Determinants and risk factors for renal damage: where do patients hospitalized for severe anorexia nervosa stand? A multi-center study.

BACKGROUND: Although renal damage is increasingly reported among the most undernourished patients with Anorexia Nervosa (AN), it remains underestimated in current practice, and often associated with acute dehydration. The purpose of our study was to evaluate the frequency, the extent, and the risk factors of renal involvement among adolescents and adults hospitalized in specialized units for AN. METHODS: In this multi-center study, 197 consecutive participants were included, aged 13-65, from 11 inpatient eating disorder psychiatric units. Information on the course of AN, clinical characteristics, biological data, and medication were collected. RESULTS: At admission, mean BMI was 13.1 (± 1.6) kg/m2 for a mean age of 20.74 (± 6.5) years and the z-score was - 3.6 (± 1.33). Six participants (3.0%) had hyponatremia, four (2.0%) had hypokalemia, and nine (4.5%) had hypochloremia. The Blood Urea Nitrogen/Creatinine ratio was over 20 for 21 (10.6%) participants. The mean plasma creatinine was 65.22 (± 12.8) µmol/L, and the mean eGFR was 74.74 (± 18.9) ml/min. Thirty- five participants (17.8%) had an eGFR > 90 ml/min, 123 (62.4%) from 60 to 90 ml/min, 35 (17.8%) from 45 to 60 ml/min, and 4 (2%) under 45 ml/min. In multivariate analysis, only BMI on admission was a determinant of renal impairment. The lower the BMI the more severe was the renal impairment. CONCLUSION: When eGFR is calculated, it highlights renal dysfunction found in severe AN requiring hospitalisation in specialized units. The severity of undernutrition is an independent associated factor. Kidney functionality tests using eGFR, in addition to creatinine alone, should be part of routine care for patients with AN to detect underlying renal dysfunction.

AN is a psychiatric illness with organic repercussions that are not always visible nor frequently investigated. Renal damage, if detected, is often attributed to dehydration, and is thought to be rapidly reversible. Assessment of its severity and evolution is therefore not systematic, even in eating disorder units specialised in the care of patients with AN. Our study explored the assessment of renal impairment among adolescents and adults hospitalized in psychiatric units using eGFR calculation. Our results showed that fewer than 18% of the patients hospitalized had normal renal function and that among the various criteria, only BMI on admission was related to the extent of this impairment. Assessment of renal function by eGFR calculation and not only by creatinine measures should be performed routinely in all situations requiring hospitalization in anorexia nervosa, regardless of the reason for hospitalization.

Trajectories and predictive factors of weight recovery in patients with anorexia nervosa completing treatment. A latent class mixed model approach.

BACKGROUND: Treatment of anorexia nervosa (AN) sometimes requires hospitalisation, which is often lengthy, with little ability to predict individual trajectory. Depicting specific profiles of treatment response and their clinical predictors could be beneficial to tailor inpatient management. The aim of this research was to identify clusters of weight recovery during inpatient treatment, and their clinical predictors. METHODS: A sample of 181 inpatients who completed a treatment programme for AN was included in a retrospective study. A latent class mixed model approach was used to identify distinct weight-gain trajectories. Clinical variables were introduced in a multinomial logistic regression model as predictors of the different classes. RESULTS: A four-class quadratic model was retained, able to correctly classify 63.7% of the cohort. It encompassed a late-rising, flattening, moderate trajectory of body mass index (BMI) increase (class 1), a late-rising, steady, high trajectory (class 2), an early-rising, flattening, high trajectory (class 3) and an early-rising, steady, high trajectory (class 4). Significant predictors of belonging to a class were baseline BMI (all classes), illness duration (class 2), and benzodiazepine prescription (class 3). CONCLUSION: Predicting different kinetics of weight recovery based on routinely collected clinical indicators could improve clinician awareness and patient engagement by enabling shared expectations of treatment response.

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.

Somatic Outcomes and Nutritional Management of Anorexia Nervosa.

This Special Issue of Nutrients, entitled "Nutritional Management and Outcomes in Anorexia Nervosa", aims to advance aspects of the scientific understanding of some serious or frequent somatic involvements and of the precocious nutrition management of severe forms of the disease in order to assist clinicians in the management of such patients [...].

Association of gut-specific non-inflammatory T lymphocytes with chronic anorexia nervosa and constitutional thinness.

OBJECTIVE: Previous studies of AN showed low-grade inflammation. Are low-grade inflammation and circulating lymphocytes associated with chronic conditions? METHOD: Peripheric blood cytokines were measured using Luminex™ technology in a chronic AN cohort (mean = 67.42 months), compared to Constitutional Thinness (CT), Constitutional Obesity (CO), and Healthy Controls (HC). Secondarily a prospective cohort of chronic AN (mean = 54.11 months) was recruited to compare the functional lymphocyte profile in blood by flow cytometry to CT and HC. RESULTS: In the AN group, most cytokine concentrations were lower than in CT and HC groups. The IL-23 (98.02 pg/ml) was elevated related to HC and CO, and the IL-10 (4.178 pg/ml) was elevated versus CO. In the CT group, IL-9 (0.06216 pg/ml) was elevated compared to AN. The AN group had high Treg (9.259% of CD4+ ) and CD8+ Integrinß7+ (9.552% of CD3+ ) versus HC for lymphocyte populations. In CT group, elevated Treg (9.7% of CD4+ ) elevated percentage of CD4+ CCR9+ (5.867% of CD3+ ) and CD8+ Integrinß7+ (10.21% of CD3+ ) were found versus HC. CONCLUSIONS: The chronic state of AN and CT is surprisingly non-inflammatory with elevated Treg cells. These results suggest that maintaining a dysregulated response to intestinal antigens may contribute to maintaining AN.

The Fitter I Am, the Larger I Feel-The Vicious Circle of Physical Exercise in Anorexia Nervosa.

Introduction: Body image distortion is a core symptom of anorexia nervosa (AN), embodying dissatisfaction and overvaluation of body appearance and weight. Body image distortion is an important factor in the maintenance of weight loss behaviours such as compulsive physical exercise. Conversely, physical exercise seems to have an aggravating effect on body image in patients with AN, but the evidence is still poor. The aim of this study was to examine the relationship between body image distortion and physical exercise in AN in order to understand whether physical exercise may play a specific role in body image distortion beyond psychopathological severity. Methods: Forty patients with AN and 21 healthy controls were tested for body image distortion and different proxies of physical exercise. Univariate correlations tested the relationship between body image distortion and physical exercise in AN and control groups. Then, to experimentally assess the effect of exercise on body image distortion, participants were invited to rate their body image before and after a standardised effort test. Results: In the AN group, a correlation was found between physical activity and body image distortion (p < 0.01), which was still significant after controlling for psychopathological severity. No correlation was found in healthy controls. After a standardised effort, patients with AN had higher increases in body image distortion than healthy controls (almost 4 kg/m2 vs. 0.8 kg/m2) (p < 0.01). Discussion: Physical exercise may contribute to the distortion of body image in anorexia nervosa and explain the paradoxical augmentation of unhealthy exercise despite ongoing weight loss.

Roseburia, a decreased bacterial taxon in the gut microbiota of patients suffering from anorexia nervosa.

Anorexia nervosa (AN) is a severe eating disorder which can lead to malnutrition and life threatening complications with high mortality rates. We designed our analysis to identify gut microbial taxa differentially abundant between AN and HC across different 16S rRNA gene datasets. We identified a reduced abundance, diversity and richness of Roseburia genus in the microbiota of patients with AN. Cares leading to partial recovery of patients with AN during hospitalization did not restore Roseburia to the levels of HC. AN dietary habit, either purgative or restrictive, did not affect Roseburia abundance. Roseburia genus and related species abundance were correlated with different health host metabolic markers. Roseburia species are key functional taxa in the human gut microbiome. Low gut Roseburia levels have been linked with other human pathologies. Our study highlights Roseburia species as a major decreased component in the gut of patients with AN.

Nutritional status in patients with advanced-stage multiple sclerosis.

INTRODUCTION: Motor and swallowing dysfunctions in multiple sclerosis (MS) unbalance calorie intake and energy expenditure, modifying nutritional status. Only one study has described nutritional status in MS patients at early disease stages (median Expanded Disability Status Scale [EDSS] = 3), but this has never been assessed in the most severe cases. The goal of the present study was to describe nutritional status in advanced-stage MS. METHODS: The study was a non-interventional retrospective analysis of a prospective registry. We reviewed medical files of consecutive MS patients admitted for annual follow-up in a physical and rehabilitation medicine unit between May 2016 and October 2018. Malnutrition for frail people, according to the French Health Authority (Haute Autorité de Santé [HAS]) definition, was our composite primary outcome criterion: body mass index (BMI) <21 kg/m2 and/or albumin<35 g/L. First, we performed a descriptive analysis of the nutritional status. Second, we studied the association between malnutrition and MS characteristics in univariate and multivariate analyses. RESULTS: A total of 163 patients with median EDSS = 8 [7; 8.5] were included. Ninety-three patients (57%) met HAS malnutrition criteria (36% with albumin <35 g/L, 31% with BMI <21 kg/m2 and 10% with both). Malnutrition was associated in univariate analysis with MS severity (EDSS ≥8.5, p = 0.0003), primary progressive type of MS (p = 0.01) and swallowing disorders (p = 0.002). Multivariate analysis showed that low disability status (EDSS <7) was the only independent (protective) factor associated with malnutrition (OR = 0.2, p = 0.03). CONCLUSIONS: Malnutrition is frequent in advanced stages of MS and is probably a key point for therapeutics, which has never been demonstrated previously. A standardized evaluation should be developed to improve nutritional therapeutic strategies in this population.

Bone mineral density at extremely low weight in patients with anorexia nervosa.

OBJECTIVE: Low bone mineral density (BMD) is a frequent and invalidating consequence of chronic undernourishment in patients with anorexia nervosa (AN). The aim of this study was to assess prevalence and clinic-biological correlates of low BMD and fractures in extremely undernourished inpatients with AN. DESIGN: Retrospective cohort study. PATIENTS AND MEASUREMENTS: This study included 97 extremely malnourished female inpatients with AN consecutively admitted over 2 years. Clinical-biological variables, history of fractures and BMD by dual-energy X-ray absorptiometry (DXA) were examined to find predictors of low BMD and fractures. RESULTS: The prevalence of low BMD was of 51% for lumbar spine and 38% for femoral neck. Z-scores were lower at lumbar spine (-2.2 ± 1.2 SD) than at femoral neck (-1.9 ± 0.9 SD) (P<.01). Fragility fractures were reported by 10% of patients. BMD was mainly predicted by FFM, illness duration, age at onset and restricting AN (P<.05). Fractures were predicted by sodium concentrations, femoral neck Z-score and illness duration (P<.03). CONCLUSION: Extremely severe patients with AN have high prevalence of low BMD, predicted by severity and chronicity of malnutrition.

Evaluation of muscle-skeletal strength and peak expiratory flow in severely malnourished inpatients with anorexia nervosa: A pilot study.

OBJECTIVES: Anorexia nervosa is a complex psychiatric disorder that can lead to specific somatic complications. Malnutrition is frequent and can involve a decrease of mobility, up to functional impotence, in individuals with extremely severe cases. The aim of this pilot study was to examine muscle strength and peak expiratory flow (PEF) in severely undernourished patients with anorexia nervosa at admission and after 5 wk of renutrition by tube feeding, and to find the clinical and biological correlates of muscle-strength impairment. METHODS: A prospective observational study was conducted over 6 mo. Manual muscle testing, measures of PEF, and clinical and biologic assessments were performed at baseline and after 5 wk of renutrition. RESULTS: Twenty-three extremely malnourished female participants (mean body mass index: 11.4 ± 1.3 kg/m2) were included. All participants had global impairment in muscle strength (manual muscle testing: 37.7 ± 7.7) and PEF (253.3 ± 60 mL/min) at admission. Muscle weakness was higher in axial than peripheral muscle groups (P < 0.01), with no significant difference between proximal and distal muscles (P > 0.05). Muscle strength at admission was significantly associated with severity of undernourishment (body mass index and albumin) and transaminitis (P < 0.05). At follow-up, musculoskeletal strength and PEF were significantly improved after partial weight recovery (P < 0.01). CONCLUSIONS: Extremely undernourished people with anorexia nervosa present a decrease of PEF and musculoskeletal strength predominant on axial muscles. Both are associated with severity of malnutrition and liver damage. Partial recovery was observed after 5 wk of enteral nutrition.

Heart and anorexia nervosa.

Anorexia nervosa, one of the more frequent and severe eating disorders, is a chronic psychiatric disease with potentially serious somatic consequences. This behavioral symptomatology leads to weight loss, undernutrition, and more or less severe-potentially life-threatening-somatic complications including respiratory, hepatic, digestive and cardiac features, electrolyte disturbances, endocrine and bone impairment, immunodepression, and related opportunistic infections. In this review, the authors report an overview of cardiac diseases in this disease.

What distinguish patients with compulsory treatment for severely undernourished anorexia nervosa.

OBJECTIVE: Anorexia nervosa (AN) is a mental disorder potentially leading to severe malnutrition and life-threatening complications, with high mortality rates and dropouts from treatment. In the most severe cases, treatment refusal associated with acute nutritional disorders may require compulsory admission in specialised units. The aim of this study was to investigate clinical and nutritional parameters associated with the use of compulsory treatment for severely ill AN patients requiring intensive nutritional care. METHODS: This retrospective, single-centre study performed in a unit of specialised nutritional care compared severely undernourished inpatients, compulsorily admitted for AN, with a population of sex- and age-matched voluntarily admitted patients. Socio-demographic and clinical variables were collected for univariate comparison and logistic regression. RESULTS: Compulsory treatment in AN was mainly associated with lower socio-economic status (p < 0.01), history of lower weight (p < 0.05), more frequently prescribed psychotropic medication (p = 0.02), more previous admissions for AN, longer hospitalisations (p < 0.01) and binge eating/purging subtype (p = 0.02). Binge eating/purging subtype and the number of past admissions showed the strongest odds of compulsory treatment in multivariate analysis. CONCLUSION: The knowledge of factors associated with compulsory treatment may help practitioners of all fields to better evaluate its pertinence and indications in AN.

Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit.

OBJECTIVE: Anorexia nervosa (AN) is associated with one of the highest mortality rates of any psychiatric disorder but limited mortality data were reported for those with extremely severe malnutrition. This study aimed to estimate standardized mortality ratio (SMR), investigate predictive factors of mortality and causes of death among a sample of patients with AN admitted to a specialized clinical nutrition unit (CNU) because of extremely severe malnutrition. METHODS: Between 11/27/1997 and 01/15/2014, vital status was determined for 384 patients admitted for AN at the first time in the CNU. Sociodemographic, anamnestic, and clinical data were collected. We calculated the SMR. Univariate and multivariate Cox regression analyses were performed to identify mortality predictors. RESULTS: Crude mortality rate was 11.5%. (44 deaths) and SMR 15.9 [CI 95% (11.6-21.4)], 5.2 years post inpatient treatment. Mortality predictors at the time of hospitalization were as follows: older age, occurrence of an in-hospital suicide attempt, transfer to medical intensive care unit and the following somatic complications: frank anemia, dysnatremia, infectious and cardiac complications. Other predictors of mortality were: past or present history of discharge against medical advice, hematological comorbidities (not related to AN). A longer inpatient length of stay was a protective factor. CONCLUSION: Very severely malnourished patients with AN hospitalized in a medical unit because of extremely severe somatic issues have a medium-term mortality rate higher than the general population and even higher than patients in tertiary specialized ED units. This study highlights predictive factors of mortality that will help clinicians in recognizing and managing patients at risk of death.

Anorexia nervosa and gut microbiota: A systematic review and quantitative synthesis of pooled microbiological data.

BACKGROUND: Alterations of gut microbiota may play a role in Anorexia Nervosa (AN) through perturbations of the gut-brain axis. Some studies found differences in the gut microbiota of patients with AN compared to healthy controls, but results are heterogeneous. The aim of this work was to systematically review the existing studies comparing gut microbial composition in AN and healthy controls, and to perform a quantitative synthesis of the pooled clinical and microbiological data, when available. METHODS: A comprehensive literature search was performed to identify human studies investigating relationships between AN and gut microbiota. Microbiome datasets from studies were pooled and analysed focusing on alpha and beta-diversity and the relative abundance of microbial species in patients' gut microbiota compared to healthy controls. RESULTS: Nine studies were eligible for the systematic review, of which 4 were included in the quantitative synthesis. Preserved alpha-diversity and decreased beta-diversity in AN emerged from the qualitative synthesis, while a slight increase of alpha-diversity (d < 0.4) and comparable beta-diversity were reported by the quantitative synthesis. Out of the 46 common species compared, three had a large combined effect size (d ≥ 0.9) to differentiate patients from controls, namely Alistipes, Parabacterioides and Roseburia. The latter was also correlated with BMI (ρ = 0.29). CONCLUSIONS: The decrease of butyrate-producing species and the increase of mucine-degrading species may represent hallmarks of the gut microbiota alterations in AN, and therefore potentially interesting therapeutic targets. The heterogeneity of clinical and methodological characteristics hampers the generalizability of the results. Standardized research methods could improve comparability among studies to better identify the alterations of gut microbiota in AN.

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

BACKGROUND AND AIMS: The clinical nutrition-eating disorders-unit in Raymond Poincaré Hospital is a reference center for the management of severe malnutrition and its complications in patients with anorexia nervosa (AN). The purpose of this study is to specify socio-demographic, anamnesic and clinical characteristics of AN patients hospitalized for extreme malnutrition, to identify types and prevalence of medical complications presented during their hospitalization for refeeding and the evolution of patients nutritional status. METHODS: Demographic, clinical and paraclinical data of 354 severely malnourished AN patients were collected, during their first hospitalization in the unit, between November 1997 and January 2014, through medical records. The prevalence of medical complications was compared between the 2 AN subtypes (restricting and binging-purging). RESULTS: 339 patients were female and mean age was 28.7 ± 10.7 years old. Duration of AN was 9.5 ± 9 years, 173 (48.9%) patients had a restricting AN subtype. BMI at admission was 12.2 ± 1.6 kg/m2, 280 (79.3%) patients had already been hospitalized for AN in other hospitals before. Psychiatric comorbidities were present in 168 (47.5%) patients. Associated somatic comorbidities concerned 70 (19.8%) patients. Outcomes during hospitalization were marked by 4.1 ± 3.9 kg weight gain on 36.9 ± 30.5 days. Enteral nutrition was provided in 304 (85.9%) patients. Main medical complications during hospitalization were: anemia (79%), neutropenia (53.9%), hypertransaminasemia (53.7%), osteoporosis (46.3%), hypokalemia (39.5%), hypophosphatemia (26%), hypoglycemia (13.8%), infectious complications (24.3%), cardiac dysfunction (7.1%), and proven gelatinous bone marrow transformation (6.5%). Hypokalemia was more frequent in binging-purging subtype. Lympho-neutropenia and hypertransaminasemia were more frequent in restricting subtype. During their hospitalization, 35 (10%) patients were referred to medical intensive care unit and 5 patients died. CONCLUSIONS: AN patients hospitalized for severe malnutrition in a specialized clinical nutrition unit have severe and frequent medical complications. Psychiatric comorbidities are also frequent and could complicate medical care. A specialized and multidisciplinary management of these patients is therefore essential.

Echocardiographic abnormalities in 124 severely malnourished adult anorexia nervosa patients: frequency and relationship with body composition and biological features.

BACKGROUND: Anorexia Nervosa (AN) is a complex psychiatric disorder that can lead to specific somatic complications. Heart abnormalities are frequently reported, while their frequency and associated factors in severely malnourished AN patients remain poorly defined. OBJECTIVES: This study aimed to characterize echocardiographic abnormalities in severely malnourished AN patients and to assess associated clinical, biological and related body composition features. METHODS: Between January 2013 and January 2015, all severely malnourished adult patients with AN (Mental Disorders, 4th Edn.-DSM IVr) were included in a monocentric study performed in in a highly specialized AN inpatient unit. Electrocardiogram (ECG) and echocardiography were used to assess both heart rhythm and function. All inpatients underwent a Doppler echocardiography procedure after undergoing combined blood volume adjustment, micronutrients deficiencies supplementation and electrolyte disorders correction. Right Ventricular (RV) and Left Ventricular (LV) systolic and diastolic functions were collected and compared to 29 healthy normal subjects in a control group. RESULTS: One hundred and 24 patients (119 (96%) women, 5 (4%) men) with a mean age of 30.1 ± 11 years old and an average Body Mass Index (BMI) of 12 kg/m2 were included. Ninety patients (73%) had been diagnosed with AN Restrictive type (AN-R), 34 (27%) an AN Binge eating/Purging type (AN-BP). Eighteen patients (15%) disclosed an abnormal Left Ventricular Ejection Fraction (LVEF) (< 52% for male and < 54% for female). LVEF impairment was associated with AN-BP patients (p < 0.017) and hypertransaminasemia (AST and/or ALT ≥2 N) (p < 0.05). Left Ventricular mass (LV mass) and Left Ventricular End Diastolic Diameter (LVEDD) were significantly reduced in patients (p < 0.001, p < 0.001). Left and right ventricular tissue Doppler Imaging Velocities (TDI) peak were reduced in patients: Septal and Lateral LV Sm velocities peaks respectively 10 ± 2 cm/s (vs 14 ± 2 cm/s in controls, p < 0.001), 12 ± 3 cm/s (vs 16 ± 3 cm/s in controls, p < 0.001), basal RV Sm velocity peaks at 14 ± 3 cm/s (vs 19 ± 3 cm/s in controls, p < 0.001). Additionally, LV and RV diastolic velocity peaks were reduced: LV septal and lateral velocity peaks were respectively 13 ± 3 cm/s (vs 18 ± 2 cm/s p < 0.001), 12 ± 3 cm/s (vs 22 ± 4 cm/s, p < 0.001) and RV diastolic velocity peaks at 14 ± 3 cm/s (vs 21 ± 4 cm/s p < 0.001). LV diastolic velocity TDI peaks were significantly associated with hypertransaminasemia (p < 0.05) and tended to be associated with a low all body Fat-Free Mass Index (FFMI) (using Dual-energy X- ray Absorptiometry (DXA) (HOLOGICQDR 4500) (p = 0.056). Thirty-four patients (27%) had a pericardial effusion and were significantly associated with a decreased all body FFMI (p < 0.036). CONCLUSION: Heart abnormalities are frequent in malnourished patients with AN, particularly in AN-BP type. Both liver enzymes and body composition abnormalities tended to be associated with heart dysfunction (non-significant association). Prospective studies are needed to better characterize and describe the evolution of cardiac abnormalities during the refeeding period and subsequent weight restoration.

Micronutrients Deficiencies in 374 Severely Malnourished Anorexia Nervosa Inpatients.

INTRODUCTION: Anorexia nervosa (AN) is a complex psychiatric disorder, which can lead to specific somatic complications. Undernutrition is a major diagnostic criteria of AN and it can be associated with several micronutrients deficiencies. OBJECTIVES: This study aimed to determinate the prevalence of micronutrients deficiencies and to compare the differences between the two subtypes of AN (restricting type (AN-R) and binge-eating/purging type (AN-BP)). METHODS: We report a large retrospective, monocentric study of patients that were hospitalized in a highly specialized AN inpatient unit between January 2011 and August 2017 for severe malnutrition treatment in the context of anorexia nervosa. RESULTS: Three hundred and seventy-four patients were included, at inclusion, with a mean Body Mass Index (BMI) of 12.5 ± 1.7 kg/m². Zinc had the highest deficiency prevalence 64.3%, followed by vitamin D (54.2%), copper (37.1%), selenium (20.5%), vitamin B1 (15%), vitamin B12 (4.7%), and vitamin B9 (8.9%). Patients with AN-BP type had longer disease duration history, were older, and had a lower left ventricular ejection fraction (LVEF) (p < 0.001, p = 0.029, p = 0.009) when compared with AN-R type patients who, instead, had significantly higher Alanine Aminotransferase (ALT) and Brain Natriuretic Peptide (BNP) levels (p < 0.001, p < 0.021). In the AN-BP subgroup, as compared to AN-R, lower selenium (p < 0.001) and vitamin B12 plasma concentration (p < 0.036) was observed, whereas lower copper plasma concentration was observed in patients with AN-R type (p < 0.022). No significant differences were observed for zinc, vitamin B9, vitamin D, and vitamin B1 concentrations between the two types of AN patients. CONCLUSION: Severely malnourished AN patients have many micronutrient deficiencies. Micronutrients status must be monitored and supplemented to prevent deficiency related complications and to improve nutritional status. Prospective studies are needed to explore the symptoms and consequences of each deficiency, which can aggravate the prognosis during recovery.

Altered host-gut microbes symbiosis in severely malnourished anorexia nervosa (AN) patients undergoing enteral nutrition: An explicative factor of functional intestinal disorders?

BACKGROUND: Functional intestinal disorders (FIDs) are frequently observed in patients with anorexia nervosa (AN). Relationship between FIDs and a potential gut microbiota dysbiosis has been poorly explored. OBJECTIVE: We aimed to determine an association between FIDs severity and dysbiosis of the intestinal microbiota in a severely malnourished patient population with AN undergoing enteral nutrition. DESIGN: Faecal microbiota of AN (DSM IVr criteria) female inpatients were collected and compared to healthy controls based on 16S rRNA profiling. The severity of FIDs was evaluated in patients and healthy controls using Francis Score. RESULTS: Thirty-three patients (BMI: 11,7 ± 1,5; Age: 32 ± 12) and 22 healthy controls (BMI: 21 ± 2; age: 36 ± 12) were included. A marked dysbiosis was identified in AN patients compared to healthy controls (p = 0.03). Some potentially pathogenic bacterial genera (Klebsiella, Salmonella) were more abundant in AN patients whereas, other bacterial symbionts (Eubacterium and Roseburia) involved in immune balance were significantly less abundant in patients than controls. Severity of FIDs was strongly correlated with several microbial genera (r = -0.581 for an unknown genus belonging to Peptostreptococcaceae family; r = 0.392 for Dialister, r = 0.444 for Robinsoniella and r = 0.488 for Enterococcus). Other associations between dysbiosis, clinical and biological characteristics were identified including severity of undernutrition (BMI). CONCLUSION: Observed gut microbiota dysbiosis in malnourished patients with anorexia nervosa is correlated with the severity of FIDs and other metabolic disturbances, which strongly suggests an altered host-microbe symbiosis.

High-intensity exercise is associated with a better nutritional status in anorexia nervosa.

OBJECTIVE: Our aim is to investigate the links between duration and intensity of exercise and the nutritional status in terms of body composition in acute anorexia nervosa (AN) patients. METHOD: One hundred ninety-one hospitalized women suffering from AN were included. Exercise duration and intensity were assessed using a semistructured questionnaire. Body composition was measured using bioelectrical impedance. Linear multiple regression analyses were carried out using body mass index, fat-free mass index, and fat mass index as dependent variables and including systematically exercise duration, exercise intensity, and other confounding variables described in the literature that were significantly associated with each dependent variable in univariate analysis. RESULTS: A lower BMI was linked to lower exercise intensity, AN restrictive type, and presence of amenorrhea. A lower FFMI was linked to lower exercise intensity, older age, AN restrictive type, and premenarchal AN. Duration of exercise was not linked to the nutritional status. CONCLUSIONS: Exercising at higher intensity in AN is associated with a better nutritional status, thus, a better resistance to starvation. The impact of therapeutic physical activity sessions, adapted in terms of exercise intensity and patient's clinical status, should be evaluated during nutrition rehabilitation.

Negative role of malnutrition in cell-mediated immune response: Pneumocystis jirovecii pneumonia (PCP) in a severely malnourished, HIV-negative patient with anorexia nervosa.

It is generally acknowledged that malnutrition is a propensity factor for secondary infections in different clinical situations (malnutrition-associated infections in hospitalized patients and malnourished children in developing countries). However, it is not clear how malnutrition might facilitate the development of opportunistic infections in human immunodeficiency virus (HIV)-negative patients without a definite etiology (disease or treatment) of impaired cell-mediated immune response. We report here on a case of Pneumocystis jirovecii pneumonia in an HIV-negative patient suffering from anorexia nervosa with extreme malnutrition, which had a favorable outcome despite the severity of her respiratory failure. This report indicates the need for the early screening of nutritional status and rapid treatment initiation in patients with malnutrition, as well as the determination of opportunistic infections in the event of a low lymphocyte count.