Long-term mortality in anorexia nervosa: a report after an 8-year follow-up and a review of the most recent literature.

OBJECTIVE: To evaluate long-term mortality rate of anorexia nervosa (AN) patients in a southern Italy population compared to the most recent literature. DESIGN: Retrospective and review setting. PATIENTS AND INTERVENTIONS: One hundred and forty-seven female AN patients, consecutively admitted from 1994 to 1997 to the Outpatient Unit, were re-examined between June and November 2003. Our data are compared with 10 other studies published since 1988. RESULTS: One hundred and twenty-three deaths in 2240 patients, amounting to a total mortality rate of 5.25% were reported in the literature. Deaths due to suicide, AN-related and AN-unrelated diseases were 1.20, 3.07 and 0.98%, respectively. After correcting for unrelated deaths, mortality rate was 4.27%. In our 8-year follow-up, we found a mortality rate of 2.72% (1.82% after correcting for unrelated deaths). Standardized mortality ratio was 9.7. CONCLUSION: We interpret our favourable findings as a consequence of an integrated, clinical-nutritional and psychiatric approach. Finally, considering AN demographic characteristics, that is young female subjects in Westernized societies, mortality rate is confirmed to be dramatically high.

Hematological complications in anorexia nervosa.

BACKGROUND/OBJECTIVES: Anemia, leukopenia and, although less frequently, thrombocytopenia are possible hematological complications of anorexia nervosa considered strictly secondary to chronic malnutrition. This is a retrospective study on the prevalence of these disorders in a large cohort of 318 female patients with AN (20.4±5.6 years, body mass index (BMI) 15.9±1.6 kg/m2), recruited in the Outpatient Unit for Malnutrition secondary to Eating Disorders at the Department of Clinical Medicine and Surgery, Federico II University Hospital, since February 1991 to December 2012. SUBJECTS/METHODS: Patients were studied on an outpatient basis after obtaining medical history, clinical examination, routine hematobiochemical and endocrine tests, electrocardiography, psychiatric interview and bioelectrical impedance analysis and, in particular, phase angle determination. All patients with other comorbidities, in particular with mean corpuscular volume <80 fl, were excluded for suspected genetic alteration in the synthesis of hemoglobin. RESULTS: Hematologic data showed that 16.7% of patients had anemia, 7.9% neutropenia and 8.9% thrombocytopenia. These abnormalities were strictly related to the duration of illness (P=0.028), and to protein energy malnutrition, in particular, BMI and phase angle (P<0.001). CONCLUSIONS: Our study offers description of the incidence of hematologic defects in a selected and large sample of AN female patients, suggesting that its incidence is related to the degree and duration of protein energy malnutrition.

Comparison of bioelectrical impedance analysis and dual-energy X-ray absorptiometry for the assessment of appendicular body composition in anorexic women.

OBJECTIVE: To establish the accuracy of bioelectrical impedance analysis (BIA) for the assessment of appendicular body composition in anorexic women. DESIGN: Cross-sectional study. SETTING: Outpatient University Clinic. SUBJECTS: A total of 39 anorexic and 25 control women with a mean (s.d.) age of 21 (3) y. METHODS: Total, arm and leg fat-free mass (FFM) were measured by dual-energy X-ray absorptiometry and predicted from total and segmental BIA at 50 kHz. The predictor variable was the resistance index (Rl), that is, the ratio of height (2) to body resistance for the whole body and the ratio of length(2)/limb resistance for the arm and leg. RESULTS: Predictive equations developed on controls overestimated total, arm and leg FFM in anorexics (P<0.0001). Population-specific equations gave a satisfactory estimate of total and appendicular FFM in anorexics (P=NS) but had higher percent root mean square errors (RMSEs%) as compared to those developed on controls (8% vs 5% for whole body, 12% vs 10% for arm and 10% vs 8% for leg). The accuracy of the estimate of total and leg FFM in anorexics was improved by adding body weight (Wt) as a predictor with Rl (RMSE%=5% vs 8% and 7% vs 10%, respectively). However, the same accuracy was obtained using Wt alone, suggesting that in anorexics, BIA at 50 kHz is not superior to Wt for assessing total and leg FFM. CONCLUSION: BIA shows some potential for the assessment of appendicular body composition in anorexic women. However, Wt is preferable to BIA at 50 kHz on practical grounds. Further studies should consider whether frequencies >50 kHz give better estimates of appendicular composition in anorexics as compared to Wt. SPONSORSHIP: University of Napoli.

Heart rate variability as a measure of autonomic nervous system function in anorexia nervosa.

BACKGROUND AND HYPOTHESIS: Alteration in sympathovagal balance may be a mechanism of increased cardiovascular mortality and sudden death of patients with anorexia nervosa. This study was undertaken to characterize cardiac autonomic control in patients with anorexia nervosa by means of heart rate variability analysis. METHODS: Heart period variability by 24-h Holter recording was evaluated in 13 young women with anorexia nervosa, 10 constitutionally thin women, and 10 women of normal weight. RESULTS: High-frequency power, a measure of parasympathetic modulation of heart rate, and all-time domain measures of heart rate variability were higher in patients with anorexia nervosa than in thin women and in those of normal weight. Thin women showed lower values of total power and of most components of power spectrum. CONCLUSIONS: Our data demonstrate an increased vagal tone in young women with anorexia nervosa. The marked increase in parasympathetic activity, not in response to an increase in sympathetic activity, could be detrimental and may contribute to the higher cardiovascular mortality of these patients.

High serum HDL-cholesterol in pre- and post-menopausal women with breast cancer in southern Italy.

Up until now, conflicting results have been reported on the association between serum cholesterol and risk of breast cancer in women. In this study, the serum concentrations of cholesterol, HDL-cholesterol, triglycerides and total lipids in women with breast cancer (BC) have been compared to those of women with benign breast disease (BBD). BC women had higher serum concentration of HDL-cholesterol both in pre- and in post-menopausal age. No difference was observed in the serum concentration of total cholesterol, triglycerides and total lipids. These findings could be explained by an increased estrogen activity which is believed to be involved in the development of breast cancer, and in the modulation of lipid metabolism (lowering LDL-cholesterol and increasing HDL-cholesterol). High serum HDL-cholesterol could be a biochemical index of increased risk of having breast cancer.

[Dietetic therapy of obesity. Preliminary considerations on the combined therapy with ursodeoxycholic acid in the prevention of cholesterol lithiasis]. / Terapia dietetica dell'obesità, Considerazioni preliminari sul trattamento combinato con acido ursodesossicolico nella prevenzione della litiasi colesterinica.

The use of ursodeoxycholic acid (UDCA) was found useful in reducing the incidence of cholelithiasis (p < 0.05) without provoking any other alteration in hepatic function. This preliminary experience underlines the appropriateness of carrying out further studies on the utility of preventive treatment for the formation of cholesterol calculi with biliary acids, and in particular UDCA, in obese subjects who are receiving dietary treatment. The protective action of ursodeoxycholic acid in the prevention of biliary lithiasis during the course of low-calorie diets was evaluated in 40 obese subjects (31 females, 9 males) treated for 4 months with fibre-rich (approximately 40 g/day) low-calorie diets of 900-1200 Kcal, of whom 20 received 450-750 mg of UDCA/day and 20 were treated with placebo.

[Evaluation of body composition in anorexia nervosa]. / Valutazione della composizione corporea nell'anoressia nervosa.

Bioimpedance analysis (BI) of body composition has been carried out in 116 women: 22 patients with anorexia nervosa (AN) and IMC between 16 and 18.5 kg/m2 (MPE-I: weight 45.3+/-3.1 kg; BMI 17.0+/-0.7 kg/m2); 39 AN patients with BMI< 16 kg/m2 (MPE-II: weight 37.2+/-3.8 kg; BMI 14.5+/-1.0 kg/ m2; 55 healthy women (control= CTR: weight 60.5+/-9.0 kg; BMI 22.8+/-3.1 kg/m2). BI was determined for the whole body and for body segments (arms, legs and trunk): phase angle (AF) of 50 kHz and impedance (Z) of 100, 50 and 5 kHz. Body water was estimated from Z to 50 kHz according to Kushner et al. (AJCN 1993). AF and Z100/Z5 (multifrequency BI) were considered as related to the ratio between extracellular water and intracellular water. Total body water was significantly different between the three groups: 26.5+/-2.9 L in the MPE-II group, 23.6+/-2.9 L in the MPE-I group; 30.3+/-3.7 L in the CTR women. In comparison with the CTR group whole-body AF and leg-AF was lower (p<0.01) in the MPE-II patients while both the MPE groups differed from the CTR group with respect to arm-AF. Multifrequency BI showed differences (p<0.01) between all the groups for the whole-body and segmental measures. Significant correlations for AF and Z100/Z5 vs BMI and % BF were apparent only in the MPE-II group. In conclusion, in the AN the marked modifications of BI parameters indicated a relative increase of extracellular water and were related to BMI and % BF in the very undernourished patients.

Bioelectrical impedance phase angle in constitutionally lean females, ballet dancers and patients with anorexia nervosa.

BACKGROUND/OBJECTIVE: Several articles have described body composition in anorexia nervosa, whereas little is known about this issue in underweight ballet dancers and constitutionally lean females. The main aim of this study was to assess whether phase angle (a bioimpedance variable related to body cell mass) differs according to the type of underweight in female adolescents and young women. SUBJECTS/METHODS: Skinfold thicknesses and bioimpedance analysis (whole body and limbs) were evaluated in three groups of underweight patients (30 patients with anorexia nervosa, 10 constitutionally lean individuals and 15 classical dancers) and 30 normal weight controls. RESULTS: There were no differences between the three groups of underweight patients with respect to anthropometric and bioelectrical impedance analysis (BIA) variables with the exception of phase angle. The latter was significantly higher in dancers, lower in anorectic patients and not different in constitutionally lean patients, as compared with controls. CONCLUSIONS: Phase angle (assessed by single-frequency BIA) appears to discriminate between different forms of underweight, being an effective marker of qualitative changes in body composition.

Isospin dependence of incomplete fusion reactions at 25 MeV/nucleon.

40Ca+;{40,48}Ca,46Ti reactions at 25 MeV/nucleon have been studied using the 4pi CHIMERA detector. An isospin effect on the competition between fusionlike and binarylike reaction mechanisms has been observed. The probability of producing a heavy residue is lower in the case of N approximately Z colliding systems as compared to the case of reactions induced on the neutron rich 48Ca target. Predictions based on constrained molecular dynamics II calculations show that the competition between fusionlike and binary reactions in the selected centrality bins can constrain the parametrization of the symmetry energy and its density dependence in the nuclear equation of state.

Fast ternary and quaternary breakup of the 197Au + 197Au system in collisions at 15 MeV/nucleon.

A new reaction mechanism of violent reseparation of a heavy nucleus-nucleus system, 197Au + 197Au, into three or four massive fragments in collisions at 15 MeV/nucleon has been observed. After reseparation, the fragments are almost exactly aligned, thus showing a very short time scale of the reseparation process, of about 70-80 fm/c.

[New international migrations and migratory models in South European countries]. / Le nuove migrazioni internazionali e i modelli migratori nei paesi del Sud Europa.

PIP: Trends in international migration in the Mediterranean European countries over the course of the 1980s are reviewed. "Particular attention is paid to the different factors that explain the arrival of these migratory fluxes during a period of economic recession and in areas where there is a co-presence of immigration, emigration and unemployment. The involvement of southern European countries as target countries for immigration is not seen as a simple consequence of the [restrictive policies] practiced in the Seventies by European countries with traditional immigration; the push towards these countries as well as the pull to the same are also considered, particularly the acceleration of the internationalization process of the labor markets, the characteristics of the labor markets, and processes of segmentation and tertiarization." (EXCERPT)^ieng

Hospital admission and mortality rates in anorexia nervosa: experience from an integrated medical-psychiatric outpatient treatment.

OBJECTIVES: To evaluate the effectiveness of an integrated medical-psychiatric treatment of major eating disorders. DESIGN: Historical cohort study. SETTING: Outpatient Unit for Protein Energy Malnutrition of the Department of Clinical and Experimental Medicine, "Federico II" University of Naples, time of study: January 1994 to December 1997 PARTICIPANTS: 147 female patients with restrictive or bulimic anorexia nervosa (mean age 19.8 +/- 13.7, BMI 14.7 +/- 2.1 Kg/m2) consecutively attending the outpatient unit between January 1994 and December 1997. MAIN OUTCOME MEASURES: Hospitalization and mortality rates were evaluated up to Jan 1999 with a minimum follow-up of 18 months. RESULTS: There were 23 admissions to the Clinical Nutrition ward for 19 patients (i.e. 12.9%) mostly due to severe protein energy malnutrition, and 2 deaths, only 1 strictly related to anorexia (mortality rate 0.7%). CONCLUSIONS: Integrated outpatient medical-psychiatric treatment for major eating disorders is an effective and inexpensive procedure that reduces mortality and admissions due to medical complications in the medium term.

Integrated medical-psychiatric treatment of the "crisis phase" in severe protein-energy malnutrition secondary to major eating disorders.

C.A., a 23-year old male was admitted in the clinical nutrition medical ward for severe, complicated protein-energy malnutrition (PEM) [body mass index (BMI) 11.08 kg/m2; body weight kg 35.81 due to major eating disorders. C.A.'s personality was narcissistic, with a rigid psychic structure. During hospitalitation (lasted 72 days) two acute episodes (a possibly self-inflicted damage and a persecution feeling) occurred that we consider as part of the "crisis phase", the period in which the patient's restrictive behaviour is no longer able to keep his personality equilibrium stable. The patient was treated by an integrated medical and psychiatric approach, including periods of never forced parenteral nutrition, nutritional and intensive psychoterapeutic interventions. For a short period the patient received also a pharmacological support (aloperidol orally). Treatment was successful and the patient was discharged completely autonomous and followed up on an outpatient basis. After about one year follow-up he is still in good clinical condition and in sufficient psychological equilibrium.

Outcome predictors in the short-term treatment of anorexia nervosa: an integrated medical-psychiatric approach.

OBJECTIVES: Factors predicting clinical outcome in the short-term treatment of anorexia nervosa. DESIGN: Longitudinal follow-up study. SETTING: Department of Clinical and Experimental Medicine, "Federico II" University of Naples. PARTICIPANTS: Fifty-eight young anorectic women consecutively attending the outpatient Unit between January 1997 and December 2000. MAIN OUTCOME MEASURES: Body weight changes over six months' follow-up. RESULTS: Body weight changes in the short term was exclusively predicted by the prevalent underlying psychiatric disorder, being increased in the patients with prevalently depressive traits, decreased in those with psychotic features and unchanged in those with a prevalently narcissistic personality. CONCLUSIONS: The prevalent psychiatric disorder seems to predict clinical outcome in the short term. Body weight gain per se cannot always be the main target of medical intervention, at least in the early phase of the treatment of malnutrition secondary to major eating disorders.

The prediction of basal metabolic rate in female patients with anorexia nervosa.

OBJECTIVE: To evaluate in female patients with anorexia nervosa the accuracy of a specific predictive formula for basal metabolic rate (BMR) already proposed in the literature and to derive a new disease-specific equation with the same purpose. DESIGN: Cross-sectional study. SUBJECTS: One-hundred and twenty adolescent girls (<18 y) and young-adult women (18-30 y) with anorexia nervosa. MEASUREMENTS: BMR was determined by indirect calorimetry or predicted according to the Schebendach formula, which was specifically derived for anorexia nervosa. RESULTS: On average the Schebendach formula performed well in the adolescent group but not in the young-adult group. The range including 95% of the predicted-measured differences was in both cases wider than 2000 kJ/day. In the young-adult patients the accuracy of the prediction was also related to age and body mass index. Weight and age (but not height or body mass index) emerged as predictors of BMR in the sample as a whole, and only weight when the two age groups were considered separately, thus leading to three different equations. The intercepts of these regression lines were very close and not significantly different from zero while their standard error of estimate was 500-550 kJ/day. CONCLUSION: The Schebendach formula is not very accurate in estimating the BMR of female anorectic patients. Moreover, in this group the relationship between BMR and weight was altered. The predictive formulas proposed by the present study have a reasonable prediction power.

Are the general equations to predict BMR applicable to patients with anorexia nervosa?

AIM: To determine whether the general equations to predict basal metabolic rate (BMR) can be reliably applied to female anorectics. INDIVIDUALS AND METHODS: Two hundred and thirty-seven female patients with anorexia nervosa (AN) were divided into an adolescent group [n=43, 13-17 yrs, 39.3+/-5.0 kg, body mass index (BMI) (weight/height) 15.5+/-1.8 kg/m2] and a young-adult group (n=194, 18-40 yrs, 40.5+/-6.1 kg, BMI 15.6+/-1.9 kg/m2). BMR values determined by indirect calorimetry were compared with those predicted according to either the WHO/FAO/UNU or the Harris-Benedict general equations, or using the Schebendach correction formula (proposed for adjusting the Harris-Benedict estimates in anorectics). RESULTS: Measured BMR was 3,658+/-665 kJ/day in the adolescent and 3,907+/-760 kJ/day in the young-adult patients. In the adolescent group, the differences between predicted and measured values were (mean+/-SD) 1,466 529 kJ/day (+44+/-21%) for WHO/FAO/UNU, 1,587+/-552 kJ/day (+47+/-23%) for the Harris-Benedict and -20+/-510 kJ/day for the Schebendach (+1+/-13%), while in the young-adult group the corresponding values were 696+/-570 kJ/day (+24+/-24%), 1,252+/-644 kJ/day (+37+/-27%) and -430+/-640 kJ/day (-9+/-16%). The bias was negatively associated with weight and BMI in both groups when using the WHO/FAO/UNU and Harris-Benedict equations, and with age in the young-adult group for the Harris-Benedict and Schebendach equations. CONCLUSIONS: The WHO/FAO/UNU and Harris-Benedict equations greatly overestimate BMR in AN. Accurate estimation is to some extent dependent on individual characteristics such as age, weight or BMI. The Schebendach correction formula accurately predicts BMR in female adolescents, but not in young adult women with AN.

Familial and environmental influences on body composition and body fat distribution in childhood in southern Italy.

The aim of this paper was to evaluate the factors affecting body fat excess and distribution in prepubertal age. A cross-sectional survey was carried out on children attending the 4th grade of a primary school in Naples. Eighty-eight per cent of the total sample was examined: 52 girls, 58 boys; mean age = 9.6 yrs (s.e. +/- 0.10). Each child underwent a medical examination, anthropometric measurements and bio-impedance analysis of body composition. The parents were asked to fill in a questionnaire that included demographic data, family history, parent's weight and height, child's perinatal history and his or her involvement in sports activities. Data were analyzed by multiple linear regression. The results showed a direct correlation between parental BMI and children's anthropometric measurements: the children's BMI correlated with the fathers' (P = 0.02) and mothers' BMI (P = 0.027); the children's waist/hip ratio correlated with the fathers' BMI (P = 0.07); the children's subscapular skinfolds correlated with the father's (P = 0.07) and mothers' BMI (P = 0.02); the children's triceps skinfolds correlated with the fathers' BMI (P = 0.004). Among congenital factors, sex was shown to be correlated with the children's waist/hip ratio (P = 0.05) with a lower ratio in the female, indicating a sex influence on body fat distribution even in prepubertal age. The children's BMI correlated with their waist/hip ratio (P = 0.001). Children's systolic blood pressure showed a positive correlation with triceps (P = 0.04) and subscapular (P = 0.05) skinfolds thickness % FAT-PLI (P = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Determinants of body fat in prepubertal age]. / Determinanti della massa corporea lipidica in età prepuberale.

In order to evaluate the factors affecting body fat excess and distribution, we have studied children attending the 4th grade of a primary school randomly selected in Naples. 52 girls, 58 boys; mean age = 9.6 years (SE +/- 0.1) were examined. Among the familial factors assessed, a correlation between parental BMI and child's anthropometry was found. Among congenital factors, sex correlates with the children's waist/hip ratio ("t" = -2.07; p = 0.05). Moreover the girl's percent body fat was higher. These two findings suggest the expression of sexual characters in prepubertal age. Systolic blood pressure showed a positive correlation with children's percent body fat ("t" = 2.43; p = 0.016) and subscapular skinfold thickness ("t" = 1.19; p = 0.05), suggesting an influence of these factors on blood pressure level since this age. No correlation was found between children's BMI and weight at birth, family history of diabetes, hypertension or hyperlipidemia. Among environmental factors, only the mothers weight gain during pregnancy ("t" = -2.21; p = 0.03) and breast feeding ("t" = -2.07; p = 0.05) correlated with the children's BMI. The correlation between children's BMI and waist/hip ratio ("t" = 4.64; p = 0.0001), was not confirmed in children who exercise, suggesting a beneficial action of physical activity on body fat distribution. The identification in different populations of factors associated with childhood obesity is important for prevention planning.

Assessment of cardiac autonomic control by heart period variability in patients with early-onset familial obesity.

For quantitative assessment of cardiac autonomic control, time and frequency domain measures of heart period variability were calculated by 24 h Holter recording in 10 young obese women with early-onset familial obesity and in 10 control subjects. Ultra low frequency and very low frequency power were lower in obese subjects than in controls (P < 0.05). High frequency power, a pure measure of vagal tone, was comparable between the two groups. However, low frequency power, which analysed over a 24 h Holter recording reflects parasympathetic more than sympathetic activity, was slightly lower in obese subjects than in controls (P = 0.06). Body mass index showed an inverse correlation with total power (r = -0.62; P < 0.05) and separately with ultra low (r = -0.59; P < 0.01), very low (r = -0.64; P < 0.005), low (r = -0.61; P < 0.005) and high frequency power (r = -0.53; P < 0.05). These results demonstrate a parasympathetic withdrawal increasing body weight. The reduction of ultra low frequency and very low frequency power, which are associated with sudden death, may help to explain the higher cardiovascular risk in obesity.