Can the relationship between overweight/obesity and sleep quality be explained by affect and behaviour?

PURPOSE: Sleep impairment is reported to be a consequence of overweight and obesity. However, the weight-sleep relationship can alternately be explained by demographics (e.g. age) and covariates (i.e. mood/affect and behaviour in overweight/obese people; e.g. night-eating). Thus, we examined the weight-sleep quality relationship after controlling for the effects of affect and common behaviour (i.e. night-eating, insufficient exercise, alcohol and electronic device use). METHODS: Online questionnaires asked 161 overweight, obese or normal-weight participants about their sleep quality, night-eating, physical activity, alcohol use, electronic device use and anxiety and depression at T0 (baseline) and T1 (3 months later). Height and weight and waist and hip circumference were objectively measured at T0 and T1, and physical activity was assessed over 24 h (using actigraphy) at T0 and T1. Hierarchical multiple regression analyses evaluated whether the weight measures (i.e. body-mass-index [BMI], waist-to-hip ratio [WHR] and obesity category [overweight/obese vs. normal-weight]) predicted sleep quality and its components at T0 and T1, after controlling demographics (at step 1) and covariates (affective distress and behaviour) at step 2, and entering weight measures at step 3; maximum 8 variables in the analyses. RESULTS: High BMI predicted several aspects of sleep quality after taking into account co-existing behaviour, affect and demographics: sleep disturbances at T0 and lower sleep efficiency at T1. WHR and obesity category did not predict any aspects of sleep quality. Several co-existing behaviour were related to or predicted sleep quality score and aspects of sleep quality including night-eating, alcohol use and electronic device use and affective symptoms (i.e. anxiety, depression). CONCLUSION: Results suggest that a person's weight may impact on their sleep quality above and beyond the effects of their co-existing behaviour and affect, although their co-existing behaviour and affect may also adversely impact on sleep quality. LEVEL OF EVIDENCE: Level III, evidence obtained from well-designed cohort.

Obesity and overweight in Canada: an updated cost-of-illness study.

This study is to update the estimates of the economic burden of illness because of overweight and obesity in Canada by incorporating the increase in prevalence of overweight and obesity, findings of new related comorbidities and rise in the national healthcare expenditure. The burden was estimated from a societal perspective using the prevalence-based cost-of-illness methodology. Results from a literature review of the risks of 18 related comorbidities were combined with prevalence of overweight and obesity in Canada to estimate the extent to which each comorbidity is attributable to overweight and obesity. The direct costs were extracted from the National Health Expenditure Database and allocated to each comorbidity using weights principally from the Economic Burden of Illness in Canada. The study showed that the total direct costs attributable to overweight and obesity in Canada were $6.0 billion in 2006, with 66% attributable to obesity. This corresponds to 4.1% of the total health expenditures in Canada in 2006. The inclusion of newly identified comorbidities increased the direct cost estimates of obesity by 25%, while the rise in national healthcare expenditure accounted for a 19% increase. Policies to reduce being overweight and obese could potentially save the Canadian healthcare system millions of dollars.

Managing anxiety in eating disorders with knitting.

OBJECTIVE: Recovery from anorexia nervosa (AN) is often confounded by intrusive, anxious preoccupations with control of eating, weight and shape. These are distressing and represent a potential barrier to psychological change. Theoretical and empirical evidence suggests that performing a concurrent visuospatial task reduces the emotional intensity of distressing images. We assessed whether the visuospatial task of knitting influences the anxious preoccupation experienced by inpatients with AN. METHOD: Prospective interventional cohort. SUBJECTS: Thirty-eight women with AN admitted to a specialized eating disorder unit. INTERVENTION: All subjects were given knitting lessons and free access to supplies. MEASURE: Subjects were asked to report the qualitative effects of knitting on their psychological state using a self-report questionnaire. RESULTS: Patients reported a subjective reduction in anxious preoccupation when knitting. In particular, 28/38 (74%) reported it lessened the intensity of their fears and thoughts and cleared their minds of eating disorder preoccupations, 28/38 (74%) reported it had a calming and therapeutic effect and 20/38 (53%) reported it provided satisfaction, pride and a sense of accomplishment. DISCUSSION: This preliminary data suggests that knitting may benefit inpatients with eating disorders by reducing their anxious preoccupations about eating, weight and shape control. The specificity of this effect is yet to be determined. This preliminary outcome requires further controlled study in AN subjects. From a clinical perspective, knitting is inexpensive, easily learned, can continue during social interaction, and can provide a sense of accomplishment. The theoretical and empirical rationale for this observation, and implications for deriving alternative strategies to augment treatment in AN, are discussed.

Are plasma homocysteine and methionine elevated when binging and purging behavior complicates anorexia nervosa? Evidence against the transdiagnostic theory of eating disorders.

OBJECTIVE: To determine whether plasma total homocysteine (tHcy) and plasma methionine levels are different in anorexia nervosa restricting type (AN-R) compared to anorexia nervosa binge eating/purging type (AN-BP). METHODS: Cross-sectional design. SUBJECTS: Subjects were recruited from the outpatient program of the Eating Disorders Program at St. Paul's Hospital, Vancouver, Canada. All subjects had a current Diagnostic and Statistical Manual of mental Disorders - Fourth Edition (DSM-IV) AN-R, or AN-BP diagnosis. Controls were recruited from staff and trainees of Child and Family Research Institute, and Children's and Women's Hospital, University of British Columbia. RESULTS: Samples were obtained from AN-R (N=30), AN-BP (N=32) and control women (N=73) and men (N=33). The 5- 95th% confidence intervals from the control women were taken as the normal range. The plasma tHcy and methionine for the control group had a 5-95th percentile range of 5.66-10.57 and 15.3-40.2 microM, respectively. Plasma tHcy was elevated in women with AN-BP (9.24+/-0.85 microM, N=32) but not with AN-R (7.90+/-0.38 microM, N=30). Plasma methionine was decreased in women with AN-BP (22.2+/-1.43 microM, N=32) compared to the control group of women (25.1+/-0.89 microM). The plasma methionine/tHcy ratio was elevated in the women with AN-BP (0.50+/-0.09) but not in those with AN-R (0.34+/-0.03). CONCLUSION: Elevated plasma tHcy and decreased plasma methionine are consistent with impaired homocysteine remethylation. Altered methyl transfer capacity or methyl deficiency could impair monoamine neurotransmitter metabolism potentially impacting cognitive and psychological function.We hypothesize that the treatment of AN-BP should consider the need for nutritional support of methyl metabolism.

Anorexia nervosa: a survival analysis.

BACKGROUND: There are numerous reports of the standardized mortality ratio (SMR) of anorexia nervosa (AN). However, the life expectancy of AN, has not been reported. OBJECTIVE: To estimate the average life expectancy of patients who are diagnosed with AN at various ages. METHODS: A survival analysis was performed using decision analysis software and mortality data for British Columbia, Canada from Statscan and the SMR for AN previously reported for British Columbia, Canada. RESULTS: The life expectancy of patients who are diagnosed with AN is displayed in Table 1 and Figure 2. For example, statistically, a woman who has had AN since 15 years of age is likely to live 25 years less than predicted for the normal population. DISCUSSION: Survival curves should be used to illustrate the loss of life in AN, to motivate patients and families, and to assist in legal arguments and requests for funding.

The interrater reliability of rating non-exercise activity of inpatients with eating disorders using a visual analogue scale.

BACKGROUND: Non-exercise activity thermogenesis (NEAT) is the energy expended by body movement, other than sleeping, eating or sports-like activities. The obese have been reported to have a lower NEAT (walking, standing, and fidgeting) than controls. We hypothesize that an elevated NEAT could explain why some patients with anorexia nervosa are resistant to weight gain. OBJECTIVE: To evaluate the interrater reliability of a rating of non-exercise activity of inpatients with eating disorders (ED) using a visual analogue scale (VAS). METHOD: Health care providers were asked to rate the non-exercise activity of inpatients by marking a VAS. RESULTS: Eight patients were individually rated by 10 clinicians. Results were analyzed using the intraclass correlation coefficient (ICC) and Cohen's multi-rater kappa statistic (kappa). The ICC(3,k) was 0.257 (p<0.01) and 0.708 (p<0.01) for average measures. DISCUSSION: The ratings of NEAT using a VAS were not reliable between clinicians. This indicates that the ward staff, even on a specialized ED unit, cannot reliably estimate non-exercise activity and physiological measurements should be used.

Is there evidence that religion is a risk factor for eating disorders?

OBJECTIVE: Is there evidence that religion is a risk factor for eating disorders? METHODS: A literature search was performed to examine whether there is an association between religion and eating disorders. RESULTS: There were some cross-sectional studies, case studies, and anthropological commentaries reporting eating disorders in various cultures and religions. Religious affiliation was usually reported as an incidental finding but not analyzed. A number of prevalence studies were reported from Islamic communities. This raises the possibility that young Muslim women have a higher prevalence of elevated EAT scores compared to non-Islamic women. CONCLUSION: This literature search raises the possibility that there is an association between Islamic affiliation and positive screening for eating disorder behaviors. This supports the hypothesis that the effect of culture on eating disorders may be religious as well as secular. Carefully designed studies of the prevalence of eating disorders in multicultural populations with multiple religious affiliations may help further clarify the relationship between religion and eating disorders.

Complementary and alternative medical treatments for anorexia nervosa: case report and review of the literature.

OBJECTIVE: To report the case of a 38-year-old woman with anorexia nervosa (AN) who chose to use an alternative (Zen) therapy instead of conventional treatment and to review the literature on complementary and alternative medicine (CAM) for AN. METHOD: Case report and review of the literature using PubMed. RESULTS: A 38-year old South East Asian woman with a 5-year history of AN restrictive subtype was admitted to the eating disorders unit. During her admission, she received medical, psychological, nutritional, occupational, recreational and nursing therapy. In addition, she studied a manual on Zen therapy recommended and supervised by staff on the ward. On discharge, she chose to use Zen therapy as her sole treatment and declined further conventional treatment. A PubMed search of CAM treatment and AN yielded 18 articles, most of which were case reports. DISCUSSION: The use of CAM is reported with increased frequency for a variety of medical problems. In addition, acceptability of certain types of CAM may vary according to ethnicity or culture. Randomized controlled trials of CAM for the treatment of AN are needed to determine effectiveness.

Heart failure in anorexia nervosa: case report and review of the literature.

OBJECTIVE: To report the presentation and causes of heart failure complicating anorexia nervosa (AN). METHOD: Report of a case of heart failure occurring in a patient with AN and a review of the literature. RESULTS: A 56 year old woman with a 25 year history of AN binge-purge subtype experienced increasing shortness of breath on exertion, orthopnea, and swelling of the ankles. Investigations revealed a reduced left ventricular ejection fraction. A diagnosis of heart failure caused by severe prolonged protein-calorie malnutrition was made. She was treated with a diuretic, a beta adrenergic blocker and an angiotension enzyme inhibitor. Her cardiac function returned to normal after a year of refeeding. Protein-calorie malnutrition, ipecac toxicity, and deficiencies of thiamine, phosphorus, magnesium, and selenium have been reported to cause heart failure in patients with AN. DISCUSSION: If shortness of breath occurs in AN it may be a symptom of heart failure. The diagnosis is further suggested by increased jugular venous pressure, increasing shortness of breath on exertion, and pulmonary crepitations at the bases of the lungs on physical examination. The chest x-ray usually shows pulmonary venous redistribution, the electrocardiogram may be normal, and the echocardiogram should document a reduced left ventricular ejection fraction. Standard medical therapy for heart failure should be started. In addition, a history of ipecac use should be taken, deficiencies should be corrected, and weight restoration can reverse cardiac abnormalities.

An algorithm for the diagnosis of Münchausen's syndrome in eating disorders.

OBJECTIVE: To present an algorithm for the diagnosis of Münchausen's syndrome (MS) in patients with eating disorders (ED). METHOD: Case reports and review of the literature using PubMed. RESULTS: Two cases diagnosed with anorexia nervosa (AN): one later diagnosed with MS and one with Münchausen's syndrome by proxy (MSBP) are presented. We then present an algorithm to aid in the diagnosis of MS and MSBP in patients with eating disorders. DISCUSSION: EDs can be distinguished from MS by their distinctive psychopathological traits, including fear of weight gain, eating and shape concerns, and food restraint. However, the diagnosis of concurrent ED and MS can be difficult because patients with both disorders may manifest similar abnormal behaviours: self-injurious behaviour, manipulation, splitting, physical complaints, multiple admissions, non-compliance, and giving false information. We present an algorithm as an aid to the diagnosis of concurrent MS and ED.

Rumination in eating disorders: literature review.

Rumination is defined as regurgitation of partially digested food that is subsequently re-chewed and then swallowed or ejected by mouth. We report a case of rumination and a review of selected literature to emphasize: 1. Risk factors for rumination in eating disorders are unknown, 2. A history of rumination must be taken routinely because shame prevents patients from volunteering this history, 3. Rumination usually lessens with improvement of the eating disorder, but other methods including behavior modification, breathing techniques, and gum chewing have shown success in individual cases or small case series. There have been no controlled trials published of any treatment for rumination in eating disorders.

Using the glucagon test to predict hypoglycemia in anorexia nervosa.

BACKGROUND: Hypoglycemia is an important but uncommon complication of anorexia nervosa (AN) that usually occurs when refeeding begins. The response to an iv bolus of glucagon has been used to investigate hypoglycemia, but not in AN. There are no published standards in AN to screen for hypoglycemia, to treat hypoglycemia, or for the response of the fasting blood sugar to an intravenous bolus of glucagon. METHOD: We report the change in blood glucose that resulted from bolus iv injection of glucagon in a case series of 9 patients with AN who were suspected of having experienced hypoglycemia. Our standard protocol for the glucagon test in AN is measurement of blood sugar at baseline, 10 minutes, and 20 minutes following a 1.0 mg iv bolus of glucagon in the fasting state. We take as normal any blood glucose measurement of 7.0 mmol/l or greater. RESULTS: Five of nine patients had abnormal tests. The body mass index (BMI) was not different in those who had normal compared to those who had abnormal tests. CONCLUSION: The glucagon test may be of use to predict the likelihood of developing hypoglycemia in AN. However, a larger study is required to define the normal response to the glucagon test in AN.

How does zinc supplementation benefit anorexia nervosa?

BACKGROUND: A randomized controlled trial of zinc supplementation in anorexia nervosa (AN) reported a two-fold increase of the rate of increase of body mass index (BMI) in the zinc group. Zinc is inexpensive, readily available and free of significant side effects. However, oral zinc supplementation is infrequently prescribed as an adjunctive treatment for AN. Understanding the mechanism of action of zinc may increase its use. HYPOTHESIS: Low zinc intake, which is very common in AN, adversely affects neurotransmitters in various parts of the brain, including gamma-amino butyric acid (GABA) and the amygdala, which are abnormal in AN. Zinc supplementation corrects these abnormalities, resulting in clinical benefit in AN. CONCLUSIONS: Oral administration of 14 mg of elemental zinc daily for 2 months in all patients with AN should be routine.

Caloric requirement for refeeding inpatients with anorexia nervosa: the contribution of anxiety exercise, and cigarette smoking.

BACKGROUND: Refeeding inpatients with anorexia nervosa (AN) is costly, stressful, and can precipitate the refeeding syndrome. Caloric intake is usually increased gradually from a low starting point until a steady weight gain is achieved. There is no reliable equation that predicts the number of calories required for a weight gain. It was our clinical suspicion that anxiety, exercise, and cigarette smoking might increase the caloric need for refeeding. METHOD: We conducted an observational cohort study of 17 females with AN admitted to an inpatient eating disorder unit for refeeding. We estimated the energy intake by observation, the caloric expenditure due to exercise with a triaxial accelerometer, the number of cigarettes smoked by history, and the anxiety by the Beck Anxiety Inventory (BAI). RESULTS: Neither anxiety, exercise, or cigarette smoking predicted the caloric requirement for refeeding, individually or in combination. DISCUSSION: Our data suggest that the caloric requirement for weight gain during refeeding is not predicted by the patient's anxiety, exercise or smoking habits. The standard methods of estimating caloric requirements for refeeding remain indirect calorimetry and previous history.

Measuring change in parotid gland size: test-retest reliability of a novel method.

BACKGROUND: There is currently no convenient method for measuring parotid gland hypertrophy, a common condition among patients with bulimia nervosa (BN) and anorexia nervosa (AN). OBJECTIVE: To develop a technique for reliably estimating change in parotid gland size. METHODS: A method for measuring facial width as a surrogate marker of parotid gland size was developed using calipers to measure between defined reference points located on the parotid gland region. The method was tested for reliability when performed by a single operator and used to determine face width measurements of 15 control subjects. RESULTS: Face width measurements were reliable when performed by a single operator. Face width measurements of control subjects ranged from 9.1 cm to 15.3 cm. DISCUSSION: The caliper method of measuring changes in parotid size is a novel method of measurement of parotid hypertrophy. It is quick, non-invasive and inexpensive and is highly reliable in the hands of a single operator.

The relationship between self-rated health, stress, health care, overall quality of life and weight in a rural population.

OBJECTIVE: To determine if there is a relationship between self-rated health, stress, health care, satisfaction, overall quality of life scores and weight. DESIGN: A mailed survey and retrospective chart review of people living in the Bella Coola Valley who attend the Bella Coola Medical Clinic. STUDY POPULATION: Adults living in the Bella Coola Valley who are registered with the Bella Coola Medical Clinic. MAIN OUTCOME MEASURES: Self-rated health, stress, health care received, satisfaction with health, happiness, overall quality of life scores and weight (body mass index). RESULTS: An estimated 1734 residents live in the Bella Coola and are registered with the clinic. A total of 968 useable surveys were returned for a response rate of 56% (968/1734). Nine hundred and eighteen survey respondents had a recent weight in kilograms documented; 803 survey respondents had a height documented. A higher weight was associated with poorer self-rated health, higher stress levels, and lower satisfaction with health. It was also associated with lower self-esteem and satisfaction scores, particularly in younger obese people. A higher weight was not correlated with spirituality, overall quality of life, health care rating, or happiness scores. CONCLUSION: Increasing weight may contribute to poorer health, higher stress, lower satisfaction with health and poorer self-esteem. However, we found no evidence that increased weight impairs happiness or overall quality of life. This may be one reason for the lack of success of weight loss strategies that focus on happiness and overall quality of life to increase readiness and motivation. Alternatively, focussing on secondary medical benefits and self-esteem may be useful.

Pilot treatment program for shoplifting in eating disorders.

OBJECTIVE: There are no established treatment programs for shoplifting in eating disorder patients. Our objective was to observe the effect of an established behavioural treatment program in a series of eating disorder patients. METHODS: Patients with eating disorders who shoplift voluntarily took part in an 8-week behavioral treatment program at the Elizabeth Fry Society of Greater Vancouver, British Columbia. They completed assessments at the first session, last session, and at 1 and 6 months post intervention. RESULTS: Six patients enrolled in the study and three patients completed the treatment program. Only one patient reported a decrease in shoplifting frequency. All subjects reported an increase in self-esteem and ability to control shoplifting impulses. DISCUSSION: Our findings suggest that behavioral therapy may be effective in treating shoplifting in eating disorders, but that longer sessions and follow-up may be necessary to show benefit. A randomized control trial with longer-term follow-up is needed to determine whether there is a benefit.

The agreement between the MedGem indirect calorimeter and a standard indirect calorimeter in anorexia nervosa.

OBJECTIVES: Measurement of the basal metabolic rate (BMR) can be used to estimate the calories required for weight gain during refeeding in anorexia nervosa (AN). The reference method for measuring the BMR is indirect calorimetry. MedGem has developed a new indirect calorimeter that calculates the metabolic rate much more quickly than standard indirect calorimeters. This study compared the BMR measured by the MedGem and standard indirect calorimetry in an AN population. METHODS: We measured the BMR using the Deltatrac metabolic cart followed immediately by the MedGem indirect calorimeter in 27 subjects (12 patients and 15 controls). RESULTS: Bland-Altman plots show that there is poor agreement between the BMR reported by the MedGem compared to the Deltatrac. DISCUSSION: Until better agreement with standard indirect calorimetry can be shown the MedGem should not be used for calorimetry in AN. Possible factors that may limit the MedGem's reliability include patient discomfort with the mouthpiece, use of a fixed RQ, and the short sampling period.

A blinded laxative taper for patients with eating disorders.

OBJECTIVE: To evaluate a blinded laxative taper, supervised entirely by pharmacists, in eating disorder patients with laxative dependency. METHODS: All subjects received a blinded laxative taper according to a set protocol, in addition to the usual treatment for their eating disorder. No specific treatment was given for laxative dependency other than the pharmacist's supervisions of the blinded taper. RESULTS: Ten patients were enrolled, of whom seven completed the study. Five of the seven patients (71%) decreased their laxative intake by at least 50%. Of these seven patients, three withdraw completely from laxative use. DISCUSSION: A standardized blinded laxative taper shows promise as a treatment option for laxative dependency in patients with eating disorders. The laxative taper may be less costly and more available than inpatient or psychologically based treatment because it can be given on an outpatient basis under the supervision of a pharmacist.

Unreported sauna use in anorexia nervosa: evidence from the world-wide-web.

Weight loss methods employed in anorexia nervosa (AN) are vomiting, laxatives, diuretics, enemas, suppositories, ipecac, weight loss medications and inadequate insulin in diabetics. Some methods result in weight loss from fluid depletion and not a reduction in body fat. Sauna use causes rapid fluid loss, but has not been reported in the medical literature as a weight loss strategy used in AN. We found reports of sauna use in AN on the world-wide-web are rare. We hypothesize that the warming caused by the use of sauna, may result in physical improvement in AN and thereby reduce its acceptability as a weight loss strategy.