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Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial.
Golden, NH, Cheng, J, Kapphahn, CJ, Buckelew, SM, Machen, VI, Kreiter, A, Accurso, EC, Adams, SH, Le Grange, D, Moscicki, AB, et al
Pediatrics. 2021;(4)
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Abstract
BACKGROUND AND OBJECTIVES We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations. METHODS In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time. RESULTS Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR. CONCLUSIONS The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.
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A Systematic Review and Meta-Analysis Finds Increased Blood Levels of All Forms of Ghrelin in Both Restricting and Binge-Eating/Purging Subtypes of Anorexia Nervosa.
Seidel, M, Markmann Jensen, S, Healy, D, Dureja, A, Watson, HJ, Holst, B, Bulik, CM, Sjögren, JM
Nutrients. 2021;(2)
Abstract
Anorexia nervosa (AN) is a severe psychiatric condition associated with high mortality and chronicity. The hunt for state, trait, subtyping, and prognostic biomarkers is ongoing and the orexigenic hormone ghrelin and its different forms, acyl ghrelin and desacyl ghrelin, have been proposed to be increased in AN, especially in the restrictive subtype. A systematic literature search was performed using established databases up to 30 November 2020. Forty-nine studies met inclusion criteria for cross-sectional and longitudinal meta-analyses on total ghrelin, acyl ghrelin, and desacyl ghrelin. All forms of ghrelin were increased in the acute stage of anorexia nervosa during fasting compared to healthy controls. Previous notions on differences in ghrelin levels between AN subtypes were not supported by current data. In addition, a significant decrease in total ghrelin was observed pre-treatment to follow-up. However, total ghrelin levels at follow-up were still marginally elevated compared to healthy controls, whereas for acyl ghrelin, no overall effect of treatment was observed. Due to heterogeneity in follow-up designs and only few data on long-term recovered patients, longitudinal results should be interpreted with caution. While the first steps towards a biomarker in acute AN have been completed, the value of ghrelin as a potential indicator of treatment success or recovery status or its use in subtype differentiation are yet to be established.
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Anorexia Nervosa-What Has Changed in the State of Knowledge about Nutritional Rehabilitation for Patients over the Past 10 Years? A Review of Literature.
Jowik, K, Tyszkiewicz-Nwafor, M, Słopień, A
Nutrients. 2021;(11)
Abstract
Anorexia nervosa (AN) is a psycho-metabolic disorder with a high risk of somatic complications such as refeeding syndrome (RFS) and carries the highest mortality rate of all psychiatric illnesses. To date, the consensus on the care for patients with AN has been based on recommendations for a combination of alimentation and psychotherapy. It is important to establish an initial caloric intake that will provide weight gain and minimize the risk of complications in the treatment of undernourished patients. Research over the past few years suggests that current treatment recommendations may be too stringent and should be updated. The aim of this paper is to systematize the current reports on nutritional rehabilitation in AN, to present the results of studies on the safe supplementation of patients and its potential impact on improving prognosis and the healing process. This review of literature, from 2011-2021, describes the changing trend in the nutritional protocols used and the research on their efficacy, safety, and long-term effects. In addition, it presents previous reports on the potential benefits of introducing vitamin, pro-and prebiotic and fatty acid supplementation.
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Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial.
Garber, AK, Cheng, J, Accurso, EC, Adams, SH, Buckelew, SM, Kapphahn, CJ, Kreiter, A, Le Grange, D, Machen, VI, Moscicki, AB, et al
JAMA pediatrics. 2021;(1):19-27
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Abstract
IMPORTANCE The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome. OBJECTIVE To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa. DESIGN, SETTING, AND PARTICIPANTS In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach. INTERVENTIONS Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day. MAIN OUTCOMES AND MEASURES Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay. RESULTS Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant. CONCLUSIONS AND RELEVANCE In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02488109.
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Body Composition in Adolescents and Young Adults with Anorexia Nervosa: A Clinical Review.
Tannir, H, Itani, L, Kreidieh, D, El Masri, D, Traboulsi, S, El Ghoch, M
Current rheumatology reviews. 2020;(2):92-98
Abstract
BACKGROUND Anorexia nervosa is a serious health condition characterized by a significant low body weight and alteration in body composition components. AIM: In the current paper, we aim to summarize the available literature concerning changes in body fat, lean, and bone masses, during anorexia nervosa and after complete weight restoration. METHODS Data were summarized using a narrative approach based on clinical expertise in the interpretation of the available evidence base in the literature. RESULTS The available data revealed three main findings. Firstly, anorexia nervosa causes a significant reduction in body fat mass, however it is completely restored after short-term weight normalization but with a central adiposity phenotype that does not seem to negatively influence treatment outcomes and appears to normalize after 1 year of normal weight maintenance. Secondly, anorexia nervosa causes a significant reduction in bone mineral density, but weight restoration is associated first (≈12 months) with stabilization of bone mineral density, followed by improvements (after ≈16 months); and finally, with complete normalization (after ≈30 months) after normal-weight maintenance. Thirdly, during anorexia nervosa loss of lean and skeletal body mass occurring in particular from the extremities rather than the central regions has been consistently reported, especially in patients with a Body Mass Index (BMI) ≤ 16.5 Kg/m2 however short-term weight restoration is associated with complete normalization. CONCLUSION Anorexia nervosa adversely affects body composition, however this medical complication seems to be reversible through the main treatment strategy of body weight restoration followed by normal weight maintenance, and this should be openly discussed with patients.
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Feasibility and effect of a Pilates program on the clinical, physical and sleep parameters of adolescents with anorexia nervosa.
Martínez-Sánchez, SM, Martínez-García, TE, Bueno-Antequera, J, Munguía-Izquierdo, D
Complementary therapies in clinical practice. 2020;:101161
Abstract
BACKGROUND AND PURPOSE Anorexia nervosa (AN) becomes chronic, with high physical, psychological and social morbidity and high mortality without early and effective treatment. The impact of physical exercise as a coadjutant to conventional treatment in this clinical population has been studied with favorable results. Although a Pilates program could be beneficial for patients with AN, no study has analyzed its feasibility and effects in adolescents with AN. Therefore, this study evaluated the safety of a Pilates program and investigated the feasibility and effect in adolescents with AN. MATERIALS AND METHODS In this prospective quasi-experimental study, body composition, blood analysis, sedentary time, physical activity and time of sleep, and physical fitness were measured objectively before and after a 10-week Pilates supervised program. RESULTS Twelve female adolescents with AN (14.6 ± 1.7 years old) completed the program, with a session attendance rate of 96%, a persistence rate of 100%. There were significant increases in height, plasma calcium and sleep efficiency. Significant decreases in plasma follitropin, sleep duration and, duration and number of night perturbations were observed. CONCLUSION A Pilates program is safe and feasible in adolescents with AN when they have a controlled and stable weight, and such a program could be a viable alternative among treatment programs to achieve better sleep quality.
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A comparison of food-based decision-making between restricting and binge-eating/purging subtypes of anorexia nervosa.
Uniacke, B, Slattery, R, Walsh, BT, Shohamy, D, Foerde, K, Steinglass, J
The International journal of eating disorders. 2020;(10):1751-1756
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OBJECTIVE By definition, restricting (ANR) and binge-eating/purging (ANBP) subtypes of anorexia nervosa (AN) differ in some manifestations of maladaptive eating behavior. This study aimed to determine whether the groups differ in the choices they make about what to eat, and whether there are differences in valuation related to food choice, using an experimental paradigm. METHOD Inpatients with ANR (n = 40) and ANBP (n = 46) participated in a Food Choice Task. During the task, participants rated 76 food images for healthiness and tastiness, and choice preferences. Groups were compared in percent selection of high-fat and low-fat foods, value ratings of foods, and engagement of self-control in food choice. RESULTS There were no differences between AN subtypes in healthiness or tastiness ratings, or in tendency to limit choice of high-fat foods. There was no difference between the groups in measures of self-control in food choice. DISCUSSION Individuals with ANR and ANBP similarly manifest reduced choices of high-fat foods, with similar tendencies to undervalue the tastiness of high-fat foods. These results suggest that while individuals with ANR and ANBP differ across a range of clinical characteristics, the decision-making process associated with the maladaptive restriction of high-fat foods characteristic of AN is shared by both subtypes.
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Emotional and non-emotional facets of impulsivity in eating disorders: From anorexia nervosa to bulimic spectrum disorders.
Mallorquí-Bagué, N, Testa, G, Lozano-Madrid, M, Vintró-Alcaraz, C, Sánchez, I, Riesco, N, Granero, R, Perales, JC, Navas, JF, Megías-Robles, A, et al
European eating disorders review : the journal of the Eating Disorders Association. 2020;(4):410-422
Abstract
OBJECTIVE Impulsivity and difficulties in regulating emotions are considered to be transdiagnostic characteristics of patients with eating disorders (EDs). The study aimed to investigate trait impulsivity and inhibitory components of impulsivity, related or unrelated to emotions in patients with EDs. METHOD A total of 17 patients with anorexia nervosa (AN), 16 patients with bulimic-spectrum EDs (BSD) and 20 healthy control (HC) participants completed an impulsivity scale (UPPS-P) before performing an emotional inhibitory control task during electroencephalography (EEG) acquisition. RESULTS Higher trait impulsivity in EDs than HC (with higher scores among BSD patients) was observed. However, no differences in behavioural measures or neural indexes [event-related potential (ERP)] of emotional and non-emotional inhibitory control were observed between patients and HC. CONCLUSION The present results highlighted negative urgency, an impulsive personality trait related to emotions, as a common feature of AN and BSD. Lack of perseverance, a trait which is less related to emotions, specifically characterises patients with BSD. On the other hand, behavioural and ERP data did not show altered inhibitory control in EDs, for either general or emotional-related response inhibition.
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Specialist Supportive Clinical Management for anorexia nervosa: what it is (and what it is not).
Jordan, J, McIntosh, VV, Bulik, CM
Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists. 2020;(2):156-159
Abstract
OBJECTIVE Specialist Supportive Clinical Management (SSCM) is a psychotherapy comprising a clinical management focus addressing anorexia nervosa (AN) symptoms and a supportive therapy component. SSCM has been an active control therapy in randomised controlled trials for AN, but has proven to be an effective therapy in its own right. There has been speculation about how this relatively straightforward therapy works. Some of the commentaries and descriptors used for SSCM, however, do not reflect the content or principles of SSCM. This paper clarifies areas of misunderstanding by describing what SSCM is and what it is not, particularly in relation to commentary about its constituent characteristics. CONCLUSIONS SSCM utilises well established clinical management for AN (with a sustained focus on normalised eating and weight restoration) coupled with supportive therapy principles and strategies. Common factors across both arms include core counselling skills and a positive therapeutic alliance to promote adherence and retention in treatment for AN. Compared to other comparator therapies to date, SSCM is a simpler therapy without unique or novel theoretically derived strategies. Comparable outcomes with more complex psychotherapies raise the question of whether the combined core components of SSCM may be sufficient for many people with AN.
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Necrotising enterocolitis in an adult with anorexia nervosa.
Schapira, B, Nazarian, S, Thanapal, M, Parmar, C, Mukhtar, H
Annals of the Royal College of Surgeons of England. 2020;(8):560-565
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Necrotising enterocolitis (NEC) is a rare cause of the acute abdomen in adults and carries one of the highest mortality rates in gastroenterology. However, its rarity confines research to small case reports. Both its pathogenesis and aetiology remain enigmatic in adult patients, proving timely diagnosis and management a challenge. This paper reports on one case of NEC in an adult patient with underlying anorexia nervosa, following a seven-day period of starvation. She underwent emergency laparotomy for resection of necrotic bowel and subsequently made a good recovery. To date, there have only been eight reports linking NEC with anorexia nervosa. We review our patient in the context of plausible mechanisms hypothesised in these cases. Successful management depends on prompt diagnosis, resuscitation and surgical intervention.