Nutritional indicators and metabolic alterations in outpatients with anorexia nervosa: a retrospective study.

PURPOSE: In patients living with Anorexia Nervosa (AN), dehydration and haemoconcentration, may prevent a correct interpretation of laboratory nutritional parameters. Our study aims to evaluate if some indicators of disease severity, as body mass index (BMI), Phase Angle (PhA) and months of amenorrhea may be predictors of metabolic alterations (serum albumin, liver enzymes). METHODS: In 154 outpatients with AN, case history was collected, and anthropometric and laboratory parameters measured. Patients were divided according to the following tertiles (T) of BMI, duration of amenorrhea and PhA: (1) BMI (T1 < 15.6; T2 15.6-16.8; T3 > 16.8 kg/m2); (2) Amenorrhea duration (T1 < 7; T2 7-14; T3 > 14 months); (3) PhA value (T1 < 4.64; T2 4.64-5.35; T3: > 5.35°). ROC curves were used to determine which of these three indicators (BMI, PhA and amenorrhea duration) might better identify patients belonging to Group A or B (less than 3 or more metabolic abnormalities). RESULTS: The most frequent registered metabolic alterations were for alkaline phosphatase (ALP), alanine aminotransferase, cholesterol and hemoglobin. Aspartate aminotransferase, ALP and gamma glutamyl transferase abnormalities were frequent in the first tertiles of all the three indicators. Albumin was low in the T1 of BMI and PhA. No differences in nutritional alterations emerged according to amenorrhea duration. PhA had the best performance (AUCs: 0.721) in identifying patients with 3 or more abnormalities, with the optimal cut-off value of 4.5°. CONCLUSIONS: Our data confirmed PhA as the more reliable predictor of metabolic alterations, followed by BMI and amenorrhea duration, especially in the first tertile. EVIDENCE-BASED MEDICINE: Level 2.

A proposal for reference values of hand grip strength in women with different body mass indexes.

OBJECTIVE: Hand grip strength (HGS) is frequently used in clinical practice, resulting in a potential marker of nutritional status. This study aimed to develop reference values of HGS in Italian women with different categories of body mass index (BMI). Additionally, the main predictors of HGS were identified. METHODS: A cross-sectional study was conducted in Italian women between ages 16 and 55 y with different categories of BMI at the Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples Italy. The whole sample was divided into tertiles according to BMI: 15 to 17.29 kg/m2 (T1), 17.3 to 19.9 kg/m2 (T2), and 20 to 25 kg/m2 (T3). Anthropometry, bioimpedance analysis, and muscle strength by an HGS test were evaluated. The cut-off values for HGS were developed for all participants and stratified by age group. Finally, a multivariate linear regression analysis was performed to assess the main predictors of HGS. RESULTS: A total of 529 women with a mean age of 23.2 ± 7.0 y and an average BMI of 18.9 ± 2.5 kg/m2 were analyzed. HGS was higher for the dominant hand than for the non-dominant hand in all BMI tertiles. On both sides, according to age groups, HGS increased with increasing age in T1 and T3, whereas it increased in the women between ages 20 and 30 y in T2 only. Multivariate linear regression analysis showed that predictors of HGS varied according to tertiles. Specifically, we found that body weight (R2 = 0.252) was the main predictor in T1, whereas phase angle (PhA) was the main determinant in both T2 (R2 = 0.240) and T3 (R2 = 0.216). CONCLUSION: This study defined the normal reference values of HGS in Italian women with different BMI ranges, stratifying the sample group by age. Additionally, the main predictors of HGS were assessed for each BMI tertile. In primary malnutrition (T1), the main predictor of HGS was body weight, whereas in the other two tertiles (T2, T3), the PhA was the main predictor of HGS.

Long-Term Outcomes from a 10-Year Follow-Up of Women Living with a Restrictive Eating Disorder: A Brief Report.

BACKGROUND: This study aimed to evaluate several socio-demographic and long-term clinical outcomes in a cohort of women living with a restrictive eating disorder. METHODS: Patients were asked to fill in a general data collection form aiming to investigate their current conditions and to attend the outpatient unit for a 10-year follow-up clinical and laboratory evaluation. RESULTS: Forty-four patients completed the follow-up general data collection form and 20 agreed to attend the outpatient unit for the 10 year-follow-up evaluation. In total, 52% of patients were single, 55% had achieved a university degree, and 55% had steady employment. After 10 years, there was a clear improvement in biochemical markers, but cholesterol levels were still slightly high. The prevalence of osteopenia in the whole sample was 70% when measured on the lumbar column and 20% on the total body, while osteoporosis was found in 10% of patients and only on the lumbar column. CONCLUSION: According to the collected data, women with a history of restrictive eating disorders appear to re-adapt well to social life by obtaining the level of their unaffected peers in terms of education and employment.

Resting Energy Expenditure, Body Composition and Phase Angle in Anorectic, Ballet Dancers and Constitutionally Lean Males.

BACKGROUND: The prevalence of anorexia nervosa among males is increasing but few data are available in the literature. This cross sectional study aims to evaluate resting energy expenditure (REE) and phase angle as a marker of qualitative changes of fat free mass (FFM) in three leanness groups as compared with control subjects. METHODS: 17 anorectic (AN) males, 15 constitutionally lean (CL) individuals, 12 ballet dancers (DC), and 18 control (CTR) subjects were evaluated. REE was measured by indirect calorimetry (V max29- Sensormedics), and body composition was evaluated by bioimpedance analysis (BIA) at 50 kHz (DS Medica). Phase angle (a bioimpedance variable related to nutritional status) was used to evaluate differences in FFM characteristics between these three types of leanness. RESULTS: REE, adjusted for FFM and fat mass (FM), were significantly higher in CL and lower in AN individuals (1783 ± 47 vs. 1291 ± 58 kcal, p < 0.05) compared to the other groups. Body composition was similar in AN and CL whereas dancers had the highest FFM (58.9 ± 4.8 kg, p < 0.05); anorectic males showed the lowest phase angle (5.8 ± 1.2 degrees vs. other groups, p < 0.05) and dancers the highest phase angle (7.9 ± 0.7 degree vs. other group, p < 0.05). CONCLUSIONS: Our findings confirm that phase angle could be a useful marker of qualitative changes, above all in the field of sport activities. On the other hand, there is the need to further evaluate the relationship between resting energy expenditure, body composition and endocrine status in different conditions of physical activity and dietary intake.

Prediction of body composition in anorexia nervosa: Results from a retrospective study.

BACKGROUND & AIMS: The assessment of body composition is crucial in evaluating nutritional status in female subjects with anorexia nervosa (AN) and improving their clinical management. The aim of this retrospective study was to assess the accuracy of selected BIA (bioimpedance analysis) equations for fat-free mass (FFM) in female AN subjects and to formulate a specific equation for these subjects. METHODS: Eighty-two restrictive female AN subjects (age 20.5 ± 3.7 yrs, BMI 15.7 ± 1.7 kg/m2) were studied. Body composition was determined with dual-energy X-ray absorptiometry (DXA) and estimated by BIA using five different equations. Linear correlation analysis was carried out to evaluate the association of FFM with selected variables. Multiple regression analysis was used to formulate specific equations to predict FFM in AN. RESULTS: All predictive equations underestimated FFM at the population level with a bias from -5.6 to -11.7%, while the percentage of accurate predictions varied from 12.2% to 35.4%. More interestingly, multiple regression analysis clearly indicates that, in addition to weight, ZI100 or RI also emerged as independent predictors of DXA-derived FFM, increasing the prediction power of the equation well above that observed with anthropometric characteristics only. CONCLUSIONS: This study shows that the selected predictive BIA equations considered exhibit an insufficient accuracy at the population and the individual level. Predictive formulas based on body weight plus BIA parameters such as RI and ZI100 offer a rather accurate prediction of FFM (with high R squared).

Fecal Short Chain Fatty Acids and Dietary Intake in Italian Women With Restrictive Anorexia Nervosa: A Pilot Study.

Nutritional disorders such as Anorexia Nervosa (AN) can shape the composition of gut microbiota and its metabolites such as short chain fatty acid (SCFA). This study aims to compare fecal SCFA along with dietary intake of women with restrictive AN (r-AN = 10) and those of sex-matched lean controls (C = 8). The main fecal short chain fatty acids (SCFA) were assessed by gas chromatography equipped with a flame ionization detector. All participants completed 7-day food record and underwent indirect calorimetry for measuring resting energy expenditure (REE). Butyrate and propionate fecal concentrations were significantly reduced in r-AN patients compared to controls. The intake of carbohydrate and fat was significantly lower in r-AN patients than controls as well as energy intake and REE; whereas the amount of protein and fiber did not differ between groups. These preliminary results showed that r-AN patients had a reduced excretion of fecal SCFA, likely as a mechanism to compensate for the lower energy and carbohydrate intake observed between groups. Therefore, further studies need to be performed in patients with AN to explore the link between nutritional disorders, gut microbiota and its metabolites.

BMR variability in women of different weight.

BACKGROUND & AIMS: Non-exercise activity thermogenesis (NEAT) and substrate oxidation are significant components of Energy Balance; their regulation may be modulated according to nutritional status and their impairment has been advocated as a factor facilitating the development of excess body fat. METHODS: In this study body composition, resting metabolic rate (RMR), fidgeting as a component of NEAT and respiratory quotient (RQ), an index of preferential substrate oxidation, have been evaluated in 80 young women: 20 restrictive anorexia nervosa (rAN: BMI 15.1+/-1.6 kg/m(2)); 20 constitutional leanness (CL: BMI 17.2+/-1.0); 20 obese patients (Ob: BMI 43.8+/-10.0) and 20 controls (CTR: BMI 21.7+/-2.4). RESULTS: Fat free mass, fat mass and RMR progressively increased from rAN to Ob (p < 0.05). Fidgeting was higher in CL (67.2+/-27.2 kcal; p < 0.05) than in the other groups. Lipid oxidation, evaluated with RQ showed a negative correlation with fidgeting in CL (r=-0.433; p<0.05) and positive in Ob (r=0.572; p<0.05) and in rAN (r=0.434; p<0.05). CONCLUSION: Our findings support the regulatory function of NEAT, its protective role to prevent excess body fat accumulation and its positive relation with fat oxidation in CL.

Adequacy of nutrient intake in women with restrictive anorexia nervosa.

OBJECTIVE: The aim of the present study was to assess energy and nutrient intake in a group of women with restrictive AN (r-AN) compared with a control group. METHODS: Thirteen r-AN patients and 13 healthy female controls completed 7-d food records. Intake of macro- and micronutrients was compared between the two groups as well as to the Dietary Reference Intake for the Italian Population (LARN) for specific ages. Additionally, the r-AN patients underwent indirect calorimetry for measuring resting energy expenditure (REE). RESULTS: Total energy intake was significantly lower in the r-AN group than in controls (906 ± 224 vs 1660 ± 139, respectively; P < 0.01). Nutrient composition significantly differed, as well. Mean intake of sodium, phosphorus, and zinc was higher in controls than in the women with r-AN (P < 0.01), but neither group of women met LARN recommendations for potassium, calcium, or iron intake. With respect to vitamins, no significant differences were found for riboflavin or vitamins A, B12, or C between groups, whereas levels of other vitamins differed (P < 0.01). Both groups failed to meet the LARN recommendation for vitamin D intake; moreover, none of the r-AN patients met recommended intake levels of vitamin E, thiamine, niacin, and folate. CONCLUSIONS: Intakes reported by r-AN patients did not meet requirements for most micronutrients evaluated in this study and, as expected, both energy needs and specific dietary patterns differed between groups. Therefore, a careful evaluation of food consumption should be recommended to reduce nutritional gaps in these patients. According to these preliminary observations, nutritional counseling, mainly focused on calcium and vitamin D intake, should be suggested for healthy women, as well.

Phase angle is a predictor of basal metabolic rate in female patients with anorexia nervosa.

The aim of the study was to evaluate the relationship between basal metabolic rate (BMR) and bioelectrical impedance analysis (BIA) in undernourished female patients with anorexia nervosa. Participants were 86 female patients with anorexia nervosa (age 20.8+/-4.7 years; weight 39.3+/-5.2 kg; body mass index 15.4+/-1.6 kg m-2). BMR was measured by indirect calorimetry and single-frequency BIA was determined at 50 kHz on the whole body. The BIA variables considered were resistance, reactance, phase angle and the bioimpedance index (height2/resistance). Fat-free mass was calculated from subcutaneous skin fold thickness. In the study group BMR was 3782+/-661 kJ d-1 while bioimpedance index varied between 27.6 and 49.9 cm2 Omega-1 and phase angle between 2.54 degrees and 6.49 degrees. BMR was significantly correlated with weight, height, body mass index and fat-free mass, and, among BIA variables, with reactance and phase angle. Multiple regression analysis indicated that phase angle was a predictor of BMR not only when solely BIA variables were considered, but also in combination with either weight and age or fat-free mass. In conclusion, phase angle emerged as a strong predictor of BMR in female patients with anorexia nervosa. Nevertheless, further studies are necessary to confirm this finding in other forms of protein energy malnutrition and justify the inclusion of BIA variables in the equations used to predict BMR in the clinical setting.

Menstrual status and serum leptin levels in anorectic and in menstruating women with low body mass indexes.

OBJECTIVE: To evaluate serum leptin levels in anorectic women, menstruating women with low body mass indexes (BMI) and normally menstruating women with normal BMI. DESIGN: Prospective study. SETTING: University clinics. PATIENT(S): Fourteen amenorrheic patients with anorexia nervosa (group A), 11 menstruating women with a BMI <18 kg/m(2) (group B), and 20 normal controls. MAIN OUTCOME MEASURE(S): Determination of BMI, caloric intake, total fat mass, ovarian volume, and serum leptin, insulin-like growth factor I, FSH, LH, E(2), PRL, and TSH levels. INTERVENTION(S): None. RESULT(S): Mean BMI and fat mass were similar in groups A and B and significantly higher in controls. Mean caloric intake was significantly lower in group A than in group B and controls. Median serum leptin levels were significantly lower in group A than in group B and controls, and significantly lower in group B than in controls. Median serum insulin-like growth factor I levels were significantly lower in group A than in group B and controls. Binary segmentation analysis of groups A and B showed that LH was the most relevant variable in differentiating the two groups, followed by leptin. CONCLUSION(S): A threshold of leptin levels exist above which, even in the presence of low body mass indexes, the menstrual function is preserved.

Evidence of brown fat activity in constitutional leanness.

BACKGROUND: Brown adipose tissue (BAT) was considered essentially nonexistent in adults until recent evidence obtained using 18-fluorodeoxyglucose (18-FDG) positron emission tomography/computed tomography. It seems to play a role in whole body metabolism, but it has not been evaluated in underweight conditions, such as in young females with constitutional leanness (CL) or anorexia nervosa (AN). SUBJECTS AND METHODS: Thirty-eight subjects were evaluated from October 2011 to March 2012 : 7 CL (21.7 ± 3.6 y, body mass index [BMI] 16.2 ± 1.0 kg/m(2)), 7 AN (23.4 ± 4.5 y, BMI 15.5 ± 0.8), 3 of the 7 AN after stable refeeding (R-AN, 21.3 ± 1.5 y, BMI 18.8 ± 1.1), and 24 normal weight (NW) women (25.6 ± 3.9 y, BMI 22.2 ± 1.5). Fasting resting metabolic rate and respiratory quotient were measured by indirect calorimetry, body composition by bioimpedentiometry (only in CL, AN, and refed AN), and BAT activity by 18-FDG positron emission tomography/computed tomography scan, all in standardized conditions. RESULTS: All CL (100%), none of the AN and refed AN (0%), and 3 of the 24 NW (12%) subjects showed FDG uptake. Average FDG maximum standardized uptake value was 11.4 + 6.7 g/mL in CL and 5.5 ± 1.2 g/mL (min 3.7, max 8.3) in the 3 NW subjects. In CL, the maximum standardized uptake value was directly correlated to resting metabolic rate, corrected for fat-free mass, and inversely correlated with respiratory quotient. CONCLUSION: BAT activity has been shown in CL in resting thermoneutral conditions and may exert a role against adipose tissue deposition.

Cholinesterase and other serum liver enzymes in underweight outpatients with eating disorders.

OBJECTIVE: The present study aimed to evaluate serum liver enzymes in underweight outpatients with anorexia nervosa (A-NERV) or eating disorders not otherwise specified (EDNOS). METHOD: Serum alanine amino transferase (ALT), aspartate amino transferase (AST), lactic dehydrogenase (LDH), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), and cholinesterase (CHE) were determined in 97 patients with A-NERV, 66 patients with EDNOS, and 56 controls. RESULTS: In the A-NERV group AST, LDH, and GGT were higher, as compared with controls, and inversely related to weight, while ALP and CHE were lower. AST and GGT increased and CHE decreased in patients with EDNOS. Hypertransaminasemia occurred in 14.4 and 15.2%, and low CHE in 29.9% of the A-NERV group and 13.6% and EDNOS group, respectively. Three or more abnormalities were found in 9.3% of patients with A-NERV and 7.5% of those with EDNOS. CONCLUSION: Abnormalities in serum liver enzymes are common in outpatients with eating disorders plus underweight. CHE might be considered as a marker of the effects of primary malnutrition on liver function.