[Prevention of eating disorders in obesity]. / Prevención de los trastornos de laconducta alimentaria en la obesidad.

Introduction: Obesity is a public health problem due to its high prevalence, high morbidity, and high mortality. The relationship between eating disorders (ED) and obesity is widely established. A healthcare professional that cares for people with obesity must take into account a series of best practices to minimize the risk of developing an ED in the course of treatment for weight loss. Bariatric surgery (BS) is an effective, long-term treatment in selected patients with severe obesity. During the preoperative period, it is essential to detect any ED due to its high prevalence in this group. After surgery, the presence of a post-op ED and its possible relationship in terms of poorer outcomes make screening during follow-up after surgery essential. From a preventive perspective, cognitive-behavioral therapy before BS could positively influence postoperative results, and its use after BS could improve weight loss efficacy and reduce binge eating and grazing. From a more holistic preventive perspective, many believe in an integrative approach to both obesity and ED. In order to be successful, it is essential to identify any relevant risk and protective factors for both disorders.

Introducción: La obesidad constituye un problema de salud pública por su alta prevalencia y elevada morbimortalidad. La relación entre los trastornos de la conducta alimentaria (TCA) y la obesidad está ampliamente establecida. Es importante que el profesional que atiende a personas con obesidad tenga en cuenta una serie de premisas que minimicen el riesgo de aparición de un trastorno alimentario en el transcurso del tratamiento para perder peso. La cirugía bariátrica (CB) constituye un tratamiento efectivo a largo plazo en los pacientes adecuadamente seleccionados con obesidad grave. Por un lado, la elevada prevalencia de los TCA en este colectivo hace imprescindible la detección de estos trastornos en el preoperatorio. Por otro lado, la presencia de los TCA después de la cirugía y su posible relación en cuanto a peores resultados hace fundamental el cribado durante el seguimiento tras la intervención. Desde el punto de vista preventivo, la realización de una terapia cognitivo-conductual antes de la CB podría influir positivamente en los resultados posoperatorios y su empleo después podría mejorar la eficacia en cuanto a pérdida de peso y disminuir los atracones y el "grazing". Desde una perspectiva más global en relación a la prevención, son muchos quienes apuestan por un enfoque integrador para la obesidad y los TCA. Para ello es fundamental identificar los factores de riesgo y los protectores que tengan relevancia en ambos trastornos.

Narrative review: Risk of eating disorders and nutritional deficiencies with dietary therapies for irritable bowel syndrome.

BACKGROUND AND AIMS: Dietary treatments are growing in popularity as interventions for chronic digestive conditions. Patients with irritable bowel syndrome (IBS) often change their eating behaviors to mitigate symptoms. This can occur under the direction of their physician, a dietitian, or be self-directed. Poorly implemented and monitored diet treatments occur frequently with considerable risks for negative consequences. We aim to review the literature related to dietary treatments and risks associated with nutritional deficiencies and disordered eating. METHODS: Searches were conducted from June to December 2020 on PubMed, MEDLINE, EMBASE, DARE and the Cochrane Database of Systematic Reviews using relevant keywords based on the Patient, Intervention, Comparator and Outcome (PICO) format. Studies included both adult and pediatric populations. Results are synthesized into a narrative review. RESULTS: While dietary approaches are efficacious in many research studies, their translation to clinical practice has been less clear. Patients with IBS are at risk for nutritional deficiencies, disordered eating, increased anxiety, and decreases in quality of life in both adult and pediatric groups. CONCLUSIONS: Physicians prescribing dietary treatment for IBS should be aware of nutritional and psychological risks and implement mitigation measures. These include using a combination of brief, validated questionnaires and clinical history, and collaboration with registered dietitians and/or psychologists. Recommendations for clinical decisions are provided.

Maternal dietary imbalance between omega-6 and omega-3 fatty acids triggers the offspring's overeating in mice.

The increasing prevalence of obesity and its effects on our society warrant intensifying basic animal research for understanding why habitual intake of highly palatable foods has increased due to recent global environmental changes. Here, we report that pregnant mice that consume a diet high in omega-6 (n-6) polyunsaturated fatty acids (PUFAs) and low in omega-3 (n-3) PUFAs (an n-6high/n-3low diet), whose n-6/n-3 ratio is approximately 120, induces hedonic consumption in the offspring by upregulating the midbrain dopaminergic system. We found that exposure to the n-6high/n-3low diet specifically increases the consumption of palatable foods via increased mesolimbic dopamine release. In addition, neurodevelopmental analyses revealed that this induced hedonic consumption is programmed during embryogenesis, as dopaminergic neurogenesis is increased during in utero access to the n-6high/n-3low diet. Our findings reveal that maternal consumption of PUFAs can have long-lasting effects on the offspring's pattern for consuming highly palatable foods.

Combined mutations of NKX2-1 and surfactant protein C genes for refractory low oxyhemoglobin saturation and interstitial pneumonia: A case report.

RATIONALE: Mutations of the NKX2-1 gene are associated with brain-lung-thyroid syndrome, which is characterized by benign hereditary chorea, hypothyroidism, and pulmonary disease with variable presentation. Surfactant protein C (SFTPC) gene mutations result in chronic interstitial lung disease in adults or severe neonatal respiratory distress syndrome. PATIENT CONCERNS: Recurrent hypoxemia was observed shortly after birth in a baby at a gestational age of 40 weeks and birth weight of 3150 g. The need for respiratory support gradually increased. He had hypothyroidism and experienced feeding difficulties and irritability. DIAGNOSIS: Genetic examination of the peripheral blood revealed combined mutations of the NKX2-1 and SFTPC genes. INTERVENTIONS: The patient was administered respiratory support, antibiotics, low-dose dexamethasone, supplementary thyroxine, venous nutrition, and other supportive measures. OUTCOMES: The patient's guardian stopped treatment 3 months after commencement of treatment, due to the seriousness of his condition and the patient died. LESSONS: Combined mutations of NKX2-1 and SFTPC genes are very rare. Thus, idiopathic interstitial pneumonia with hypothyroidism and neurological disorders require special attention.

Higher body mass index is linked to altered hypothalamic microstructure.

Animal studies suggest that obesity-related diets induce structural changes in the hypothalamus, a key brain area involved in energy homeostasis. Whether this translates to humans is however largely unknown. Using a novel multimodal approach with manual segmentation, we here show that a higher body mass index (BMI) selectively predicted higher proton diffusivity within the hypothalamus, indicative of compromised microstructure in the underlying tissue, in a well-characterized population-based cohort (n1 = 338, 48% females, age 21-78 years, BMI 18-43 kg/m²). Results were independent from confounders and confirmed in another independent sample (n2 = 236). In addition, while hypothalamic volume was not associated with obesity, we identified a sexual dimorphism and larger hypothalamic volumes in the left compared to the right hemisphere. Using two large samples of the general population, we showed that a higher BMI specifically relates to altered microstructure in the hypothalamus, independent from confounders such as age, sex and obesity-associated co-morbidities. This points to persisting microstructural changes in a key regulatory area of energy homeostasis occurring with excessive weight. Our findings may help to better understand the pathomechanisms of obesity and other eating-related disorders.

Congruence of multiple patient-related outcomes within a single day.

OBJECTIVE: Clinic-based collection of patient-reported outcome (PRO) quantifying symptom burden provide crucial information for effective care. We have pioneered point-of-care electronic assessment using the Edmonton Symptom Assessment Scale (ESAS) with direct linkage to the electronic medical record (EMR) which has been readily adopted by our oncology patients. As some patients may complete more than one ESAS per day in different clinics, the goal of the current analyses was to compare the within-patient congruence of ESAS assessments completed on the same day. METHODS: A total of 9621 ESAS records from 4021 patients of the Supportive Care Medicine and Radiation Oncology clinics between February and November 2017 were retrieved from the EMR. Patients completed the ESAS-r-CSS, which added sleep disturbance, constipation, and spiritual well-being domains to the standard ESAS-r. RESULTS: A total of 65 patients provided more than one ESAS report within the same day. The data were curated, removing those sporadic missing data and those with obvious technical error. This process left 130 samples for analysis. There was no statistical difference among different ESAS collection intervals for domains of tiredness, nausea, appetite, overall well-being, spiritual well-being, constipation, and difficulty sleeping, but there was a significant difference for pain, drowsiness, shortness of breath, depression, and anxiety. Repeat tests that occurred within 1 h of one another demonstrated higher congruence than those completed over longer periods. CONCLUSION: Patients reported significant worsening of several symptoms over the course of the day, with greatest concordance observed within smaller time periods.

Determining the relationship between body mass index, healthy lifestyle behaviors and social appearance anxiety.

The aim of this study was to describe the relationship between nutritional status, healthy lifestyle behaviors and social appearance anxiety of individuals aged 20-65 (n = 500). A significant, positive relationship was seen between body mass index and nutrition, and negative relationship between body mass index and spiritual development, interpersonal relations, stress management. There was a negative relationship between the ORTO-15 score and health responsibility, physical activity, nutrition, spiritual development, interpersonal relationships, stress management. There was also a negative relationship between the Social Appearance Anxiety Scale and spiritual development, interpersonal relationships.

Psychological Considerations and Interventions in Inflammatory Bowel Disease Patient Care.

The presence of psychological comorbidities, specifically anxiety and depression, is well documented in inflammatory bowel disease (IBD). The drivers of these conditions typically reflect 4 areas of concern: disease impact, treatment concerns, intimacy, and stigma. Various demographic and disease characteristics increase risk for psychological distress. However, the risk for anxiety and depression is consistent throughout IBD course and is independent of disease activity. Early intervention before psychological distress becomes uncontrolled is ideal, but mental health often is unaddressed during patient visits. Understanding available psychological treatments and establishing referral resources is an important part of the evolution of IBD patient care.

Copper deficiency caused by excessive alcohol consumption.

Copper deficiency is a disease that causes cytopaenia and neuropathy and can be treated by copper supplementation. Long-term tube feeding, long-term total parenteral nutrition, intestinal resection and ingestion of zinc are known copper deficiency risk factors; however, alcohol abuse is not. In this case, a 71-year-old man had difficulty waking. He had a history of drinking more than five glasses of spirits daily. He was well until 3 months ago. A month before his visit to our hospital, he could not eat meals but continued drinking. He had macrocytic anaemia on admission. Copper and ceruloplasmin levels were markedly low, and we diagnosed copper deficiency. There were no other known risk factors for copper deficiency. After he began drinking cocoa as a copper supplement, the anaemia ameliorated and he was able to walk. This is the first report showing alcohol abuse as a risk factor for copper deficiency.

Pediatric feeding and swallowing rehabilitation: An overview.

Children with neurological disabilities frequently have problems with feeding and swallowing. Such problems have a significant impact on the health and well-being of these children and their families. The primary aims in the rehabilitation of pediatric feeding and swallowing disorders are focused on supporting growth, nutrition and hydration, the development of feeding activities, and ensuring safe swallowing with the aim of preventing choking and aspiration pneumonia. Pediatric feeding and swallowing disorders can be divided into four groups: transient, developmental, chronic or progressive.This article provides an overview of the available literature about the rehabilitation of feeding and swallowing disorders in infants and children. Principles of motor control, motor learning and neuroplasticity are discussed for the four groups of children with feeding and swallowing disorders.

Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder.

CASE: Kendra is a 4-year-old girl with autism spectrum disorder (ASD) who presents for follow-up of feeding problems to her pediatric clinician. She is an only child in a family where both parents are scientists. Feeding concerns date to infancy, when she was diagnosed with Gastroesophageal Reflux Disease (GERD) associated with persistent bottle refusal and the acceptance of few pureed foods. At 13 months, milk and peanut allergies were diagnosed. Following a feeding clinic evaluation at 24 months, she was prescribed a soy milk supplement and an H2 blocker. There was no concern for oral-motor dysfunction. She was also referred to early intervention for feeding therapy. However, her parents terminated participation after 6 months because she became anxious and had tantrum prior to treatment groups.She was seen in another feeding program at 3 years; zinc, folate, thyroid, and a celiac panel were normal, and an endoscopy was negative for eosinophilic esophagitis. She began individual feeding therapy, where concerns for rigidity, difficulty transitioning, and limited peer interactions led to a neuropsychological evaluation. Kendra was diagnosed with an ASD and avoidant/restrictive food intake disorder (ARFID). Her cognitive skills were average, and expressive and receptive language skills were low average.Her diet consisted of French fries, Ritz crackers, pretzels, and 32 ounces of soy formula daily. She had stopped accepting Cheerios and saltines 2 months prior. She controlled other aspects of feeding, insisting on a specific parking spot at a fast food restaurant and drinking from a particular sippy cup. Her parents accepted these demands with concern about her caloric intake, which they tracked daily.Following diagnosis with ARFID, she resumed feeding therapy using a systematic desensitization approach with rewards. At the first session, she kissed and licked 2 new foods without gagging. Her mother appeared receptive to recommendations that included continuing the "food game" at home, replacing 1 ounce of soy formula by offering water each day, limiting between-meal grazing, and refusing specific feeding demands.Currently, her parents plan to discontinue feeding therapy with concerns that the treatment was "too harsh." Her father produces logs of her caloric and micronutrient intake as evidence that she did not replace missed formula with other foods and reports that she subsequently became more difficult to manage behaviorally. Her father now demands to see randomized controlled trials of feeding therapy approaches. Her weight is stable, but she has now limited her pretzel intake to a specific brand. How would you approach her continued care?

Severe vitamin C deficiency in a child newly diagnosed with T-cell ALL due to nutrient gap.

A 10-year-old boy developed a perifollicular rash during interim maintenance of T-Cell acute lymphoblastic leukaemia. Differential diagnoses included drug reaction and inflammatory process. Before diagnosis, the patient had a limited diet--low in vegetables and fruits--due to selective eating, with later anorexia and taste aversions due to chemotherapy treatment. Despite nutritional counselling and starting a multivitamin, the patient incurred severe weight loss (18.5% of his usual body weight). Serum levels of ascorbic acid were non-detectable, at <5 µmol/L, indicative of vitamin C deficiency. The patient began vitamin C supplementation containing 125 mg ascorbic acid three times a day for 7 days, then 125 mg once daily for 3 months to normalise serum vitamin C. After ascorbic acid treatment was completed, the patient started a complete multivitamin and made efforts to eat fruits and vegetables rich in vitamin C. His serum ascorbic acid concentrations normalised to 52 µmol/L 3 months after receiving supplementation.

Craniopharyngioma and hypothalamic injury: latest insights into consequent eating disorders and obesity.

PURPOSE OF REVIEW: Hypothalamic alterations, pathological or treatment induced, have major impact on prognosis in craniopharyngioma patients mainly because of consequent hypothalamic obesity. Recent insight in molecular genetics, treatment strategies, risk factors and outcomes associated with hypothalamic obesity provide novel therapeutic perspectives. This review includes relevant publications since 2013. RECENT FINDINGS: Recent findings confirm that alterations in posterior hypothalamic areas because of tumour location and/or treatment-related injuries are associated with severe hypothalamic obesity, reduced overall survival and impaired quality of life in long-term survivors of childhood-onset craniopharyngioma. However, eating disorders are observed because of hypothalamic obesity without clear disease-specific patterns. Treatment options for hypothalamic obesity are very limited. Treatment with invasive, nonreversible bariatric methods such as Roux-en-Y gastric bypass is most efficient in weight reduction, but controversial in the paediatric population because of medical, ethical, and legal considerations. Accordingly, treatment in craniopharyngioma should focus on prevention of (further) hypothalamic injury. Presurgical imaging for grading of hypothalamic involvement should be the basis for hypothalamus-sparing strategies conducted by experienced multidisciplinary teams. SUMMARY: Until a nonsurgical therapeutic option for hypothalamic obesity for paediatric patients is found, prevention of hypothalamic injury should be the preferred treatment strategy, conducted exclusively by experienced multidisciplinary teams.

[Posterior reversible encephalopathy syndrome of the midbrain and hypothalamus - a case report of uremic encephalopathy presenting with hypersomnia].

We report the case of a 73-year-old woman presenting with hypersomnia and loss of appetite. She suffered from diabetic nephropathy without receiving dialysis, in addition to hypertension, which was well controlled without marked fluctuation. There were no objective neurological findings. Her laboratory findings showed renal failure with 3.7 mg/dl of serum creatinine and decreased serum sodium and potassium. Brain magnetic resonance imaging (MRI) showed posterior reversible encephalopathy syndrome (PRES) with vasogenic edema, which was distributed in the dorsal midbrain, medial thalamus, and hypothalamus. After we addressed the electrolyte imbalance and dehydration, her symptoms and MRI findings gradually improved, but faint high signals on MRI were still present 3 months later. Orexin in the cerebrospinal fluid was decreased on admission, but improved 6 months later. We diagnosed uremic encephalopathy with atypical form PRES showing functional disturbance of the hypothalamus.

Detailed volumetric analysis of the hypothalamus in behavioral variant frontotemporal dementia.

Abnormal eating behaviors are frequently reported in behavioral variant frontotemporal dementia (bvFTD). The hypothalamus is the regulatory center for feeding and satiety but its involvement in bvFTD has not been fully clarified, partly due to its difficult identification on MR images. We measured hypothalamic volume in 18 patients with bvFTD (including 9 MAPT and 6 C9orf72 mutation carriers) and 18 cognitively normal controls using a novel optimized multimodal segmentation protocol, combining 3D T1 and T2-weighted 3T MRIs (intrarater intraclass correlation coefficients ≥0.93). The whole hypothalamus was subsequently segmented into five subunits: the anterior (superior and inferior), tuberal (superior and inferior), and posterior regions. The presence of abnormal eating behavior was assessed with the revised version of the Cambridge Behavioural Inventory (CBI-R). The bvFTD group showed a 17% lower hypothalamic volume compared with controls (p < 0.001): mean 783 (standard deviation 113) versus 944 (73) mm(3) (corrected for total intracranial volume). In the hypothalamic subunit analysis, the superior parts of the anterior and tuberal regions and the posterior region were significantly smaller in the bvFTD group compared with controls. There was a trend for a smaller hypothalamic volume, particularly in the superior tuberal region, in those with severe eating disturbance scores on the CBI-R. Differences were seen between the two genetic subgroups with significantly smaller volumes in the MAPT but not the C9orf72 group compared with controls. In summary, bvFTD patients had lower hypothalamic volumes compared with controls. Different genetic mutations may have a differential impact on the hypothalamus.

Weight loss and psychological-related states in high-level judo athletes.

PURPOSE: This study aimed at comparing weight loss methods (WLM) performed near competition by elite judo athletes from different age and gender groups and relating WLM with the prevalence of eating disorders. METHODS: 144 athletes (66 females and 78 males) from the Spanish judo teams participated in this observational descriptive study grouped into cadets, juniors, and seniors. Data were collected during previous training meetings to international tournaments. The used tools are a basic data questionnaire, State-Trait Anxiety Inventory (STAI-T), Food Craving Questionnaire-Trait (FCQ-T), Restraint Scale (RS), and Eating Attitude Test (EAT- 40). Two-way ANOVAs and chi-square tests were used to compare groups. RESULTS: Seniors presented higher use of WLM, especially one week before competition compared with juniors. Judoists were more involved in their diets and reduced more weight as they were older. Females were more concerned about their diets, presented higher anxiety, scored higher in the emotion scale, and more eating disorders symptoms, although weight loss was lower. Anxiety and eating disorders symptoms differences were more common in juniors and cadets, respectively, with higher scores in females. CONCLUSIONS AND IMPLICATIONS: Seniors seem to develop more effective strategies to cope with weight loss. Cadet and junior females are more likely to suffer from the psychological-related states associated to weight loss. IMPLICATIONS: (1) Educational programs might help competitors and coaches to adopt and promote healthier weight loss processes, (2) special attention should be paid to female young judoists to detect eating disorders in its early stages, and (3) judo organizations should consider implementing new rules to sanction harmful weight loss practices.

Loss of pons-to-hypothalamic white matter tracks in brainstem obesity.

Hyperphagia and obesity have been reported following damage to the hypothalamus in humans. Other brain sites are also postulated to be involved in the control of food intake and body weight regulation, such as the amygdala and brainstem. The brainstem, however, is thought to primarily integrate short-term meal-related signals but not affect long-term alterations in body weight, which is controlled by higher centers. The objective of this study was to identify structural pathways damaged in a patient with a brainstem cavernoma who experienced sudden onset of hyperphagia and >50 kg weight gain in <1 year following surgical drainage via a midline suboccipital craniotomy. Diffusion tensor imaging revealed loss of nerve fiber connections between her brainstem, hypothalamus and higher brain centers with preservation of motor tracks. Imaging and endocrine testing confirmed normal hypothalamic structure and function. Gastric bypass surgery restored normal appetite and body weight to baseline. This is the first report of 'brainstem obesity' and adds to the brain regions that can determine the long-term body weight set point in humans.

Behavior changes after minor emergency procedures.

OBJECTIVES: Procedures are common in pediatric emergency departments and frequently cause distress from pain and/or anxiety. The objective of this study was to describe the incidence, types, and magnitude of long-term behavior changes after procedures in the emergency setting. METHODS: This is a descriptive pilot study to determine if children display negative behavioral changes after a minor emergency department procedure (abscess drainage or laceration repair). Behavior change was measured at 1 week by telephone follow-up using the 27-item Post Hospitalization Behavior Questionnaire, a well-validated instrument that measures behavior changes across 6 categories: general anxiety, separation anxiety, anxiety about sleep, eating disturbances, aggression toward authority, and apathy/withdrawal. Significant behavior change was defined as 5 or more negative behavior changes on the 27-item questionnaire. RESULTS: Twenty percent of children who underwent abscess drainage (n = 30) and 20% who underwent laceration repair (n = 30) displayed significant negative behavior change at 1 week. Children who displayed significant negative behavior change tended to be younger (3.6 vs 5.9 years) and trended toward being more likely to have received anxiolysis or sedation (16.7% vs 8.3%). Separation anxiety, sleep difficulties, and aggression toward authority were the most common behavior changes. CONCLUSIONS: In this pilot study, a significant percentage of children undergoing common emergency procedures exhibited an appreciable burden of negative behavior change at 1 week; these results demonstrate the need for further rigorous investigation of predictors of these changes and interventions, which can ameliorate these changes.