Extremely severe anorexia nervosa: Hospital course of 354 adult patients in a clinical nutrition-eating disorders-unit

Gut microbiota and inflammatory factor characteristics in major depressive disorder patients with anorexia

BACKGROUND

This study aimed to explore the gut microbiota and inflammatory factor characteristics in major depressive disorder (MDD) patients with anorexia and to analyze the correlation between gut microbiota and inflammatory factors, anorexia, and HAMD scores.

METHODS

46 MDD patients and 46 healthy controls (HC) were included in the study. The 46 MDD patients were divided into two groups according to whether they had anorexia:20 MDD without anorexia (MDA0 group) and 26 MDD with anorexia (MDA1 group). We used the Hamilton Depression Scale-24 (HAMD-24) to evaluate the depression status of all participants and 16 S ribosomal RNA (16 S rRNA)sequencing to evaluate the composition of the gut microbiota. Inflammatory factors in peripheral blood such as C-reactive protein (CRP) were detected using enzyme-linked immunosorbent assay (ELISA). Spearman's correlation analysis was used to evaluate the correlation between gut microbiota and inflammatory factors, HAMD scores, and anorexia.

RESULTS

1). CRP was significantly higher in the MDA0, MDA1, than HC. 2). An analysis of α-diversity shows: the Simpson and Pielou indices of the HC group are higher than the MDA1 group (P < 0.05). 3). The β-diversity analysis shows differences in the composition of microbial communities between the MDA0, MDA1, and HC group. 4). A correlation analysis showed that Blautia positively correlated with anorexia, HAMD scores, and CRP level, whereas Faecalibacterium, Bacteroides, Roseburia, and Parabacteroides negatively correlated with anorexia, HAMD scores, and CRP level. 5). The receiver operating characteristic (ROC) curve was drawn using the differential bacterial genera between MDD patients with or without anorexia as biomarkers to identify whether MDD patients were accompanied with anorexia, and its area under curve (AUC) was 0.85. The ROC curve was drawn using the differential bacterial genera between MDD patients with anorexia and healthy controls as biomarkers to diagnose MDD patients with anorexia, with its AUC was 0.97.

CONCLUSION

This study suggested that MDD patients with anorexia had a distinct gut microbiota compared to healthy individuals, with higher level of CRP. Blautia was more abundant in MDD patients with anorexia and positively correlated with CRP, HAMD scores, and anorexia. The gut microbiota might have influenced MDD and anorexia through the inflammatory factor CRP.

Longitudinal investigation of patients receiving involuntary treatment for extremely severe anorexia nervosa

INTRODUCTION

Involuntary treatment may be a life-saving option for extremely severe anorexia nervosa (AN) in the context of life-threatening conditions and refusal of care. The long-term outcomes of patients undergoing involuntary treatment for AN are poorly understood. This study aims to explore quality of life, long-term outcomes and attitudes towards involuntary treatment in patients involuntarily treated for extremely severe AN.

METHODS

23 patients involuntarily admitted for extremely severe AN (I-AN), and 25 voluntarily admitted patients (V-AN) were compared for body mass index (BMI), residual symptoms, quality of life, and attitudes towards treatment almost four years after discharge. In I-AN, clinical variables were also compared between admission and follow-up.

RESULTS

At follow-up, weight restoration was higher in V-AN (p = 0.01), while differences in quality of life, BMI, and mortality rates were not significant between I-AN and V-AN (p > 0.05). In I-AN, BMI increased and weight-controlling strategies decreased at follow-up (p < 0.05). Despite negative experiences of involuntary treatment, the perception of the necessity of treatment increased from admission to follow-up (p < 0.01) and became comparable to V-AN (p > 0.05).

DISCUSSION

Involuntary treatment for AN does not appear to be a barrier to weight gain and clinical improvement, nor to long-term attitudes towards treatment.

Description of patients with eating disorders by general practitioners: a cohort study and focus on co-management with depression

BACKGROUND

International guidelines often state that general practitioners (GPs) provide early management for most patients with eating disorders (EDs). GP management of EDs has not been studied in France. Depressive disorders are often a comorbidity of EDs. The aims of this study were to describe in France the characteristics of people with all subcategories of EDs (Anorexia Nervosa, Bulimia Nervosa, ED Not Otherwise Specified) managed by their GPs and to study the management temporality between depression and all subcategories of EDs.

METHODS

Retrospective cohort study of patients with EDs visiting French GPs. Data collected from 1994 through 2009 were extracted from the French society of general electronic health record. A descriptive analysis of the population focused on depression, medication such as antidepressants and anxiolytics, and the management temporality between depression and EDs.

RESULTS

1310 patients aged 8 years or older were seen at least once for an ED by a GP participating in the database out of 355,848 patients, with a prevalence rate of 0.3%. They had a mean age of 35.19 years, 82.67% were women. 41.6% had anorexia nervosa, 26.4% bulimia nervosa, and 32% an ED not otherwise specified. Overall, 32.3% had been managed at least once for depression, and 18.4% had been prescribed an antidepressant of any type at least once. Benzodiazepines had been prescribed at least once for 73.9% of the patients treated for depression. Patients with an ED seen regularly by their GP ("during" profile) received care for depression more frequently than those with other profiles. 60.9% had a single visit with the participating GP for their ED Treatment and management for depression did not precede care for EDs.

CONCLUSIONS

Data extracted from the French society of general practice were the only one available in France in primary care about EDs and our study was the only one on this topic. The frequency of visits for EDs was very low in our general practice-based sample. Depressive disorders were a frequent comorbidity of EDs. GPs could manage common early signs of depression and EDs, especially if they improved their communication skills and developed collaborative professional management.

Narrative review of inpatient nutritional management of anorexia nervosa with management recommendations for Australian tertiary health services

BACKGROUND

Patients with anorexia nervosa (AN) may experience life-threatening malnutrition-related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high-level evidence.

AIMS

To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN.

METHODS

MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of <10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia.

RESULTS

The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high-calorie refeeding and micronutrient supplementation.

CONCLUSION

The evidence supports high-calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence-based health care.

Analysis of symptom clusters amongst adults with anorexia nervosa: Key severity indicators

This study used cluster analysis to explore clinically relevant subgroups of adult patients with anorexia nervosa (AN). Patients were clustered based on their body mass index (BMI), eating disorder symptomatology, anxiety and depression symptoms and autistic characteristics. The difference between clusters in work and social functioning, duration of illness, bingeing and purging behaviour, previous hospitalisations and number of comorbidities was also investigated. Two meaningful clusters emerged: a higher symptoms cluster with more severe eating pathology, anxiety, depression, and more autistic traits, and a second cluster with lower symptoms. BMI did not make major contributions to cluster formation. The higher symptoms cluster also reported lower self-efficacy to change, more previous hospitalisations, comorbid diagnoses, binge eating and purging behaviours and use of psychotropic medication. Our findings suggest that weight alone may not be a significant severity indicator amongst inpatients with AN, and targeted treatment of AN should consider a broader range of symptom severity indicators.

Systematic Review of the Incidence and/or Prevalence of Eating Disorders in Individuals With Food Allergies

BACKGROUND

Chronic diseases involving strict dietary adherence have been associated with an increased risk of eating disorders (EDs). This is the first systematic review investigating the rate of EDs among individuals with food allergies (FAs).

OBJECTIVE

To report the incidence, prevalence, and types of EDs in individuals with FAs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases for studies published to January 2022 that reported the prevalence or incidence of EDs in samples with immunoglobulin E (IgE) or non-IgE-mediated allergy. Risk of bias was assessed and evidence qualitatively synthesized.

RESULTS

From 1,180 papers identified, 9 met inclusion criteria. There were 4,161 adult and pediatric participants with IgE-mediated FAs or eosinophilic esophagitis. Avoidant/Restrictive Food Intake Disorder (ARFID) or anorexia nervosa/bulimia nervosa were the main EDs identified. The prevalence of EDs in samples with FA ranged from 0.8% to 62.9%. Among studies investigating IgE-mediated FA (n = 6), the prevalence of anorexia nervosa and/or bulimia nervosa ranged from 17.6 to 61%, ARFID was 62.9%, and unspecified EDs was 0.8% to 6%. Among samples with eosinophilic esophagitis (n = 3), ARFID prevalence ranged from 4.5% to 51%. Most studies were limited by small sample size, possible selection bias, and lack of diagnostic EDs tools validated for food allergic populations.

CONCLUSIONS

Eating disorders appear prevalent in individuals with FA; however, prevalence estimates varied widely. Large studies with healthy control groups and validated measures to identify EDs in individuals with FA are needed to accurately determine the prevalence of EDs.

Eating disorder outcomes: findings from a rapid review of over a decade of research

BACKGROUND

Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality.

METHODS

This paper forms part of a Rapid Review series scoping the evidence for the field of ED, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/MEDLINE were searched for studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review.

RESULTS

Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates.

CONCLUSION

Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

The impact of the COVID-19 pandemic on eating disorders risk and symptoms: a retrospective study

BACKGROUND

Social distancing and quarantine imposed by the authority during the COVID-19 pandemic caused restrictions, which had a negative impact on eating behavior, especially among adolescents. We proposed a retrospective study aimed to evaluate the effect of the COVID-19 pandemic on eating disorders risk and symptoms.

METHODS

In this study, a group of 127 pediatric patients (117 females and 10 males) with eating disorders admitted to the Bambino Gesù Children's Hospital of Rome (Italy), in the period between August 2019 and April 2021, was analyzed. All patient data were collected from patients' electronic medical records.

RESULTS

We found that 80.3% of patients were at the onset of eating disorders and that 26% of patients had familiarity for psychotic disorders. Often these patients had comorbidities and alterations in blood parameters such as leukocytopenia, neutropenia, hypovitaminosis and hormonal problems that could affect their future.

CONCLUSIONS

Our findings could provide a framework for developing clinical and educational interventions to mitigate the short- and long-term negative impact of the pandemic on adolescent future health.

The effect of oral refeeding compared with nasogastric refeeding on the quality of care for patients hospitalised with an eating disorder: A systematic review

AIM

The aim of this systematic review was to compare the benefits and harms of nasogastric and oral-based refeeding on the quality of care, including effectiveness, safety, and patient experience, for patients hospitalised with an eating disorder.

METHODS

A systematic search for studies measuring comparative data between nasogastric and oral refeeding methods was conducted in August 2021. Title and abstracts and remaining full texts were screened by both authors. Risk of bias was evaluated using the PEDro scale, and overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation narrative synthesis.

RESULTS

Seven studies (one randomised controlled trial, five non-randomised studies of interventions, and one qualitative study) with 917 participants were included. There was low certainty evidence that nasogastric refeeding resulted in no difference or a small increase in weekly weight gain, and moderate certainty of greater total weight gain, and very low certainty of increased length of stay compared to oral refeeding. There was no difference or a small increase in discharge weight and body mass index with nasogastric refeeding compared to oral refeeding. No serious adverse events were reported.

CONCLUSION

Patients selected for nasogastric refeeding have a longer duration of illness and lower admission weight, making it difficult to determine which refeeding approach is superior. However, the lack of clear difference in weekly weight gain and the lack of reported harms suggests that other factors such as the normalisation of eating behaviour may be taken into account when choosing the most appropriate refeeding method.

A Multi-Disciplinary Approach to Managing End-Stage Renal Disease in Anorexia Nervosa: A Case Report

Background

Renal dysfunction and electrolyte abnormalities are common complications of anorexia nervosa (AN), particularly in the binge-eating/purging type (AN-BP). Hypokalemic, or kaliopenic, nephropathy is an established clinical entity and a leading cause of end-stage renal disease (ESRD) in AN. Here, we present a case which demonstrates the difficulties of managing refeeding and nutrition in a psychiatrically and medically complex patient with severe AN-BP and ESRD most likely secondary to hypokalemic nephropathy.

Case Report

A 54-year-old female with AN-BP that has resulted in chronic hypokalemia, with newly diagnosed ESRD on hemodialysis, presented to an eating disorder medical stabilization unit for weight restoration and treatment of the medical complications associated with her severe malnutrition and ESRD. She was admitted with a body mass index (BMI) of 15 kg/m², serum potassium of 2.8 mmol/L and serum creatinine of 6.91 mg/dL. She had failed to gain weight in the outpatient setting while on hemodialysis. She initially denied having an eating disorder, but ultimately a history of excessive laxative abuse for many years, without primary physician follow up, was revealed. While she did not undergo a renal biopsy to confirm the etiology of her ESRD, given her history of long-standing hypokalemia and lack of other risk factors, her ESRD was presumed to be secondary to hypokalemic nephropathy. She required significant oversight from a multidisciplinary eating disorder treatment team to restore weight while also managing her ESRD.

Conclusion

This case report highlights the complexity of managing ESRD in patients with AN who require weight restoration. A multidisciplinary team was vital to ensure this patient's adherence to treatment. With this case, we hope to raise awareness of the deleterious effect on the kidneys from prolonged hypokalemia, the elevated risk of poor renal outcomes in patients with AN-BP, and the danger of easy accessibility to over-the-counter stimulant laxatives.

Monitoring and treating hypoglycemia during meal-based rapid nutritional rehabilitation in patients with extreme anorexia nervosa

PURPOSE

Hypoglycemia, a complication of prolonged starvation, can be life-threatening and is presumed to contribute to the high mortality of anorexia nervosa. Furthermore, early refeeding in severe anorexia nervosa can precipitate paradoxical post-prandial hypoglycemia. Few studies have analyzed the course of hypoglycemia during nutritional rehabilitation in patients with extremely low-weight anorexia nervosa. No standard practice guidelines exist and recommended strategies for managing hypoglycemia (i.e., nasogastric feeds, high-fat diets) have limitations.

METHODS

This cohort study assessed prevalence and correlates of hypoglycemia in 34 individuals with very low body mass index (BMI < 14.5 kg/m²) anorexia nervosa treated in an intensive eating disorders program with an exclusively meal-based rapid weight gain nutritional protocol. Hypoglycemia was monitored with frequent point of care (POC) glucose testing and treated with oral snacks and continuous slow intravenous 5% dextrose in 0.45% saline (IV D5 1/2 NS) infusion.

RESULTS

POC hypoglycemia was detected in 50% of patients with highest prevalence noted on the day of admission. Hypoglycemia resolved during the first week of hospitalization in most cases and was generally asymptomatic. Seven patients (20.6%) experienced at least one episode of severe hypoglycemia with POC glucose < 50 mg/dl. Lower admission BMI was associated with higher likelihood of developing hypoglycemia and longer duration of hypoglycemia.

CONCLUSION

Meal-based management of hypoglycemia supplemented by continuous IV D5 1/2 NS appears a viable alternative to alternate strategies such as enteral tube feeding. We discuss recommendations for hypoglycemia monitoring during nutritional rehabilitation and directions for future research.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Evaluation of Geriatric Sarcopenia and Nutrition in the Case of Cachexia before Exitus: An Observational Study for Health Professionals

It is important to assess the physical and nutritional status of the body using a bioelectrical impedance analyzer (BIA) in patients with cachexia; however, the correlation between cachexia and nutritional evaluations remains unclear. The objective of this study is to follow the effects of diet therapy in patients with cachexia/sarcopenia, using parameters measured by BIA, clinical parameters, and other nutrition-related assessments in patients with osteoporosis. This study aims to clarify the correlation between BIA-measured parameters, clinical parameters, and other nutrition-related assessments. Methods: Measurements of body composition, a clinical assessment of the sarcopenia/cachexia, and nutritional goal setting/a nutrition care process were performed. Results: The number of subjects was 200, of which 15 people (7.5%) were diagnosed with sarcopenia/cachexia. Univariate analyses showed that participants with a high body-fat mass tend to develop sarcopenic obesity (p = 0.029), those who lost a significant and progressive amount of muscle mass tend to develop sarcopenia (p = 0.001), as well as those with malnutrition (p < 0.001). The regression study shows not only the correlation but also the cause of the correlation, as is the case with obesity. As obesity increases, so does the sarcopenic index (this can explain sarcopenic obesity), and as fat mass decreases it leads to muscle mass loss, increasing the risk of cachexia with age. Conclusions: There was an improvement, but statistically insignificant, in cachexia and the nutritional objectives (p > 0.05); at the same time, correlations were established between the independent parameters (sex, age) and malnutrition parameters (hemoglobin and amylase) with the parameters of the research.

Restrictive type and infectious complications might predict nadir hematological values among individuals with anorexia nervosa during the refeeding period: a retrospective study

BACKGROUND

Although hematological abnormalities in patients with anorexia nervosa have been documented, the mechanisms involved have not been fully clarified, especially during the refeeding period when hematological values further decrease after admission prior to improving. Here we address potential mechanisms underlying the hematological abnormalities of inpatients with anorexia nervosa during the refeeding period.

METHODS

We recruited patients from 101 admissions corresponding to 55 individual patients with anorexia nervosa with severe malnutrition (body mass index, 13.4 ± 3.4) from the neuropsychiatry unit in Ashikaga Red Cross Hospital during the period from October 1999 to March 2018. We analyzed three hematological cell measures, i.e., hemoglobin, white cell count, and platelet count, to determine their levels at admission and their lowest levels during the refeeding period and calculated the percent decrease in those values from admission to the nadir levels. We analyzed each measure using a general mixed model with explanatory variables, including data upon admission and a treatment-related indicator, i.e., energy intake.

RESULTS

The initial hemoglobin value of 12.1 ± 2.7 g/dl decreased by 22.3% to 9.4 ± 2.5 g/dl; the initial white cell count was 5387 ± 3474/μl, which decreased by 33.6% to 3576 ± 1440/μl; the initial platelet count of 226 ± 101 × 10³/μl decreased by 24.3% to 171 ± 80 × 10³/μl. All nadir levels were observed during the refeeding period from the fifth to tenth day of hospitalization. Significant correlations among the three hematological cell measures, particularly at the nadir levels, were found. Of note, 41.7% of our patients who received red blood cell transfusion during hospitalization showed normal hemoglobin levels upon admission. The anorexia nervosa restrictive type was associated with a lower nadir level of white blood cell count. Infectious complications were related to a lower nadir level of hemoglobin and a greater percent decrease in hemoglobin level as well as to the need for red blood cell transfusion.

CONCLUSIONS

Nadir hematological cell measures of inpatients with anorexia nervosa might be predicted by the restrictive type and infectious complications. The anorexia nervosa restrictive type was associated with further decrease in hematological values during the refeeding period.

Hypokalemia in patients with anorexia nervosa during refeeding is associated with binge-purge behavior, lower body mass index, and hypoalbuminemia

BACKGROUND

Hypokalemia is frequently found in patients with anorexia nervosa and sometimes leads to life-threatening conditions. Although their serum potassium levels are considered to further decrease during refeeding, no previous studies have addressed actual changes in the serum potassium levels and potential mechanisms underlying hypokalemia during the refeeding period of patients with anorexia nervosa. In this study, we investigated factors associated with hypokalemia during refeeding of patients with anorexia nervosa.

METHODS

We recruited 52 independent patients from 89 admissions with anorexia nervosa (body mass index, 13.0 ± 3.3) from the psychiatry unit in Ashikaga Red Cross Hospital during the period from April 2003 to March 2018 and analyzed serum potassium levels at admission. Of the 89 admissions, 66 admissions with > 1-week hospitalization were recruited to determine the lowest potassium levels during the refeeding period. We analyzed these levels with multiple linear regression analysis with explanatory variables, including data upon admission and treatment-related indicators.

RESULTS

The initial serum potassium level of 3.6 ± 0.9 mg/dl decreased to 3.1 ± 0.7 mg/dl at nadir hypophosphatemia, which was observed an average of 2.5 days after admission. A lower serum potassium level at admission and a lower nadir potassium level during refeeding were associated with a lower body mass index, hypoalbuminemia, and binge-purge behavior. Similar results were obtained when the analysis included restrictive or binge-purge types as well as the independent patient group.

CONCLUSIONS

Lower body mass index, hypoalbuminemia, and binge-purge behavior might be used as indicators to guide clinical approaches for controlling serum potassium levels in patients with anorexia nervosa during refeeding. Hypokalemia, low levels of serum potassium, in patients with anorexia nervosa sometimes leads to life-threatening conditions. Thus, it is of great importance to predict the risk of hypokalemia in patients with anorexia nervosa during the refeeding period. Our study found that hypokalemia in patients with anorexia nervosa during refeeding is associated with a lower body mass index and hypoalbuminemia (low levels of serum albumin), in addition to binge-purge behavior.

COVID-19, anorexia nervosa and obese patients with an eating disorder - some considerations for practitioners and researchers

Since COVID-19 is a global health emergency, there is an urgent need to share experiences on decision-making with regard to safety recommendations and for hypotheses that can inform a more focused prevention and treatment. Moreover, combining research into eating disorders and obesity with research into COVID-19 may provide a unique opportunity to shed light on the susceptibility to COVID-19.