Severe anorexia nervosa in males: clinical presentations and medical treatment

Sex differences in electrolyte abnormalities indicating refeeding syndrome risk among hospitalized adolescents and young adults with eating disorders

BACKGROUND

Refeeding syndrome is the gravest possible medical complication in malnourished patients undergoing refeeding in the hospital. We previously reported that males with malnutrition secondary to eating disorders required more calories and had longer hospital stays than females; however, sex differences in electrolyte abnormalities indicating refeeding syndrome risk remain unknown. The objective of this study was to assess differences in electrolyte abnormalities indicating refeeding syndrome risk among male and female adolescents and young adults with eating disorders hospitalized for medical instability.

METHODS

We retrospectively reviewed the electronic medical records of 558 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability between May 2012 and August 2020. Serum was drawn per standard of care between 5 and 7 am each morning and electrolyte abnormalities indicating refeeding syndrome risk were defined as: hypophosphatemia (< 3.0 mg/dL), hypokalemia (< 3.5 mEq/L), and hypomagnesemia (< 1.8 mg/dL). Logistic regression was used to assess factors associated with electrolyte abnormalities indicating refeeding syndrome risk.

RESULTS

Participants included 86 (15.4%) males and 472 (84.6%) females, mean (SD) age 15.5 (2.8) years. Rates of refeeding hypophosphatemia (3.5%), hypokalemia (8.1%), and hypomagnesemia (11.6%) in males hospitalized with eating disorders were low, with no statistically significant differences from females. Older age was associated with higher odds of refeeding hypophosphatemia and hypomagnesemia. Lower percent median body mass index and greater weight suppression at admission were associated with higher odds of refeeding hypophosphatemia.

CONCLUSIONS

Rates of electrolyte abnormalities indicating refeeding syndrome risk were low in males hospitalized for eating disorders and rates did not significantly differ from females. Together with our finding that males have higher caloric requirements and longer hospital length of stay, the finding that electrolyte abnormalities indicating refeeding syndrome risk were not greater in males than females supports future research to evaluate the safety and efficacy of higher calorie and/or faster advancing refeeding protocols for males.

Cardiac involvement and its clinical significance in patients with anorexia nervosa

Cardiac complications are a major concern in patients with anorexia nervosa (AN) which contribute to morbidity and mortality. However, limited information exists regarding risk factors for the development of these complications. Our objective was to investigate the prevalence and associated risk factors of cardiac involvement among children and adolescents with AN admitted to a tertiary pediatric hospital. We collected demographic, clinical, and laboratory data from individuals with AN hospitalized between 2011 and 2020 in Schneider Children's Medical Center in Israel. Diagnosis was based on established criteria (DSM-5). Patients with other co-morbidities were excluded. Cardiac investigations included electrocardiograms (ECG) and echocardiograms. We conducted correlation tests between cardiac findings and clinical and laboratory indicators. A total of 403 AN patients (81.4% were females) with a median age of 15 ± 2 years were included in the study. Sinus bradycardia was the most common abnormality, observed in 155 (38%) participants. Echocardiogram was performed in 170 (42.2%) patients, of whom 37 (22%) demonstrated mild cardiac aberrations. Among those aberrations, 94.6% could be attributed to the current metabolic state, including pericardial effusion (15.3%) and valve dysfunction (8.8%). Systolic or diastolic cardiac dysfunction, tachyarrhythmias, or conduction disorders were not observed. Patients with new echocardiographic aberration had significantly lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension was higher in this group.

CONCLUSIONS

The prevalence of cardiac involvement, except for sinus bradycardia, was notably low in our cohort. The presence of cardiac aberrations is correlated with several clinical variables: lower body mass index (BMI) and the presence of amenorrhea and hypotension at admission. Patients presenting with these variables may be at high risk for cardiac findings per echocardiography. Dividing the patients into high and low risk groups may enable targeted evaluation, while avoiding unnecessary cardiac investigations in low-risk patients.

WHAT IS KNOWN

• Cardiac involvement in anorexia nervosa (AN) patients is a major concern, which contributes to morbidity and mortality. • It is unknown which patients are prone to develop this complication.

WHAT IS NEW

• Cardiac complications in our cohort are less frequent compared to previous studies, and it is correlated with lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

The influence of the family on the formation of eating and weight disorders

The аim is to study family influence on formation of eating and weight disorders. The concept of an “alimentary family” is defined as a family with dysfunctional, disharmonious relationships, which is a prerequisite for emergence and support of distorted patterns of eating behaviour, leading in the future to children’s eating and weight disorders.

Methods: The research was carried out using the method of a thematic retrospective analysis (MTRA)-food, which is a variant of the narrative method, the questionnaire “Parental convictions and control tactics as for eating behaviour of their children during food taking”. The data was processed by the content analysis method; Fisher’s φ-criterion was used to compare differences between the groups.

Results: The research has allowed us to clarify eating behavioural characteristics and to identify the “roots” of eating disorders. Various forms of forcing at eating, direct and indirect ways of making children to eat or blocking of eating are manifested in ignoring of children’s taste preferences, their desire and readiness to eat. Parents often use manipulative techniques influencing children’s eating behaviour (encouragement, inducement, reward promises, approval, recognition, warning, or switching attention), direct means of influence (coercion: prohibition, restriction, rejection, destructive criticism, intimidation, deprivation from various pleasures). There is the statistical confirmation that parents’ use of manipulative means and / or direct coercion towards their children during eating predetermines formation of pathological processes of corporeality, attitudes and psychological mechanisms stipulating eating disorders.

Conclusions: The research results indicate necessity to develop psychotherapeutic programs for people with eating disorders, as well as programs to help parents improve family relationships and, accordingly, to apply correctional effects on their children.

It's raining men: descriptive results for engaging men with eating disorders in a specialized male assessment and treatment track (MATT)

PURPOSE

Men with eating disorders are not well understood and there is a need for innovative methods for engaging men in specialized outpatient assessment and treatment. We examined data collected over a 4-year period to explore whether the addition of a designated track for men at a hospital-based adult eating disorders program influenced the number of referrals or treatment engagement.

METHODS

During assessment and treatment as usual (ATAU; September 2013-August 2015), 283 referrals were received (275 women, 8 men), with 3 men engaging in assessment and treatment (M_age = 36 years, SD = 14.18). After instatement of a male assessment and treatment track (MATT; September 2015-August 2017), 320 referrals were received (300 women, 20 men), with 14 men engaging in the specialized assessment and treatment (M_age = 28.21 years, SD = 8.04). Both groups of men completed measures of demographic characteristics, life satisfaction, depressive and anxiety symptoms, and eating disorder symptoms.

RESULTS

Significantly more referrals for men, but not women, were received after the instatement of the MATT (i.e., a 250% increase). More men also engaged in specialized assessment and treatment after the instatement of the MATT (i.e., a 467% increase in engagement).

CONCLUSIONS

The current study describes the number of referrals and the number of men who engaged in treatment before and after the instatement of a specialized treatment track for men. The results suggest that the addition of the MATT helped to increase the number of men referred and promoted their engagement in recommended care.

LEVEL OF EVIDENCE

V retrospective descriptive study.

α4-GABAA receptors of hippocampal pyramidal neurons are associated with resilience against activity-based anorexia for adolescent female mice but not for males

Activity-based anorexia (ABA) is an animal model of anorexia nervosa, a mental illness with highest mortality and with onset that is most frequently during adolescence. We questioned whether vulnerability of adolescent mice to ABA differs between sexes and whether individual differences in resilience are causally linked to α4βδ-GABAAR expression. C57BL6/J WT and α4-KO adolescent male and female mice underwent ABA induction by combining wheel access with food restriction. ABA vulnerability was measured as the extent of food restriction-evoked hyperactivity on a running wheel and body weight losses. α4βδ-GABAAR levels at plasma membranes of pyramidal cells in dorsal hippocampus were assessed by electron microscopic immunocytochemistry. Temporal patterns and extent of weight loss during ABA induction were similar between sexes. Both sexes also exhibited individual differences in ABA vulnerability. Correlation analyses revealed that, for both sexes, body weight changes precede and thus are likely to drive suppression of wheel running. However, the suppression was during the food-anticipatory hours for males, while for females, suppression was delayed by a day and during food-access hours. Correspondingly, only females adaptively increased food intake. ABA induced up-regulation of α4βδ-GABAARs at plasma membranes of dorsal hippocampal pyramidal cells of females, and especially those females exhibiting resilience. Conversely, α4-KO females exhibited greater food restriction-evoked hyperactivity than WT females. In contrast, ABA males did not up-regulate α4βδ-GABAARs, did not exhibit genotype differences in vulnerability, and exhibited no correlation between plasmalemmal α4βδ-GABAARs and ABA resilience. Thus, food restriction-evoked hyperactivity is driven by anxiety but can be suppressed through upregulation of hippocampal α4βδ-GABAARs for females but not for males. This knowledge of sex-related differences in the underlying mechanisms of resilience to ABA indicates that drugs targeting α4βδ-GABAARs may be helpful for treating stress-induced anxiety and anorexia nervosa of females but not males.

Medical complications of anorexia nervosa and their treatments: an update on some critical aspects

Anorexia nervosa has the highest mortality rate of any psychiatric disorder. Many of the deaths are attributable to medical complications which arise as the malnutrition and weight loss worsens. Every body system may be adversely affected by anorexia nervosa. Yet, remarkably, most of the medical complications of anorexia nervosa are treatable and reversible with optimal medical care, as part of a multidisciplinary team who are often involved in the care of these patients. Herein, we will describe the medical complications of anorexia nervosa and their treatments.

Treatment of patients with severe and enduring eating disorders

PURPOSE OF REVIEW

Severe and enduring eating disorder is a new concept to the field that has potential to aid assessment and inform treatment. The aim of this review is to report recent developments in the conceptualization and treatment of people with severe and enduring eating disorder.

RECENT FINDINGS

A systematic search identified 28 included papers. These addressed conceptualization of recovery and staging models (4 studies), clinical care, presentations and treatment experiences (7 studies), four new randomized controlled trials of treatment (9 studies), two open trials of novel approaches (2 studies) and problems of treatment resistance and involuntary care (6 studies).

SUMMARY

The staging model appears to have validity and clinical utility in anorexia nervosa, but this is less clear in other eating disorders. Most literature on treatment, including new randomised controlled trials, is on underweight individuals, and there is a small literature on emerging psychological therapies that may improve outcomes. There is an expectation that with better treatment engagement, there may also be a reduced need for involuntary interventions.

Male youth with eating disorders: clinical and medical characteristics of a sample of inpatients

A retrospective chart review was conducted to elucidate the clinical and medical characteristics of male youth admitted to a tertiary inpatient treatment center for eating disorders. A total of 23 male youth were identified who had received treatment between January 2003 and February 2014, and for whom charts were available. The majority of the sample (n = 19; 82.6%) received a diagnosis of anorexia nervosa, and the data suggest that these male youth were significantly medically compromised. The patterns in this data will be discussed in the context of previous published research on male youth with eating disorders.

Anorexia nervosa - medical complications

In contrast to other mental health disorders, eating disorders have a high prevalence of concomitant medical complications. Specifically, patients suffering from anorexia nervosa (AN) have a litany of medical complications which are commonly present as part of their eating disorders. Almost every body system can be adversely, affected by this state of progressive malnutrition. Moreover, some of the complications can have permanent adverse effects even after there is a successful program of nutritional rehabilitation and weight restoration. Within this article we will review all body systems affected by AN. There is also salient information about both, how to diagnose these medical complications and which are the likely ones to result in permanent sequelae if not diagnosed and addressed early in the course of AN. In a subsequent article, the definitive medical treatment for these complications will be presented in a clinically practical manner.