolute count (OR: 0.888，95%CI: 0.789-1.000, P = 0.049), IgD + CD24- B cell (OR: 0.917，95%CI: 0.862-0.975, P = 0.006), HVEM+ T cell (OR: 0.945，95%CI: 0.894-0.999, P = 0.045), CD40 + CD14 + CD16- monocyte (OR: 0.937，95%CI: 0.882-0.996, P = 0.038), CD64 + CD14 + CD16- monocyte (OR: 0.966，95%CI: 0.939-0.993, P = 0.016), CD8+ natural killer T cells (OR: 0.911，95%CI: 0.836-0.992, P = 0.032), HLA-DR+ T cells (OR: 0.921，95%CI: 0.866-0.980, P = 0.010), CD28-CD8+ T cells (OR: 0.886，95%CI: 0.792-0.991, P = 0.034). There are 26 risk factors. Reverse MR analysis showed that AN had a causal effect on 31 immune cells. AN increases the expression levels of five types of immune cells, including CD40 + CD14-CD16+ monocytes (OR: 1.087，95%CI: 1.004-1.177, P = 0.041), PDL-1+ CD14-CD16+ monocytes (OR: 1.082，95%CI: 1.002-1.168, P = 0.046), CD45+ CD33dim HLA-DR+ cells (OR: 1.145，95%CI: 1.019-1.287, P = 0.023), CD45+ basophils (OR: 1.164，95%CI: 1.036-1.307, P = 0.011), CD8+ natural killer T cells (OR: 1.102, 95%CI: 1.015-1.196, P = 0.020), and also decreases the expression levels of 26 immune cells. 6 liposomes showed exhibit protective effects against AN, including phosphatidylcholine (18:0_20:3) levels (OR: 0.852, 95%CI: 0.740-0.981, P = 0.026), phosphatidylcholine (O-18:2_18:1) levels (OR: 0.800, 95%CI: 0.672-0.952, P = 0.012), phosphatidylinositol (18:0_18:1) levels (OR: 0.873, 95%CI: 0.773-0.986, P = 0.029), phosphatidylinositol (18:1_18:2) levels (OR: 0.844, 95%CI: 0.734-0.971, P = 0.018), sphingomyelin (d38:1) levels (OR: 0.903，95%CI: 0.820-0.995, P = 0.039), and triacylglycerol (56:4) levels (OR: 0.786, 95%CI: 0.660-0.936, P = 0.007). There are 3 risk factors, including diacylglycerol (16:1_18:1) levels (OR: 1.208, 95%CI: 1.040-1.404, P = 0.014), phosphatidylcholine (18:1_18:3) levels (OR: 1.237, 95%CI: 1.003-1.526, P = 0.047), and phosphatidylinositol (16:0_20:4) levels (OR: 1.148, 95%CI: 1.003-1.314, P = 0.045). Reverse MR analysis showed that AN had a causal effect on 3 phosphatidylcholine (15:0_18:2) levels (OR: 1.075, 95%CI: 1.001-1.154, P = 0.048), phosphatidylcholine (O-16:2_18:0) levels (OR: 1.078, 95%CI: 1.002-1.159, P = 0.043), and triacylglycerol (51:1) levels (OR: 0.919, 95%CI: 0.850-0.994, P = 0.035). 6 inflammatory proteins have causal effects on AN, with protective factors including Glial cell line-derived neurotrophic factor levels (OR: 0.822，95%CI: 0.692-0.978, P = 0.027) and Interleukin-15 receptor subunit alpha levels (OR: 0.886, 95%CI: 0.789-0.995, P = 0.041) and risk factors including CC motif chemokine 4 levels (OR: 1.126, 95%CI: 1.011-1.254, P = 0.031), Interleukin-12 subunit beta levels (OR: 1.135, 95%CI: 1.033-1.248, P = 0.008), Monocyte chemoattractant protein-1 levels (OR: 1.152, 95%CI: 1.010-1.314, P = 0.035), and Sulfotransferase 1A1 levels (OR: 1.166, 95%CI: 1.006-1.351, P = 0.042). Reverse MR analysis showed that AN had a causal effect on Transforming growth factor-alpha (OR: 1.054，95%CI: 1.010-1.101, P = 0.016).

CONCLUSIONS

This study used large-scale and novel GWAS data, for the first time reveals through mediation analysis and multi-omics MR analysis the roles of gut microbiota, metabolites, immune cells, lipids, and inflammatory proteins in the pathogenesis of AN. These findings provide new biomarkers and targets for further prevention and treatment strategies.

Hypothalamic-pituitary-adrenal axis in anorexia nervosa; an underestimated endocrine dysfunction among adolescents

In patients affected by anorexia nervosa (AN) different endocrine abnormalities have been described, but, among them, hypothalamic-pituitary-adrenal (HPA) dysfunction, although associated to important side effects, is underestimated and has no therapeutical options. We present a narrative literature review to investigate the HPA axis in patients with AN, in order to highlight HPA dysfunction and its effects. We also described the crucial role of HPA monitoring, and to consider eventual therapeutic and preventive strategies in AN patients. The literature now available demonstrates that women and girls suffering from AN have higher measures of cortisol and lower levels of androgens as compared to controls. These endocrinological disturbances have deleterious effects on the subjects, both from the physical and from the psychological point of view. It's fundamental for physicians to consider these aspects when assessing AN patients. The mechanisms behind the adrenocortical dysfunctions in eating disorders patients remain an open question and there are no available treatments, thus research on this issue would be extremely useful and highly necessary, especially in the pediatric field.

Pharmacotherapeutic strategies for the treatment of anorexia nervosa - novel targets to break a vicious cycle

INTRODUCTION

Anorexia nervosa (AN) has one of the highest mortality rates of all mental illnesses. No approved pharmacological treatments exist for AN, but novel neurobiological targets show promise.

AREAS COVERED

Studies show that in individuals with AN, there are alterations in brain neurotransmitter signaling, alongside associated mental rigidity and comorbid anxiety and depression. Available and new therapies could be used to improve alterations in neurobiology and behavior. This narrative review serves as a review of previously published literature assessing the efficacy of traditional pharmacotherapy in treating AN while also exploring novel treatments, including dissociative anesthetics, psychedelics, cannabinoids, hormones, neurosteroids, and ketogenic nutrition.

EXPERT OPINION

If best practice psychotherapeutic interventions have failed, we recommend a neuroscience and brain research-based medication approach that targets dopamine neurotransmitter receptors to enhance cognitive flexibility and illness insight while reducing dread and avoidance toward food. It is furthermore essential to recognize and treat comorbid conditions such as anxiety, depression, or obsessive-compulsive disorder as they interfere with recovery, and typically do not resolve even with successful AN treatment. Novel strategies have the promise to show efficacy in improving mood and reducing specific AN psychopathology with hopes to be used in clinical practice soon.

Subtyping of Cushing's Syndrome: A Step Ahead

Cushing's Syndrome (CS) is a rare disease due to chronic endogenous cortisol secretion. In recent years, new developments have broadened the spectrum of differential diagnosis, traditionally categorized as adrenocorticotropic hormone (ACTH)-dependent and ACTH-independent forms. Moreover, increased awareness of the detrimental effects of cortisol on cardiometabolic health and the risk of cardiovascular events lead to increased diagnosis of mild forms, especially in the context of adrenal incidentalomas.This review provides an up-to-date narrative of the most recent literature regarding the challenges of CS diagnosis. After the description of the diagnostic tools available, the functional non-neoplastic hypercortisolism (formerly known as pseudo-Cushing state) is characterized, followed by the subtyping of the different conditions of hypercortisolism, including the differential diagnosis of ACTH-dependent forms and the management of adrenal hypercortisolism, with peculiar attention to the new genetic classification of adrenal CS, mild autonomous cortisol secretion, and bilateral adrenal adenomas.

[Case Report of a 14-Year-Old Girl with Addison's Disease Under Initial Presumptive Diagnosis of Anorexia Nervosa: Confusingly Similar and Yet so Different?]

Case Report of a 14-Year-Old Girl with Addison's Disease Under Initial Presumptive Diagnosis of Anorexia Nervosa: Confusingly Similar and Yet so Different? Abstract: Objective: Primary adrenal insufficiency (Addison's disease) is a rare differential diagnosis of anorexia nervosa. This case report presents important differential diagnostic aspects. Methods: We prepared a case report of a 14-year-old female patient according to the CARE guidelines, taking the patient's and the child's parents' view into consideration. Results: The diagnosis of primary adrenocortical insufficiency was reached using specific laboratory diagnostics approximately 9 months after the onset of symptoms, including sudden body weight loss. Significant differential diagnostic aspects were the absence of a body schema disorder and skin hyperpigmentation prominent in the physical examination. The patient experienced a high psychosocial burden because of the unclear diagnosis over 9 months. The diagnosis and substitution therapy with hydrocortisone led to a rapid improvement of the physical and psychological symptoms. Conclusions: This case report emphasizes the importance of a thorough somatic differential diagnosis in the context of a suspected anorexia nervosa.

Dietary Patterns of Healthy Underweight Individuals Compared to Normal-BMI Individuals Using Photographic Food Diaries

BACKGROUND

Previously, we found that healthy underweight (HU) subjects, with BMI < 18.5, eat about 12% less food (by calories) each day. It is presently unclear whether this lower intake is associated with them making food choices that provide high satiation and satiety.

METHODS

Using 7-day photographic records of food intake, we analyzed 52 HU and 50 normal-weight participants.

RESULTS

We included 52 HU and 50 normal-weight participants in the final analysis. HU individuals ate 25% fewer calories than normal-weight individuals. Their intake included a higher % of rice (p = 0.0013) and vegetables (p = 0.0006) and a lower % of livestock meat (p = 0.0007), poultry meat (p < 0.0001), and starchy roots (p = 0.0015), compared with the normal-weight population. The percent energy from carbohydrates was significantly higher (p = 0.0234), and the % energy from fat was significantly lower (p < 0.0001) in the HU group, with no difference in the % energy from protein. HU individuals sourced more of their protein from plants. Dietary patterns were grouped into three clusters, with 24 individuals grouped into cluster 1 (87.5% normal-weight population), 28 individuals into cluster 2 (64.3% normal-weight group), and 50 individuals into cluster 3 (78% HU group).

CONCLUSIONS

The HU group ate less overall and had proportionally more rice and vegetables and less poultry and livestock meat, starchy roots, and drinks. With respect to macronutrients, they also ate a greater % carbohydrates and less % fat, and they sourced more of their protein intake from plant sources. HU individuals did not follow a low-carbohydrate lifestyle.

Trajectory of ghrelin and PYY around a test meal in males and females with avoidant/restrictive food intake disorder versus healthy controls

Disruptions in appetite-regulating hormones may contribute to the development and/or maintenance of avoidant/restrictive food intake disorder (ARFID). No study has previously assessed fasting levels of orexigenic ghrelin or anorexigenic peptide YY (PYY), nor their trajectory in response to food intake among youth with ARFID across the weight spectrum. We measured fasting and postprandial (30, 60, 120 minutes post-meal) levels of ghrelin and PYY among 127 males and females with full and subthreshold ARFID (n = 95) and healthy controls (HC; n = 32). We used latent growth curve analyses to examine differences in the trajectories of ghrelin and PYY between ARFID and HC. Fasting levels of ghrelin did not differ in ARFID compared to HC. Among ARFID, ghrelin levels declined more gradually than among HC in the first hour post meal (p =.005), but continued to decline between 60 and 120 minutes post meal, whereas HC plateaued (p =.005). Fasting and PYY trajectory did not differ by group. Findings did not change after adjusting for BMI percentile (M(SD)ARFID = 37(35); M(SD)HC = 53(26); p =.006) or calories consumed during the test meal (M(SD)ARFID = 294(118); M(SD)HC = 384 (48); p <.001). These data highlight a distinct trajectory of ghrelin following a test meal in youth with ARFID. Future research should examine ghrelin dysfunction as an etiological or maintenance factor of ARFID.

Body shape rather than facial emotion of others alters interpersonal distance in patients with anorexia nervosa

OBJECTIVE

The study investigated interpersonal distance in patients with anorexia nervosa (AN), focussing on the role of other's facial expression and morphology, also assessing physiological and subjective responses.

METHOD

Twenty-nine patients with AN and 30 controls (CTL) were exposed to virtual characters either with an angry, neutral, or happy facial expression or with an overweight, normal-weight, or underweight morphology presented either in the near or far space while we recorded electrodermal activity. Participants had to judge their preferred interpersonal distance with the characters and rated them in terms of valence and arousal.

RESULTS

Unlike CTL, patients with AN exhibited heightened electrodermal activity for morphological stimuli only, when presented in the near space. They also preferred larger and smaller interpersonal distances with overweight and underweight characters respectively, although rating both negatively. Finally, and similar to CTL, they preferred larger interpersonal distance with angry than neutral or happy characters.

DISCUSSION

Although patients with AN exhibited behavioural response to emotional stimuli similar to CTL, they lacked corresponding physiological response, indicating emotional blunting towards emotional social stimuli. Moreover, they showed distinct behavioural and physiological adjustments in response to body shape, confirming the specific emotional significance attached to body shape.

Shared Genetic Architecture Between Schizophrenia and Anorexia Nervosa: A Cross-trait Genome-Wide Analysis

BACKGROUND AND HYPOTHESIS

Schizophrenia (SCZ) and anorexia nervosa (AN) are 2 severe and highly heterogeneous disorders showing substantial familial co-aggregation. Genetic factors play a significant role in both disorders, but the shared genetic etiology between them is yet to be investigated.

STUDY DESIGN

Using summary statistics from recent large genome-wide association studies on SCZ (Ncases = 53 386) and AN (Ncases = 16 992), a 2-sample Mendelian randomization analysis was conducted to explore the causal relationship between SCZ and AN. MiXeR was employed to quantify their polygenic overlap. A conditional/conjunctional false discovery rate (condFDR/conjFDR) framework was adopted to identify loci jointly associated with both disorders. Functional annotation and enrichment analyses were performed on the shared loci.

STUDY RESULTS

We observed a cross-trait genetic enrichment, a suggestive bidirectional causal relationship, and a considerable polygenic overlap (Dice coefficient = 62.2%) between SCZ and AN. The proportion of variants with concordant effect directions among all shared variants was 69.9%. Leveraging overlapping genetic associations, we identified 6 novel loci for AN and 33 novel loci for SCZ at condFDR <0.01. At conjFDR <0.05, we identified 10 loci jointly associated with both disorders, implicating multiple genes highly expressed in the cerebellum and pituitary and involved in synapse organization. Particularly, high expression of the shared genes was observed in the hippocampus in adolescence and orbitofrontal cortex during infancy.

CONCLUSIONS

This study provides novel insights into the relationship between SCZ and AN by revealing a shared genetic component and offers a window into their complex etiology.

Medical Considerations and Consequences of Eating Disorders

Eating disorders may result in medical complications that affect every body system with both acute and chronic consequences. Although some medical complications may require acute medical hospitalization to manage, other complications, such as low bone mineral density, may not present until malnutrition has become chronic. It is critical for team members to be aware of the early clinical signs of malnutrition and disordered eating behaviors, as well as longer-term complications that may affect their patients. When identifying eating disorder concerns, appropriate colleagues from the medical, nutrition, and psychiatric fields can be engaged in order to collaborate on stabilizing and improving the health of patients.

Assessing biomarkers of remission in female patients with anorexia nervosa (REMANO): a protocol for a prospective cohort study with a nested case-control study using clinical, neurocognitive, biological, genetic, epigenetic and neuroimaging markers in a French specialised inpatient unit

BACKGROUND

Anorexia nervosa (AN) is a severe psychiatric disorder associated with frequent relapses and variability in treatment responses. Previous literature suggested that such variability is influenced by premorbid vulnerabilities such as abnormalities of the reward system. Several factors may indicate these vulnerabilities, such as neurocognitive markers (tendency to favour delayed reward, poor cognitive flexibility, abnormal decision process), genetic and epigenetic markers, biological and hormonal markers, and physiological markers.The present study will aim to identify markers that can predict body mass index (BMI) stability 6 months after discharge. The secondary aim of this study will be focused on characterising the biological, genetic, epigenetic and neurocognitive markers of remission in AN.

METHODS AND ANALYSIS

One hundred and twenty-five (n=125) female adult inpatients diagnosed with AN will be recruited and evaluated at three different times: at the beginning of hospitalisation, when discharged and 6 months later. Depending on the BMI at the third visit, patients will be split into two groups: stable remission (BMI≥18.5 kg/m²) or unstable remission (BMI<18.5 kg/m²). One hundred (n=100) volunteers will be included as healthy controls.Each visit will consist in self-reported inventories (measuring depression, anxiety, suicidal thoughts and feelings, eating disorders symptoms, exercise addiction and the presence of comorbidities), neurocognitive tasks (Delay Discounting Task, Trail-Making Test, Brixton Test and Slip-of-action Task), the collection of blood samples, the repeated collection of blood samples around a standard meal and MRI scans at rest and while resolving a delay discounting task.Analyses will mainly consist in comparing patients stabilised 6 months later and patients who relapsed during these 6 months.

ETHICS AND DISSEMINATION

Investigators will ask all participants to give written informed consent prior to participation, and all data will be recorded anonymously. The study will be conducted according to ethics recommendations from the Helsinki declaration (World Medical Association, 2013). It was registered on clinicaltrials.gov on 25 August 2020 as 'Remission Factors in Anorexia Nervosa (REMANO)', with the identifier NCT04560517 (for more details, see https://clinicaltrials.gov/ct2/show/record/NCT04560517). The present article is based on the latest protocol version from 29 November 2019. The sponsor, Institut National de la Santé Et de la Recherche Médicale (INSERM, https://www.inserm.fr/), is an academic institution responsible for the monitoring of the study, with an audit planned on a yearly basis.The results will be published after final analysis in the form of scientific articles in peer-reviewed journals and may be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

clinicaltrials.govNCT04560517.

Adaptive Effects of Endocrine Hormones on Metabolism of Macronutrients during Fasting and Starvation: A Scoping Review

Food deprivation can occur for different reasons. Fasting (<24 h duration) occurs to meet religious or well-being goals. Starvation (>1-day duration) occurs when there is intentional (hunger strike or treatment of a medical condition) or unintentional (anorexia nervosa, drought, epidemic famine, war, or natural disaster) food deprivation. A scoping review was undertaken using the PubMed database to explore 1805 abstracts and review 88 eligible full-text articles to explore the adaptive relationships that emerge between cortisol, insulin, glucagon, and thyroid hormones on the metabolic pathways of macronutrients in humans during fasting and starvation. The collected data indicate that fasting and starvation prime the human body to increase cortisol levels and decrease the insulin/glucagon ratio and triiodothyronine (T3) levels. During fasting, increased levels of cortisol and a decreased insulin/glucagon ratio enhance glycogenolysis and reduce the peripheral uptake of glucose and glycogenesis, whereas decreased T3 levels potentially reduce glycogenolysis. During starvation, increased levels of cortisol and a decreased insulin/glucagon ratio enhance lipolysis, proteolysis, fatty acid and amino acid oxidation, ketogenesis, and ureagenesis, and decreased T3 levels reduce thermogenesis. We present a potential crosstalk between T3 and the above hormones, including between T3 and leptin, to extend their adaptive roles in the metabolism of endogenous macronutrients during food deprivation.

Nucleus accumbens D1- and D2-expressing neurons control the balance between feeding and activity-mediated energy expenditure

Accumulating evidence points to dysregulations of the Nucleus Accumbens (NAc) in eating disorders (ED), however its precise contribution to ED symptomatic dimensions remains unclear. Using chemogenetic manipulations in male mice, we found that activity of dopamine D1 receptor-expressing neurons of the NAc core subregion facilitated effort for a food reward as well as voluntary exercise, but decreased food intake, while D2-expressing neurons have opposite effects. These effects are congruent with D2-neurons being more active than D1-neurons during feeding while it is the opposite during running. Chronic manipulations of each subpopulations had limited effects on energy balance. However, repeated activation of D1-neurons combined with inhibition of D2-neurons biased behavior toward activity-related energy expenditure, whilst the opposite manipulations favored energy intake. Strikingly, concomitant activation of D1-neurons and inhibition of D2-neurons precipitated weight loss in anorexia models. These results suggest that dysregulations of NAc dopaminoceptive neurons might be at the core of EDs.

Prevalence, Risk Factors, and Prognostic Value of Anxiety and Depression in Acute Myeloid Leukemia

INTRODUCTION

Limited studies report anxiety and depression prevalence and their correlations with prognosis in acute myeloid leukemia (AML). Even worse, their risk factors for AML remained unclear. This study aimed to investigate the prevalence, risk factors, and prognostic value of anxiety and depression in AML patients.

METHODS

Totally, 132 de novo AML patients, 60 non-malignant hematological disease patients (as disease controls), and 60 healthy controls were enrolled. Anxiety and depression status were evaluated by the Hospital Anxiety and Depression Scale (HADS) in all participants.

RESULTS

HADS-anxiety score (8.2 ± 3.2 vs. 6.1 ± 2.9 vs. 4.7 ± 2.8), anxiety rate (48.5% vs. 25.0% vs. 10.0%), HADS-depression score (7.8 ± 3.0 vs. 5.8 ± 3.0 vs. 4.0 ± 2.8), and depression rate (43.2% vs. 23.3% vs. 8.3%) were highest in AML patients, followed by disease controls, and the lowest in healthy controls (all p < 0.001). Multivariate logistic regression analysis identified that factors independently associated with anxiety included male (p = 0.002, odds ratio [OR] = 0.240), smoking (p = 0.043, OR = 2.474), education duration (p = 0.024, OR = 0.889), and NCCN high-risk stratification (p = 0.008, OR = 2.347), while those independently associated with depression were age (p = 0.005, OR = 1.055), single/divorced/widowed status (p = 0.014, OR = 3.149), NCCN high-risk stratification (p = 0.002, OR = 3.077), and white blood cell (WBC) (p < 0.001, OR = 1.062). Additionally, depression was correlated with shorter accumulating event-free survival (p = 0.012) and overall survival (p = 0.041) in AML patients, whereas anxiety was not.

CONCLUSIONS

Anxiety and depression are prevalent, among which depression is associated with poor survival profile, but anxiety is not; moreover, age, male, education, single/divorced/widowed status, smoking, NCCN high-risk stratification, and WBC were independent related factors of anxiety and depression in AML patients.

[Medical complications in anorexia and bulimia nervosa]

Anorexia nervosa and bulimia nervosa are eating disorders associated with life-threatening multisystemic medical complications. This narrative review aimed to present the medical complications most related to these disorders. In anorexia nervosa, many of them are linked to malnutrition and underweight, usually reversible with renutrition and weight restoration, although refeeding can also be linked to some medical complications. Purging behaviors observed in the anorexia nervosa binge-purging subtype and bulimia nervosa have been mainly related to hydrolectrolyte and acid-base disturbances, in addition to local complications. Thus, an early identification and therapeutic intervention of these disorders is considered crucial. Integral medical monitoring should be ensured to prevent potential serious complications from the early stages, with the involvement of physicians, psychologists, nutritionists, and other specialists in a multidisciplinary approach according to the patient's needs.

Dietary Effects of Fasting on the Lipid Panel

INTRODUCTION

Dietary habits, such as the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH), have been shown to improve cardiac health. Another more recent popular form of dieting incorporates periods of fasting known as intermittent fasting. The two main forms are alternate-day fasting and time-restricted eating.

METHODS

PubMed search and literature review was undertaken. This review evaluates the current literature regarding the effects of the fasting dietary model and other types of fasting upon the lipid panel.

RESULTS

There have been studies that have shown that intermittent fasting does provide a benefit in cardiovascular health, weight loss, and hypertension. However, the effect on cholesterol and triglyceride levels during intermittent fasting is in question.

CONCLUSION

The effect that fasting has on one's lipid panel is unclear, there are studies that show that different forms of fasting affect the lipid panel in various ways. There are studies that show that intermittent fasting does improve one's lipid profile and provides health benefits. Randomized controlled clinical trials with a large sample size are needed to evaluate the effects that intermittent fasting has based on race, ethnicity, gender, obesity, dyslipidemia, diabetic and healthy patients, and will lead to definitive evidence of lipid panel outcomes beyond current evidence based solely upon observational cohorts with numerous and multifactorial confounding factors and biases.

Early traumatic experiences and the hypothalamus-pituitary-adrenal axis in people with eating disorders: A narrative review

Exposure to trauma during childhood is a non-specific risk factor for psychiatric disorders, including eating disorders (EDs), over the life course. Moreover, an association between stressful life events and the onset/maintenance of EDs has been documented. Therefore, the hypothalamus-pituitary-adrenal (HPA) axis, namely the main component of the endogenous stress response system, has been proposed to be implicated in the pathophysiology of EDs. In this narrative review the current knowledge concerning the effects of early trauma exposure on the HPA axis activity and their putative role in the pathophysiology of EDs will be illustrated. Research findings corroborate the idea that childhood trauma exposure has long-lasting dysregulating effects on the activity of the HPA axis, which may contribute to the biological background of the early trauma-related risk for the development of EDs across the life span. Moreover, literature data support the existence of a "maltreated ecophenotype" in EDs characterized by specific clinic and neuroendocrine features, which may have important implications in treatment programming for such a type of patients.

Persistence of gut dysbiosis in individuals with anorexia nervosa

Recent evidence suggests a crucial role of the gut microbiota in the pathogenesis of anorexia nervosa (AN). In this study, we carried out a series of multiple analyses of the gut microbiota of hospitalized individuals with AN over three months using 16S or 23S rRNA-targeted reverse transcription-quantitative polymerase chain reaction (PCR) technology (YIF-SCAN®), which is highly sensitive and enables the precise quantification of viable microorganisms. Despite the weight gain and improvements in psychological features observed during treatment, individuals with AN exhibited persistent gut microbial dysbiosis over the three-month duration. Principal component analysis further underscored the distinct microbial profile of individuals with AN, compared with that of age-matched healthy women at all time points. Regarding the kinetics of bacterial detection, the detection rate of Lactiplantibacillus spp. significantly increased after inpatient treatment. Additionally, the elevation in the Bifidobacterium counts during inpatient treatment was significantly correlated with the subsequent body weight gain after one year. Collectively, these findings suggest that gut dysbiosis in individuals with AN may not be easily restored solely through weight gain, highlighting the potential of therapeutic interventions targeting microbiota via dietary modifications or live biotherapeutics.

Microbiota in anorexia nervosa: potential for treatment

Anorexia nervosa (AN) is characterised by the restriction of energy intake in relation to energy needs and a significantly lowered body weight than normally expected, coupled with an intense fear of gaining weight. Treatment of AN is currently based on psychological and refeeding approaches, but their efficacy remains limited since 40% of patients after 10 years of medical care still present symptoms of AN. The intestine hosts a large community of microorganisms, called the "microbiota", which live in symbiosis with the human host. The gut microbiota of a healthy human is dominated by bacteria from two phyla: Firmicutes and, majorly, Bacteroidetes. However, the proportion in their representation differs on an individual basis and depends on many external factors including medical treatment, geographical location and hereditary, immunological and lifestyle factors. Drastic changes in dietary intake may profoundly impact the composition of the gut microbiota, and the resulting dysbiosis may play a part in the onset and/or maintenance of comorbidities associated with AN, such as gastrointestinal disorders, anxiety and depression, as well as appetite dysregulation. Furthermore, studies have reported the presence of atypical intestinal microbial composition in patients with AN compared with healthy normal-weight controls. This review addresses the current knowledge about the role of the gut microbiota in the pathogenesis and treatment of AN. The review also focuses on the bidirectional interaction between the gastrointestinal tract and the central nervous system (microbiota-gut-brain axis), considering the potential use of the gut microbiota manipulation in the prevention and treatment of AN.

The Impact of Clinical Factors, Vitamin B12 and Total Cholesterol on Severity of Anorexia Nervosa: A Multicentric Cross-Sectional Study

Severe forms of Anorexia Nervosa (AN) are characterized by medical complications, psychiatric comorbidity, and high mortality. This study investigated potential associations between clinical/biological factors and the severity of AN, measured by the Body Mass Index (BMI). Red and white blood cells, hemoglobin, platelets, iron, vitamins D and B12, folate, and total cholesterol were measured in a mixed sample of 78 inpatients and outpatients. Linear regressions and one-way analyses of variance (ANOVAs) were carried out to evaluate the relationship between BMI and clinical/biochemical variables. BMI was significantly lower in hospitalized patients (F = 4.662; p = 0.034) and in those under pharmacological treatment (F = 5.733; p = 0.019) or poly-therapy (F = 5.635; p = 0.021). Higher vitamin B12 (β = -0.556, p < 0.001), total cholesterol (β = -0.320, p = 0.027), and later age at onset (with a trend towards significance) (β = -0.376, p = 0.058) were associated with a lower BMI. Increased total cholesterol and vitamin B12, later age at onset, current pharmacological treatment, and poly-therapy might be distinctive in patients with a lower BMI. In clinical practice, these findings may contribute to the early identification of AN patients at higher risk of developing complicated or chronic forms of the disorder. Further studies on larger samples are needed to identify potential predictive factors of AN severity in the framework of precision medicine.

Similarities and differences regarding acute anorexia nervosa and semi-starvation: does behavioral thermoregulation play a central role?

Objective

To clarify the association between acute anorexia nervosa (AN) and semi-starvation (SS) by focusing on similarities and differences in physiology, mood, and behavior.

Method

A comparison of published literature between these two groups.

Results

Both groups show similar hormonal and metabolic changes in response to caloric restriction and extreme weight loss (~25%). Associated changes result in a reduced body temperature (Tcore-low). Maintenance of body temperature within a specific range is crucial to survival. However, both groups cannot activate autonomic strategies to maintain their Tcore-low, such as increasing metabolic rate, constricting skin blood vessels, or shivering. Furthermore, Tcore-low increases the individuals' "coldness sensations" throughout the body, hence the frequent reports from ANs and SSs of "feeling cold." To eliminate these uncomfortable "coldness sensations" and, importantly, to maintain Tcore-low, ANs, and SSs "select" different thermoregulatory behavioral strategies. It is proposed that the primary differences between AN and SS, based on genetics, now manifest due to the "selection" of different thermo-regulatory behaviors. AN patients (ANs) "select" hyperactive behavior (HyAc), which increases internal metabolic heat and thus assists with maintaining Tcore-low; in harmony with hyperactive behavior is a lively mood. Also related to this elevated arousal pattern, ANs experience disrupted sleep. In contrast, SS individuals "select" a passive thermo-behavioral strategy, "shallow torpor," which includes reduced activity, resulting in energy conservation. In addition, this inactivity aids in the retention of generated metabolic heat. Corresponding to this lethargic behavior, SS individuals display a listless mood and increased sleep.

Conclusion

Initial similarities between the two are attributable to physiological changes related to extreme weight loss. Differences are most likely attributable to genetically programmed "selection" of alternate thermoregulatory strategies, primarily to maintain Tcore-low. However, if acute AN is prolonged and evolves into a chronic condition, AN will more closely align with starvation and more precisely reflect SS symptomology.

The Effect of Transcranial Direct Current Stimulation (tDCS) on Anorexia Nervosa: A Narrative Review

(1) Introduction: Anorexia nervosa (AN) is a severe, debilitating disease with high incidence and high mortality. The methods of treatment used so far are moderately effective. Evidence from neuroimaging studies helps to design modern methods of therapy. One of them is transcranial direct current stimulation (tDCS), a non-invasive brain neuromodulation technique. (2) Methods: The purpose of this narrative review is to bring together all studies investigating the use of tDCS in the treatment of AN and to evaluate its effect and efficiency. Searches were conducted in the Pubmed/Medline, Research Gate, and Cochrane databases. (3) Results: The literature search resulted in five articles. These studies provide preliminary evidence that tDCS has the potential to alter eating behaviour, body weight, and food intake. Additionally, tDCS reduced symptoms of depression. Throughout all trials, stimulation targeted the left dorsolateral prefrontal cortex (DLPFC). Although the number of studies included is limited, attempts were made to elucidate the potential mechanisms underlying tDCS action in individuals with AN. Recommendations for future tDCS research in AN were issued. (4) Conclusions: The included studies have shown that tDCS stimulation of the left DLPFC has a positive effect on AN clinical symptoms and may improve them, as measured by various assessment measures. It is important to conduct more in-depth research on the potential benefits of using tDCS for treating AN. This should entail well-designed studies incorporating advanced neuroimaging techniques, such as fMRI. The aim is to gain a better understanding of how tDCS works in AN.

The causality between gut microbiome and anorexia nervosa: a Mendelian randomization analysis

Background and aim

Nutrient production by intestinal microbiota corresponds to regulate appetite while gut microbial composition was influenced by diet ingestion. However, the causal relationship between gut microbial taxa and anorexia nervosa (AN) remains unclear. Mendelian Randomization (MR) is a novel research method that effectively eliminates the interference of confounding factors and allows for the exploration of the direct causal effects between exposure and outcome. This study employs MR to explore the causal effect between AN and specific gut microbiome.

Methods

Large-scale Genome Wide Association Study (GWAS) data of AN and 211 gut microbes were obtained from the IEU open GWAS project and Mibiogen Consortium. Two-sample MR was performed to determine the causal relationship between gut microbiota and AN. Furthermore, a bi-directional MR analysis was to examine the direction of the causal relations. The Bonferroni correction test was used to adjust potential correlations among microbial taxa.

Result

In forward MR analysis, 10specific gut microbial taxa have an impact on the occurrence of AN (the p value of IVW <0.05). The high abundance of Genus Eubacteriumnodatumgroup ID: 11297 (OR:0.78, 95% CI:0.62-0.98, p = 0.035) and Class Melainabacteria ID: 1589 (OR:0.72, 95% CI:0.51-0.99, p = 0.045) may be considered protective factors for AN. But after Bonferroni correction, only Class Actinobacteria ID:419 (OR:1.53, 95% CI:1.19-1.96, p = 0.00089) remained significantly associated and high abundance of Class Actinobacteria ID:419 considered as a risk factor for AN. In the reverse MR analysis, AN influences 8 gut microbial taxa with none-statistically significant associations after adjustment.

Conclusion

We identified a significant correlation between AN and 18 microbial taxa which have not been previously reported. Among them, 10 kinds of gut bacteria may affect the occurrence of AN, and the status of AN would affect 8 kinds of gut bacteria. After correction, the Class Actinobacteria ID:419 continued to exert an influence on AN.

Comparative and Predictive Analysis of Clinical and Metabolic Features of Anorexia Nervosa and Bulimia Nervosa

Background

Eating disorders have become increasingly prevalent over the years; the age at which they appear has decreased, and they can lead to serious illness or death. Therefore, the number of studies on the matter has increased. Eating disorders like anorexia nervosa (AN) and bulimia nervosa (BN) are affected by many factors including mental illnesses that can have serious physical and psychological consequences. Accordingly, the present study aimed to compare the clinical and metabolic features of patients with AN and BN and identify potential biomarkers for distinguishing between the two disorders.

Methods

Clinical data of 41 participants who sought treatment for eating disorders between 2012 and 2022, including 29 AN patients and 12 BN patients, were obtained from NPIstanbul Brain Hospital in Istanbul, Turkey. The study included the clinical variables of both outpatient and inpatient treatments. Principal component analysis (PCA) was utilized to gain insights into differentiating AN and BN patients based on clinical characteristics, while machine learning techniques were applied to identify eating disorders.

Findings

The study found that thyroid hormone levels in patients with AN and BN were influenced by non-thyroidal illness syndrome (NTIS), which could be attributed to various factors, including psychiatric disorders, substance abuse, and medication use. Lipid profile comparisons revealed higher triglyceride levels in the BN group (P<0.05), indicating increased triglyceride synthesis and storage as an energy source. Liver function tests showed lower levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in BN patients (P<0.05), while higher prolactin levels (P<0.05) suggested an altered hypothalamic-pituitary-gonadal axis. Imbalances in minerals such as calcium and magnesium (P<0.05) were observed in individuals with eating disorders. PCA effectively differentiated AN and BN patients based on clinical features, and the Naïve Bayes (NB) model showed promising results in identifying eating disorders.

Conclusion

The findings of the study provide important insights into AN and BN patients' clinical features and may help guide future research and treatment strategies for these conditions.

Endocrinology of Underweight and Anorexia Nervosa

More than any other mental illness, the course, prognosis, and therapy of anorexia nervosa are shaped by the physical changes associated with being underweight. This article provides an overview of the endocrine changes associated with malnutrition and underweight. This overview serves as a basis for understanding the other articles in this special issue, which deal with the health risks associated with being underweight. In this context, the differences between underweight in anorexia nervosa and in constitutional thinness are of particular importance in assessing the impact of intentional weight loss. In this context, the regulation of hunger and satiety deserves special interest, as this is the area in which the intentional influence on body weight comes into play. Clinical consequences on, for example, fertility, bone metabolism, the homeostasis of, for example, serum glucose levels, or body temperature have been observed for a long time; nonetheless, the medical responses, apart from vitamin supplementations and advice to gain weight, are still limited. Therefore, emphasis was placed on the potential improvement of outcomes through the administration of central or peripheral hormones. Studies were identified on PubMed via a selection of relevant keywords; original texts that were cited in reviews were studied where it was advantageous. This review found some promising data on bone health and the administration of transdermal oestrogen, which is not yet widely used, as well as distinct hormonal markers to differentiate between CT and AN. We concluded that the continuous efforts to investigate the role of endocrinology in underweight and/or anorexia nervosa lead to outcome benefits and that more and higher-powered studies are needed.

Surgical treatment methods in the course of psychiatric disorders: Deep brain stimulation-Novel insights and indications

Deep brain stimulation (DBS) is a relatively dated treatment procedure that emerged in the late 1980s. Nonetheless, numerous studies are being carried out to examine its influence on the human brain and develop new treatment indications. This systematic review aims to summarize the current state of knowledge referring to DBS, investigate novel insights into its indications, and discuss the technical aspects and rationale behind DBS application. In particular, we sought to subject to scrutiny the application of DBS specifically in anorexia nervosa (AN), various addiction types, depression, and obsessive-compulsive disorders (OCDs). The method is supposed to offer promising results, especially in pharmacologically resistant forms of the upper-mentioned psychiatric disorders. Moreover, further insight has been provided into the historical notions of the method and differences in the surgical approach in specific disease entities. Furthermore, we mark the possible influence of comorbidities on treatment results. Our review consists of articles and studies found on PubMed, Google Scholar, Cochrane, and Scopus, which were then analyzed with scrutiny in the identification process, including the most resourceful ones. After methodological quality and risk of bias assessment, a total of 53 studies were included. To this date, DBS's usefulness in the treatment of AN, OCDs, depression, and addictions has been proven, despite an ongoing debate concerning the technical aspects and parameters when applying DBS. To the best of our knowledge, we have not found any paper that would recapitulate the current state of DBS in the context of psychiatric disorders with an addition of technical insights.

Cellular and extracellular vaginal changes following murine ovarian removal

Loss of estrogen as a result of aging, pelvic cancer therapy, genetics, or eating disorders affects numerous body systems including the reproductive tract. Specifically, a chronic hypoestrogenic state fosters debilitating vaginal symptoms like atrophy, dryness, and dyspareunia. Current treatment options, including vaginal estrogen and hyaluronan (HA), anecdotally improve symptoms, but rectifying mechanisms are largely understudied. In order to study the hypoestrogenic vaginal environment, in particular the extracellular matrix (ECM), as well as understand the mechanisms behind current treatments and develop new therapies, we characterized a reliable and reproducible animal model. Bilateral ovariectomies (OVX) were performed on 9-week-old CD1 mice. After 1 month of estrogen loss due to ovarian removal, a phenotype that is similar to human vaginal tissue in an estrogen reduced state was noted in mice compared to sham-operated controls. The uterine to body weight ratio decreased by 80% and vaginal epithelium was significantly thinner in OVX compared to sham mice. Estrogen signaling was altered in OVX, but submucosal ERα localization did not reach statistical differences. HA localization in the submucosal area was altered and CD44 expression decreased in OVX mice. Collagen turn-over was altered following OVX. The inflammation profile was also disrupted, and submucosal vaginal CD45+ and F4/80+ cell populations were significantly reduced in the OVX mice. These results show altered cellular and molecular changes due to reduced estrogen levels. Developing new treatments for hypoestrogenic vaginal symptoms rely on better understanding of not only the cellular changes, but also the altered vaginal ECM environment. Further studies using this mouse model has the potential to advance women's vaginal health treatments and aid in understanding the interplay between organ systems in both healthy, aged, and diseased states.

Modified activity-based anorexia paradigm dampens chronic food restriction-induced hyperadiponectinemia in adolescent female mice

Anorexia nervosa (AN) is a chronic, life-threatening disease with mental and physical components that include excessive weight loss, persistent food restriction, and altered body image. It is sometimes accompanied by hyperactivity, day-night reversal, and amenorrhea. No medications have been approved specific to the treatment of AN, partially due to its unclear etiopathogenesis. Because adiponectin is an appetite-regulating cytokine released by adipose tissue, we hypothesized that it could be useful as a specific biomarker that reflects the disease state of AN, so we developed a modified AN mouse model to test this hypothesis. Twenty-eight 3-week-old female C57BL/6J mice were randomly assigned to the following groups: 1) no intervention; 2) running wheel access; 3) food restriction (FR); and 4) activity-based anorexia (ABA) that included running wheel access plus FR. After a 10-day cage adaptation period, the mice of the FR and ABA groups were given 40% of their baseline food intake until 30% weight reduction (acute FR), then the body weight was maintained for 2.5 weeks (chronic FR). Running wheel activity and the incidence of the estrous cycle were assessed. Spontaneous food restriction and the plasma adiponectin level were evaluated at the end of the acute and chronic FR phases. An increase in running wheel activity was found in the light phase, and amenorrhea was found solely in the ABA group, which indicates that this is a good model of AN. This group showed a slight decrease in spontaneous food intake accompanied with an attenuated level of normally induced plasma adiponectin at the end of the chronic FR phase. These results indicate that the plasma adiponectin level may be a useful candidate biomarker for the status or stage of AN.

Prevalence of eating disorders in patients with bipolar disorder: a scoping review of the literature

BACKGROUND

Eating disorder (ED) and bipolar disorder (BD) exhibit certain phenomenological similarities rooted in eating behavior and emotional regulation. However, despite the growing body of research on the comorbidity of ED and BD, scientific data on the concurrent course of these disorders has remained poorly systematized.

AIM

To conduct a scoping review of published data on the prevalence of various types of ED among patients with BD types I and II in the context of the sex and clinical features of the concurrent course of these disorders.

METHODS

The analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search was conducted in the MEDLINE electronic database. Studies were included if they were focused samples of patients diagnosed with BD and ED, and the Diagnostic and Statistical Manual of Mental Disorders, fourth and fifth editions (DSM-IV, DSM-5), or International Statistical Classification of Diseases and Related Health Problems, tenth Revision (ICD-10), were used for the verification of the ED and BD diagnoses. The descriptive analysis method was used to summarize the review findings.

RESULTS

A total of 41 studies were selected for the review. Lifetime ED in patients with BD ranged from 2.2% to 31.1%, and the prevalence rates of BD among patients with ED varied from 11.3% to 68.1%. ED nominally had a higher prevalence among individuals with BD type II and females. Additionally, the presence of ED in patients with BD was associated with earlier onset of mood disorder, a higher number of depressive episodes, higher levels of atypical depressive symptoms, suicide attempts, as well as a higher frequency of comorbid obsessive-compulsive and anxiety disorders, addictions, and various metabolic disorders.

CONCLUSION

Despite the high degree of volatility in the results, the prevalence rates of a concurrent course of ED and BD are rather high. For this reason, screening for ED in patients with BD and vice versa holds significant value in the accurate diagnosis and selection of the most effective therapy. The patterns of comorbidity among different types of ED and BD, depending on gender, need further exploration in future research.

Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome

The evaluation of suspected hypercortisolism is one of the most challenging problems in medicine. The signs and symptoms described by Dr Harvey Cushing are common and often create diagnostic confusion to even experienced endocrinologists. Cushing syndrome is classically defined as neoplastic hypercortisolism resulting from an ACTH-secreting tumor or from autonomous secretion of excess cortisol associated with benign or malignant adrenal neoplasia. The increasing recognition of the negative cardiometabolic effects of mild cortisol excess without overt physical signs of Cushing syndrome has led to more screening for endogenous hypercortisolism in patients with adrenal nodular disease, osteoporosis, and the metabolic syndrome. However, sustained or intermittent activation of the dynamic hypothalamic-pituitary-adrenal axis caused by chemical (alcohol), inflammatory (chronic kidney disease), psychologic (major depression), and physical (starvation/chronic intense exercise) stimuli can result in clinical and/or biochemical features indistinguishable from neoplastic hypercortisolism. Nonneoplastic hypercortisolism (formerly known as pseudo-Cushing syndrome) has been recognized for more than 50 years and often causes diagnostic uncertainty. This expert consultation describes two patients with features of Cushing syndrome who were referred for inferior petrosal sinus sampling for the differential diagnosis of ACTH-dependent hypercortisolism. Both patients were discovered to have nonneoplastic hypercortisolism: one from a covert alcohol use disorder and the other to chronic kidney disease. This consultation emphasizes the value of a good history and physical examination, appropriate laboratory testing, and the desmopressin acetate stimulation test to aid in distinguishing neoplastic from nonneoplastic hypercortisolism.

Sex-dependent clinical presentation, body image, and endocrine status in long-term remitted anorexia nervosa

OBJECTIVE

Although anorexia nervosa (AN) in males has recently gained attention, knowledge of its psychological and physiological outcomes is still scarce. We explore sex-specific characteristics of long-term remitted AN with respect to residual eating disorder (ED) psychopathology, body image, and endocrinology.

METHOD

We recruited 33 patients with AN in remission for at least 18 months (24 women, 9 men) and 36 matched healthy controls (HCs). Eating disorder psychopathology and body image ideals were assessed via clinical interviews, questionnaires, and an interactive 3D body morphing tool. Plasma levels of leptin, free triiodothyronine, cortisol, and sex hormones were quantified. Univariate models controlled for age and weight were used to test for the effects of diagnosis and sex.

RESULTS

Both patient groups showed residual ED psychopathology but normal weight and hormone levels relative to HCs. Male remitted patients demonstrated significantly stronger muscularity-focused body image ideals, evident in interviews, self-reports, and behavioural data, than both female patients and HCs.

CONCLUSIONS

Sex-specific body image characteristics in patients with remitted AN point towards the need to adjust test instruments and diagnostic criteria to male-specific psychopathology. In the future, sufficiently powered studies should evaluate the risk of men with AN developing muscle dysmorphia in the long term.

Causal associations between insulin-like growth factor 1 and vitamin D levels: a two-sample bidirectional Mendelian randomization study

Background

Insulin-like growth factor 1 (IGF-1) plays a vital role in the attainment and maintenance of bone mass throughout life and is closely related to the stature of children. 25-Hydroxyvitamin D (25-OHD) is an intermediate of vitamin D (Vit D) metabolism and a key indicator of Vit D nutritional status. Multiple studies have revealed that IGF-1 levels undergo a non-significant increase after Vit D supplementation. Here, we analyzed the causal and reverse causal relationships between 25-OHD and IGF-1 levels using Mendelian randomization (MR).

Methods

Two-sample MR was used to estimate an unconfounded bidirectional causal relationship between the level of IGF-1 and those of Vit D and 25-OHD. Single nucleotide polymorphisms (SNPs) were filtered from genome-wide association studies (GWAS) after a comprehensive search of the Integrative Epidemiology Unit GWAS database. Several MR methods were employed, including inverse-variance weighted (IVW) method, and a sensitivity analysis was undertaken to detect whether pleiotropy or heterogeneity biased the MR results.

Results

Genetically predicted IGF-1 was found to have a causal association with Vit D and serum 25-OHD levels, where Vit D and serum 25-OHD levels increased with increasing IGF-1 concentrations (Vit D: IVW β:0.021, 95% CI: 0.005-0.036, p = 7.74 × 10^-3; 25-OHD: IVW β: 0.041, 95% CI: 0.026-0.057, p = 2.50 × 10^-7). A reverse causal effect was also found, indicating Vit D and serum 25-OHD have a positive causal relationship with IGF-1 (Vit D: IVW β:0.182, 95% CI: 0.061-0.305, p = 3.25 × 10^-3; 25-OHD: IVW β: 0.057, 95% CI = 0.017-0.096, p = 4.73 × 10^-3). The sensitivity analysis showed that horizontal pleiotropy was unlikely to bias the causality in this study (MR-Egger: Vit D intercept p = 5.1 × 10^-5, 25-OHD intercept p = 6.4 × 10^-4 in forward analysis; Vit D intercept p = 6.6 × 10^-4, 25-OHD intercept p = 1.9 × 10^-3 in reverse analysis), and a leave-one-out analysis did not identify evidence of bias in the results.

Conclusion

The results of the MR analysis provide evidence that IGF-1 has positive causal and reverse causal relationships with Vit D and serum 25-OHD, respectively, in European populations. Our findings also provide guidance for the prevention and treatment of short stature and other related diseases.

Emerging therapeutic targets for anorexia nervosa

INTRODUCTION

Anorexia nervosa is a frequent eating disorder that affects predominantly young women and may take a severe and chronically worsening course of disease contributing to its high mortality rate. Although a multitude of treatment options exist, this disease still bears a high relapse rate. In light of these facts, an improvement of existing and development of new treatment targets and options is warranted.

AREAS COVERED

The present review article covers recent developments in psychotherapy associated with the respective neuropsychological and brain alterations as well as highlights current and future pharmacotherapeutic options.

EXPERT OPINION

Several encouraging developments in the field of psychotherapy such as interventions targeting neurocognitive profiles or addressing reward processing, brain stimulation as well as pharmacological modulation of hormones, namely leptin, oxytocin, ghrelin and nesfatin-1 signaling might be - most likely as part of a multimodal treatment approach - efficacious in order to improve treatment of patients with anorexia nervosa, especially those with a severe course of disease as well as comorbidities. As anorexia nervosa represents a complex and severe mental disorder, it seems most likely that a combination and integration of different evidence-based treatment approaches and settings will contribute to an improved prognosis of this eating disorder. This should be further explored in future studies.

Inpatient target discharge weight for early-onset anorexia nervosa: Restoring premorbid BMI percentile to improve height prognosis

OBJECTIVE

Early-onset anorexia nervosa (EO-AN) is characterized by restricted food intake leading to low body weight, emerging before 14 years old. Most patients reaching a target body mass index (BMI) around the 25th percentile at hospitalization discharge display an incomplete prospective height catch-up. A better understanding of height prognosis determinants is required.

METHODS

In 74 children with an EO-AN, we collected height and weight premorbidly, at hospitalization, and at discharge, 6 months, 12 months, and at longer-term follow-up of 36 months. We defined a height prognosis parameter (HPP) as the difference between the height percentile at follow-up times and the premorbid height percentile. We explored the relationship between weight parameters and height catch-up at follow-up with linear regression analyses.

RESULTS

A higher weight suppression (WS) - i.e., difference between premorbid and current BMI - at admission and discharge was associated with lower HPP - i.e., a greater loss of height - at 12 months and 36 months follow-up. Similarly, a higher premorbid BMI percentile was associated with a lower HPP at 12 and 36 months.

CONCLUSION

Target discharge weight for EO-AN patients should be tailored and based on premorbid BMI trajectory to improve height prognosis.

Bone health in avoidant/restrictive food intake disorder: a narrative review

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is an eating/feeding disturbance characterized by severe food avoidance or restriction that results in faltering growth, nutritional deficiencies, dependence on formula supplementation, and/or significant psychosocial impairment. Compared to other eating disorders, ARFID is observed to have an earlier childhood onset and chronic course without intervention. Childhood represents a sensitive period for longitudinal growth and bone accrual, setting the stage for long-term health outcomes associated with longevity and quality of life, including risk for fracture and osteoporosis.

RESULTS

This narrative review discusses published scientific literature on bone health in individuals with ARFID by describing the current understanding of ARFID's effect on bone health, how common dietary constraints characteristic of ARFID may present unique risks to bone health, and the current clinical recommendations for bone health assessment. Reviewing what is known of clinical data from anorexia nervosa (AN) and similar cohorts, the chronicity and etiology of dietary restriction observed in ARFID are hypothesized to compromise bone health significantly. Although limited, examination of bone health in ARFID patients suggests children with ARFID tend to have shorter stature compared to healthy reference datasets and have lower bone density compared to healthy individuals, similar to those with AN. There remains a substantial knowledge gap in how ARFID may interrupt bone accrual during childhood and adolescence, and subsequent impact on attainment of peak bone mass and peak bone strength. The longitudinal effects of ARFID may be subtle and overlooked clinically in the absence of severe weight loss or growth stunting. Early identification and remediation of threats to bone mass accrual have significant personal and population-level implications.

CONCLUSION

For patients with ARFID, delayed identification and intervention to address feeding disturbances may have a long-lasting impact on various body systems and processes, including those relating to longitudinal growth and bone mass accrual. Further research employing rigorous prospective observational and/or randomized study designs are required to clearly define effects of ARFID, as well as clinical interventions aimed at addressing ARFID-related feeding disturbances, on bone accrual.

Effects of induction chemotherapy on nutrition status in locally advanced nasopharyngeal carcinoma: a multicentre prospective study

BACKGROUND

Induction chemotherapy (IC) and concurrent chemoradiotherapy (CCRT) is the standard of care for locoregionally advanced nasopharyngeal carcinoma (LA-NPC). This intensive treatment regimen increases acute toxicities, which could negatively impact patients' nutritional status. We conducted this prospective, multicentre trial to investigate the effects of IC and CCRT on nutritional status in LA-NPC patients, so as to provide evidence for further study of nutritional intervention, which was registered in ClinicalTrials.gov (NCT02575547).

METHODS

Patients with biopsy-proven NPC and planned for IC + CCRT were recruited. IC entailed two cycles of 3-weekly docetaxel 75 mg/m² and cisplatin 75 mg/m² ; CCRT entailed two to three cycles of 3-weekly cisplatin 100 mg/m² depending on the duration of radiotherapy. Nutritional status and quality of life (QoL) were assessed pre-IC, post-cycles one and two of IC, W4 and W7 of CCRT. Primary endpoint was the cumulative proportion of ≥ 5.0% weight loss (WL_5.0 ) by the end of treatment (W7-CCRT). Secondary endpoints included body mass index, NRS2002 and PG-SGA scores, QoL, hypoalbuminaemia, treatment compliance, acute and late toxicities and survivals. The associations between primary and secondary endpoints were also evaluated.

RESULTS

One hundred and seventy-one patients were enrolled. Median follow-up was 67.4 (IQR: 64.1-71.2) months. 97.7% (167/171) patients completed two cycles of IC, and 87.7% (150/171) completed at least two cycles of concurrent chemotherapy; all, except one patient (0.6%), completed IMRT. WL was minimal during IC (median of 0.0%), but increased sharply at W4-CCRT (median of 4.0% [IQR: 0.0-7.0%]) and peaked at W7-CCRT (median of 8.5% [IQR: 4.1-11.7%]). 71.9% (123/171) of patients recorded a WL_5.0 by W7-CCRT, which was associated with a higher malnutrition risk (NRS2002 ≥ 3 points: 87.7% [WL ≥ 5.0%] vs 58.7% [WL < 5.0%], P < 0.001) and requirement of nutritional intervention (PG-SGA ≥ 9 points: 82.0% [WL ≥ 5.0%] vs 66.7% [WL < 5.0%], P = 0.038). The median %WL at W7-CCRT was higher in patients who suffered from ≥ G2 mucositis (9.0% vs 6.6%, P = 0.025) and xerostomia (9.1% vs 6.3%, P = 0.003). Besides, patients with cumulative WL_5.0 also reported a higher detriment on QoL at W7-CCRT compared with patients without, with a difference of -8.3 points (95% CI [-15.1, -1.4], P = 0.019).

CONCLUSIONS

We observed a high prevalence of WL among LA-NPC patients who were treated with IC + CCRT, which peaked during CCRT, and had a detriment on patients' QoL. Our data support the need to monitor patient's nutritional status during the later phase of treatment with IC + CCRT and inform on nutritional intervention strategies.

Stress and Growth in Children and Adolescents

The infantile, childhood, and adolescent periods of growth and development also represent times of increased vulnerability to stressors. Growth velocity in each period is dependent on the interplay of genetic, environmental, dietary, socioeconomic, developmental, behavioral, nutritional, metabolic, biochemical, and hormonal factors. A stressor may impact growth directly through modulation of the growth hormone axis or indirectly through other factors. The adaptive response to stressors culminates in behavioral, physiological, and biochemical responses which together support survival and conservation of energy. The immediate response involves activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. The time-limited stress response is at once antigrowth, antireproductive, and catabolic with no lasting adverse consequences. However, chronic activation of the stress system and hypercortisolism have consequential negative impacts on growth, thyroid function, reproduction-puberty, and metabolism. High cortisol suppresses growth hormone-insulin-like growth factor 1, hypothalamic-pituitary-gonadal, and thyroid axes and has been reported to be responsible for an increase in visceral adiposity, a decrease in lean mass, suppression of osteoblastic activity with risk of osteoporosis, and induction of insulin resistance. Early-life adversities, emotional or physical, have been associated with long-term negative physical and mental health outcomes. Existing models of chronic stress corroborate that early-life adversities can affect growth and have consequences in other aspects of well-being throughout the lifespan. Targeted interventions to reduce stress during infancy, childhood, and adolescence can have far-reaching benefits to long-term health as well as attaining adequate growth. In this review, we describe the neuroendocrinology of the stress response, the factors influencing growth, and the impact of chronic stress on growth during critical periods of infancy, childhood, and puberty with particular reference to growth, thyroid, and gonadal axis.

Gender Dysphoria in Young People: A Model of Chronic Stress

BACKGROUND

Gender dysphoria (GD) refers to the distress that may accompany gender incongruence, often heightened at the onset of puberty, with the development of secondary sex characteristics. Children and adolescents may be especially vulnerable to severe stressors, including GD, with potentially irreversible effects if these exposures occur during critical periods of development and brain maturation.

SUMMARY

We describe the evidence for GD as a chronic stressor, drawing parallels to other established models of stress, activating both innate psychological and biological stress responses. As well as being an inherently distressing experience, a person who experiences GD may also experience minority stress. Minority stress has been demonstrated in young people who experience GD with higher rates of social rejection and internalized stigma and shame. The biological stress response in young people with GD is illustrated through the activation of the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and pro-inflammatory response. The number of young people who report experiencing GD has increased exponentially worldwide in the past decade, demanding a change in the clinic infrastructure. Paediatric endocrinologists and specialists in mental health work together to both support psychosocial well-being and offer individualized treatment to align the phenotype with gender identity with the aim of alleviating the distress of GD. Medical interventions may include puberty suppression and gender-affirming hormones. Ongoing monitoring is required prior to initiation and during treatment to ensure that the goals of treatment are being achieved.

Gender and sex in eating disorders: A narrative review of the current state of knowledge, research gaps, and recommendations

INTRODUCTION

Eating disorders (EDs) have long been considered conditions exclusively affecting women, and studies in the ED field regularly exclude men. Research efforts are needed to better understand the role of gender and sex in EDs. This review describes the role of gender and sex in the development of EDs from a biopsychosocial perspective.

METHODS

The primary hypothesis of this narrative review is that gender and sex interact to influence ED risk. The literature review was conducted using the PubMed database.

RESULTS

This review first presents the general characteristics and prevalence of EDs according to gender and sex. Next, neurodevelopmental processes, neurobiology, gender roles, body image, and the minority stress model are addressed. Lastly, research perspectives to better include gender and sex in the field of EDs are discussed (e.g., representation of gender and sex diversities, development of appropriate assessment tools, and increasing awareness).

CONCLUSION

Although substantial knowledge gaps remain, there is a growing recognition of the importance of integrating gender and sex in ED research that holds promise for further development in the field.

The effects of weight loss-related amenorrhea on women's health and the therapeutic approaches: a narrative review

Background and Objective

Weight loss-related amenorrhea is defined as the reversible functional inhibition of the hypothalamic-pituitary-ovarian (HPO) axis associated with weight loss or low body weight, which occurs mostly in adolescents and women of reproductive age. The specific pathological mechanisms of this disease have not yet been elucidated, and the optimal evidence-based guidelines for its clinical assessment and management are limited. This review summarizes its adverse effects on female health, and the individualized, emerging, and multidisciplinary therapeutic approaches used to treat it.

Methods

We searched the PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) databases for Chinese and English literature on functional hypothalamic amenorrhea (FHA), and retrieved original articles (on basic and clinical research) and reviews published up to December 2022.

Key Content and Findings

We reviewed the findings on the unfavorable effects of weight loss-related amenorrhea with a focus on reproduction, the skeletal and cardiovascular system, other endocrine effects, and mental health. Lifestyle changes and hormonal replacement have been shown to alleviate the underlying causes and lead to the recovery of menstruation. However, the efficacy of treatments is affected by many factors, such as psychological stress and heterogeneity.

Conclusions

Weight loss-related amenorrhea, which is an important type of FHA, is manifested by anovulation and hypoestrogenism, and has both short- and long-term adverse effects on women's overall health. It is difficult to alleviate its underlying causes. Individualized treatments need to be optimized and emerging or multidisciplinary therapeutic approaches need to be explored that aim to recover normal menstruation and ovulation, eliminate the undesirable effects of prolonged hypoestrogenism and alleviate psychological disorders.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.