The various facets of orthorexic eating behavior: five case reports of individuals with supposed orthorexia nervosa.

BACKGROUND: Orthorexia nervosa, defined as a fixation on eating healthy according to subjective criteria, is recently being discussed as another variant of disordered eating behavior. Further characteristics are rigid adherence to nutritional rules, anxieties and avoidance behavior in the context of eating as well as a focus on health, not on body shape or weight loss, which is supposed to differentiate orthorexic from other disordered eating behavior. Although diagnostic criteria have been suggested, they have rarely been used in case reports published to date. Hence, the aim of this study was to present five individuals with supposed orthorexia nervosa, using preliminary diagnostic criteria to assess their eating behavior. CASE PRESENTATION: The five cases (three females, two males) reveal the great variety of disordered eating behavior. Fear of unhealthy overweight (case A), supposed orthorexic eating behavior as a coping strategy for anorexia nervosa (case B), the exclusive consumption of animal products with a total exclusion of fruits and vegetables (case C), the fixation on exercise and athletic goals (case D) as well as a focus on a vegan diet and unprocessed foods (case E) are facets of orthorexia nervosa with varying degrees of impairment. CONCLUSIONS: It is concluded that orthorexia nervosa manifests itself in very different ways and that more research is needed in order to determine whether it could be a useful additional category of disordered eating behavior.

Leave it or fix it? How fixation of a small posterior malleolar fragment neutralizes rotational forces in trimalleolar fractures.

INTRODUCTION: This study investigated the effects of a small posterior malleolar fragment (PMF), containing less than 25% articular surface area, on ankle joint stability via computed tomography (CT) scanning under full weight bearing in a human cadaveric ankle fracture model. MATERIALS AND METHODS: A trimalleolar fracture with a PMF of less than 25% articular surface area was created in 6 pairs of fresh-frozen human cadaveric lower legs. The specimens were randomized into 2 groups stabilized by internal fixation including a positioning screw for syndesmotic reconstruction. In Group I the PMF was addressed by direct screw osteosynthesis, whereas in Group II the fragment was not fixed. Six predefined distances within the ankle were measured under axial loading. CT scans of each specimen were performed in intact and fixated states in neutral position, dorsiflexion and plantar-flexion of the ankle. RESULTS: In plantar-flexion, significant differences were detected between the groups with regard to rotational instability. Group II demonstrated a significantly increased inward rotation of the fibula compared with Group I. No significant differences were detected between the groups for each one of the measured distances in any of the three foot positions. CONCLUSIONS: Additional reduction and fixation of a small PMF seems to neutralize rotational forces in the ankle more effectively than a sole syndesmotic screw. Clinically, this becomes relevant in certain phases of the gait cycle. Direct screw osteosynthesis of a small PMF stabilizes the ankle more effectively than a positioning screw.

Addition of Whole Wheat Flour During Injera Fermentation Degrades Phytic Acid and Triples Iron Absorption from Fortified Tef in Young Women.

BACKGROUND: Iron deficiency is a major public health concern in Ethiopia, where the traditional diet is based on tef injera. Iron absorption from injera is low due to its high phytic acid (PA) content. OBJECTIVES: We investigated ways to increase iron absorption from FeSO4-fortified tef injera in normal-weight healthy women (aged 21-29 y). METHODS: Study A (n = 22) investigated the influence on fractional iron absorption (FIA) from FeSO4-fortified injera of 1) replacing 10% tef flour with whole wheat flour (a source of wheat phytase), or 2) adding an isolated phytase from Aspergillus niger. Study B (n = 18) investigated the influence on FIA of replacing FeSO4 in tef injera with different amounts of NaFeEDTA. In both studies, the iron fortificants were labeled with stable isotopes and FIA was calculated from erythrocyte incorporation of stable iron isotopes 14 d after administration. RESULTS: In study A, the median (IQR) FIA from the 100% tef injera meal was 1.5% (0.7-2.8%). This increased significantly (P < 0.05) to 5.3% (2.4-7.1%) on addition of 10% whole wheat flour, and to 3.6% (1.6-6.2%) on addition of A. niger phytase. PA content of the 3 meals was 0.62, 0.20, and 0.02 g/meal, respectively. In study B, the median (IQR) FIA from the 100% tef injera meal was 3.3% (1.1-4.4%) and did not change significantly (P > 0.05) on replacing 50% or 75% of FeSO4 with NaFeEDTA. CONCLUSIONS: FIA from tef injera by young women was very low. NaFeEDTA was ineffective at increasing iron absorption, presumably due to the relatively low EDTA:Fe molar ratios. Phytate degradation, however, greatly increased during tef fermentation on addition of native or isolated phytases. Replacing 10% tef with whole wheat flour during injera fermentation tripled FIA in young women and should be considered as a potential strategy to improve iron status in Ethiopia.

The Potential of Fermentation and Contamination of Teff by Soil to Influence Iron Intake and Bioavailability from Injera Flatbread.

The high phytic acid (PA) concentration in the diet based on teff injera is a likely contributing cause of iron deficiency in Ethiopia. We monitored PA during teff injera fermentation in 30 households in Debre Zeyit, Ethiopia and evaluated its influence on iron bioavailability, considering contaminant soil iron in teff flour. After fermentation (48h), mean PA concentration in injera batter decreased from 0.87 to 0.58 g/100 g dm (P < 0.001). Low phytase activity in teff flour (0.44 µmol phosphate/min/g) and a rapid drop in pH, indicated that PA degradation was driven by microbial phytases. The iron concentration in injera batter among the households ranged widely from 14.5-160.4 mg/100 g dm (mean: 34.7 mg/100 g dm) principally due to contamination with soil. Estimated intrinsic iron concentration of teff based on the strong correlation between total iron and aluminium concentrations (P < 0.001; aluminium concentrations in injera batter: 28.7-184.9 mg/100 g dm) was 4.4 mg/100 g dm, indicating that 86-97 % is extrinsic iron from soil. The median daily iron intakes from 3-day weighed food records in 10 young children were 18.9 mg/day including soil iron vs. 4.9 mg/day without soil iron (P < 0.01). The PA:iron molar ratios indicated low iron bioavailability from teff injera, particularly when soil iron was excluded. Traditional fermentation thus has a modest influence on PA levels and more complete degradation is needed to improve iron bioavailability. There is an urgent need to better understand the bioavailability of contamination iron from soil before considering national fortification or biofortification strategies in Ethiopia.

Phytic acid degrading lactic acid bacteria in tef-injera fermentation.

Ethiopian injera, a soft pancake, baked from fermented batter, is preferentially prepared from tef (Eragrostis tef) flour. The phytic acid (PA) content of tef is high and is only partly degraded during the fermentation step. PA chelates with iron and zinc in the human digestive tract and strongly inhibits their absorption. With the aim to formulate a starter culture that would substantially degrade PA during injera preparation, we assessed the potential of microorganisms isolated from Ethiopian household-tef fermentations to degrade PA. Lactic acid bacteria (LAB) were found to be among the dominating microorganisms. Seventy-six isolates from thirteen different tef fermentations were analyzed for phytase activity and thirteen different isolates of seven different species were detected to be positive in a phytase screening assay. In 20-mL model tef fermentations, out of these thirteen isolates, the use of Lactobacillus (L.) buchneri strain MF58 and Pediococcus pentosaceus strain MF35 resulted in lowest PA contents in the fermented tef of 41% and 42%, respectively of its initial content. In comparison 59% of PA remained when spontaneously fermented. Full scale tef fermentation (0.6L) and injera production using L. buchneri MF58 as culture additive decreased PA in cooked injera from 1.05 to 0.34±0.02 g/100 g, representing a degradation of 68% compared to 42% in injera from non-inoculated traditional fermentation. The visual appearance of the pancakes was similar. The final molar ratios of PA to iron of 4 and to zinc of 12 achieved with L. buchneri MF58 were decreased by ca. 50% compared to the traditional fermentation. In conclusion, selected LAB strains in tef fermentations can degrade PA, with L. buchneri MF58 displaying the highest PA degrading potential. The 68% PA degradation achieved by the application of L. buchneri MF58 would be expected to improve human zinc absorption from tef-injera, but further PA degradation is probably necessary if iron absorption has to be increased.

Cortical swallowing processing in early subacute stroke.

BACKGROUND: Dysphagia is a major complication in hemispheric as well as brainstem stroke patients causing aspiration pneumonia and increased mortality. Little is known about the recovery from dysphagia after stroke. The aim of the present study was to determine the different patterns of cortical swallowing processing in patients with hemispheric and brainstem stroke with and without dysphagia in the early subacute phase. METHODS: We measured brain activity by mean of whole-head MEG in 37 patients with different stroke localisation 8.2+/-4.8 days after stroke to study changes in cortical activation during self-paced swallowing. An age matched group of healthy subjects served as controls. Data were analyzed by means of synthetic aperture magnetometry and group analyses were performed using a permutation test. RESULTS: Our results demonstrate strong bilateral reduction of cortical swallowing activation in dysphagic patients with hemispheric stroke. In hemispheric stroke without dysphagia, bilateral activation was found. In the small group of patients with brainstem stroke we observed a reduction of cortical activation and a right hemispheric lateralization. CONCLUSION: Bulbar central pattern generators coordinate the pharyngeal swallowing phase. The observed right hemispheric lateralization in brainstem stroke can therefore be interpreted as acute cortical compensation of subcortically caused dysphagia. The reduction of activation in brainstem stroke patients and dysphagic patients with cortical stroke could be explained in terms of diaschisis.

Determination of carnitine, its short chain acyl esters and metabolic precursors trimethyllysine and gamma-butyrobetaine by quasi-solid phase extraction and MS/MS detection.

For the investigation of the metabolism and biosynthesis of carnitine, sensitive determination of carnitine and its metabolic precursors, trimethyllysine and gamma-butyrobetaine, is required. We present here a new simplified method for the analysis of carnitine, its acetyl- and propyl esters, as well as trimethyllysine and gamma-butyrobetaine without need for derivatization reactions by means of normal-phase LC and electrospray ionization tandem mass spectrometry. The limits of quantification were between 5 nM for acetyl carnitine and 70 nM for carnitine. Relative standard deviations in a fivefold determination of standard solutions were between <2% for carnitine and <10% for trimethyllysine. Quantifying the formation of deuterated carnitine from deuterated gamma-butyrobetaine, this method is also suitable for the determination of the activity of gamma-butyrobetaine dioxygenase in tissues.

Activities of gamma-butyrobetaine dioxygenase and concentrations of carnitine in tissues of pigs.

In contrast to other species, less is known about carnitine homeostasis in the pig. This study was performed to yield information about the site of carnitine synthesis and carnitine concentrations in various tissues of pigs (Sus scrofa). We found that among several pig tissues, a considerable activity of gamma-butyrobetaine dioxygenase (BBD), the last enzyme of carnitine synthesis, exists, like in humans and several other species, only in liver and kidney. Activity of that enzyme in liver and kidney was lower at birth than in the subsequent weeks of life. Highest carnitine concentrations were found in skeletal muscle and heart. Carnitine concentrations in plasma, liver and kidney at birth were higher than in the subsequent weeks of life in spite of the low BBD activity at birth. In conclusion, this study shows that liver and kidney are the major sites of carnitine synthesis and that neonatal pigs do not have an insufficient carnitine status.

Supplementation of L-carnitine in pigs: absorption of carnitine and effect on plasma and tissue carnitine concentrations.

This study was performed to investigate the bioavailability of carnitine supplements and their effects on the carnitine status of pigs. Seven groups of young pigs with an average body weight of 10 kg were fed a basal diet or the same diets supplemented with 25, 50, 100, 200, 500 or 1000 mg of L-carnitine per kg for 20 days. Absorption rate of the supplemented carnitine in the small intestine, assessed by the use of titanium dioxide as an indigestible indicator, was greater than 95% for the lower doses (25, 50, 100 mg/kg) and greater than 90% for the higher doses (200, 500, 1000 mg/kg). Supplementation of carnitine caused a dose-dependent increase of free carnitine, acetyl and total carnitine concentrations in plasma, liver, kidney, heart and skeletal muscle. At the highest dose of 1000 mg/kg, plasma and tissue total carnitine concentrations were 3- to 6-fold higher than in the unsupplemented control group. In conclusion, the present study shows that young pigs have a high capacity to absorb carnitine from the diet. It is also shown that plasma and tissue carnitine concentrations in young pigs can be markedly increased by supplementation of carnitine.

A moderate excess of dietary lysine lowers plasma and tissue carnitine concentrations in pigs.

This study was performed to investigate whether dietary lysine concentration influences the carnitine status of pigs. Therefore, an experiment with twenty young pigs with an average body weight of 21 kg was performed which were fed either a control diet (9.7 g lysine/kg) or a diet with a moderate excess of lysine (16.8 g lysine/kg). Concentrations of all the other amino acids did not differ between the diets. Pigs fed the high-lysine diet had lower concentrations of free and total carnitine in plasma, liver, kidney and skeletal muscle than control pigs (P<0.05). Pigs fed the high-lysine diet moreover had an increased concentration of trimethyllysine (TML), a reduced mRNA abundance of TML dioxygenase and reduced concentrations of gamma-butyrobetaine (BB) in muscle, indicating that the conversion of TML into BB in muscle was impaired. Concentrations of BB, the metabolic precursor of carnitine, in plasma, liver and kidney were also reduced in pigs fed the high-lysine diet while the activity of BB dioxygenase in kidney was not different and that in liver was even increased compared to control pigs (P<0.05). In conclusion, this study shows that a moderate dietary excess of lysine lowers plasma and tissue carnitine concentrations in pigs. Reduced concentrations of BB in liver and kidney suggest that the depressed carnitine status was likely caused by a decreased rate of carnitine synthesis due to a diminished availability of carnitine precursor, probably mainly as a result of an impaired BB formation in muscle.

Clofibrate treatment up-regulates novel organic cation transporter (OCTN)-2 in tissues of pigs as a model of non-proliferating species.

Recent studies have shown that treatment of rodents with agonists of peroxisome proliferator-activated receptor (PPAR)-alpha causes an up-regulation of novel organic cation transporter (OCTN)-2, a carnitine transporter, and increases carnitine concentration in the liver. This study was performed to investigate whether such effects occur also in pigs which like humans have a lower expression of PPAR alpha and are less responsive to treatment with PPAR alpha agonists than rodents. An experiment with 18 pigs was performed which were fed a control diet or the same diet supplemented with 5 g clofibrate/kg for 28 days. Pigs treated with clofibrate had higher relative mRNA concentrations of OCTN2 in liver (3.1-fold), skeletal muscle (1.5-fold) and epithelial cells from small intestine (1.8-fold) than control pigs (P<0.05). Pigs treated with clofibrate had also higher concentrations of free and total carnitine in the liver and a higher concentration of free carnitine in skeletal muscle than control pigs (P<0.05). Concentrations of gamma-butyrobetaine, the precursor of endogenous formation of carnitine, in liver, muscle and plasma did not differ between both groups; the activity of gamma-butyrobetaine dioxygenase, the rate limiting enzyme of carnitine synthesis, in the liver was lower in pigs treated with clofibrate than in control pigs (P<0.05). This study shows for the first time that treatment with a PPAR alpha agonist causes an up-regulation of OCTN2 in liver, muscle and enterocytes from small intestine of pigs. This in turn increases carnitine concentrations in liver and muscle probably by enhancing carnitine uptake into cells.