Behavioral predictors of attrition in adolescents participating in a multidisciplinary obesity treatment program: EVASYON study.

The aims of this study were to identify the cognitive and behavioral predictors of dropping out and to estimate the attrition rate during different phases of an intervention program to treat overweight and obesity in adolescents. Overweight/obese adolescents (n=156, aged: 13-16 years; 71 male and 85 female subjects) were included in a multicomponent (diet, physical activity and psychological support) family-based group treatment program. At baseline and after 2 months (intensive phase) and 13 months (extensive phase) of follow-up, we measured adolescents' cognitive and behavioral dimensions, together with the parents' perception of their child's behavior. Of the 156 adolescents selected, 112 completed the full program (drop-out rate of 28.2%). The risk of dropping out during the extensive phase increased by 20% for each unit increase in the adolescent's social insecurity score (odds ratio=1.20, 95% confidence interval=1.07-1.34, P=0.002). The adolescents who had a high interoceptive awareness showed a significant decrease of 13.0% in the probability of dropping out (odds ratio=0.87, 95% confidence interval=0.77-0.99, P=0.040). Adolescents' social insecurity was the main predictor of drop-out in a multicomponent family-group-based obesity treatment program. To reduce attrition rates in these programs, the individual's social insecurity level needs to be reduced, whereas the family's awareness of eating-related behavior needs adjustment.

Analysis of the -1438 G/A polymorphism of the 5-HT2A serotonin receptor gene in bulimia nervosa patients with or without a history of anorexia nervosa.

A single nucleotide polymorphism (-1438 G/A) located 1438 base pairs upstream of the consensus start site of the 5-HT2A receptor gene has been reported. The hypothesis that this gene polymorphism may be a susceptibility factor in bulimia nervosa was explored in a female population of purgative bulimics. Bulimia nervosa patients who have suffered preceding anorexia nervosa episodes formed the so-called previous anorexia nervosa bulimic patient group. At variance with some previous reports, when the frequency distribution of genotypes and alleles was compared in patients and controls, no differences were detected regardless of whether the bulimia nervosa patients had suffered prior anorexia nervosa episodes.

Polymorphisms within the promoter and the intron 2 of the serotonin transporter gene in a population of bulimic patients.

The serotonin transporter (5-HTT) gene is a firm candidate to explain eating disorders. In this association study, two different polymorphisms were analysed: a variable number of tandem repeat (VNTR) polymorphism in intron 2 and a deletion/insertion polymorphism (5-HTTLPR) in the promoter region. The hypothesis that these gene polymorphisms may be a susceptibility factor in bulimia nervosa (BN) was explored in a female population of 102 purgative bulimics. BN patients who have suffered preceding anorexia nervosa (AN) episodes formed the so-called previous AN bulimic patient group. In our sample of normal-eater controls and purging type bulimics, regardless of whether or not the BN patients had suffered prior AN episodes, no differences were found considering the frequencies of genotypes, alleles or haplotypes of both polymorphic regions of the 5-HTT gene.

The adaptive response of the immune system to the particular malnutrition of eating disorders.

Despite the seriously undernourished state of patients with anorexia nervosa (AN) and bulimia nervosa (BN), controversial findings have been published regarding some aspects of the immune system that are otherwise impaired in more typical types of malnutrition, such as protein-energy malnutrition. In general, adaptation processes seem to occur enabling immune function to be preserved during long periods of the illness. However, cell-mediated immunity is usually altered in AN and BN as reflected by lymphocyte subset counts and the response to delayed hypersensitivity tests. Regarding the helper/cytotoxic T cell ratio (CD4:CD8), an immunological marker of the nutritional status, the results of our studies on AN and BN patients showed that the duration of the eating disorder and the time when appropriate treatment is achieved are likely contributors to the alteration of this ratio. Despite these findings, it has been repeatedly pointed out that anorexic patients seem to be free of common viral infections at least until the most advanced stages of debilitation. Some hypotheses that could explain the lack of infection symptoms are reviewed. Cytokines and the altered acute phase response to infection, as well as cortisol and leptin, are considered to be potential factors involved in the adaptation processes occurring in these syndromes. Further progress in the knowledge of the psychoneuroendocrine-immune interactions established in AN and BN will be relevant to the understanding of the aetiology and maintenance mechanisms of these pathologies.

The effects of estrogen administration on bone mineral density in adolescents with anorexia nervosa.

OBJECTIVE: Profound osteopenia is a serious complication of anorexia nervosa (AN). The aim of this work was to study the effect of prolonged AN on lumbar spine bone mineral density (BMD) and to determine whether oral estrogen administration prevents bone loss in women with this disorder. SUBJECTS AND METHODS: Thirty-eight amenorrheic women with AN (mean age: 17.3 years) were treated with estrogen (50 microg of ethinyl estradiol) and gestagen (0.5 mg of norgestrel) during 1 year. Clinical variations, biochemical indices and BMD were studied at three different time points, including after a period of amenorrhea of at least 12 months (n=38), after the administration of estrogens for 1 year (n=22), and after a 1-year follow-up period (n=12). RESULTS: Initial mean BMD was significantly lower than normal (-2.1+/-0.8 s.d.) and less than -2.5 s.d. below normal in 38% of the women with AN. The estrogen-treated group had no significant change in BMD even after the follow-up period and partial recovery of weight. Estradiol and total IGF-I levels were significantly lower throughout the study. All subjects had normal thyroxine (T(4)) and TSH levels and calcium metabolism. However, total tri-iodothyronine (T(3)) was decreased in all anorexic subjects in the first and second study points and were within normal limits after the follow-up period. CONCLUSIONS: (1) Estrogen replacement alone cannot prevent progressive osteopenia in young women with AN. (2) Other factors, such as the loss of weight, the duration of the amenorrhea and the low levels of total insulin-like growth factor-I (IGF-I) could contribute to the loss of bone mass in women with this disorder.

Prevalence of eating disorders in a Spanish school-age population.

PURPOSE: To determine the prevalence of eating disorders (anorexia nervosa, bulimia, and partial syndromes) in students in a Madrid school district during the 1993-1994 academic period. The results were compared with those of an earlier study performed in 1985-1986 and with findings in other countries. METHODS: In the first phase, 1314 adolescents (731 girls and 583 boys) with a mean age of 15.05 +/- 0.98 years were surveyed according to the Eating Disorder Inventory (EDI) and a psychosocial data survey. Of these, 1281 (97.48%) [724 girls (99.04%) and 557 boys (95.54%)] were considered appropriate for the study. The risk population included individuals with a total EDI score over 50, plus a drive for thinness (DT) score over 10; 180 girls (24.86%) and 19 boys (3.41%) were identified on this basis. To reduce possible false negatives, those whose score on the bulimia scale was over 5, with amenorrhea of more than 3 months duration and a body mass index (weight in kilograms per height in square meters) under 18 were also considered to be at risk. The total risk population thus defined consisted of 293 adolescents (22.87%): 67 boys (12.02%) and 226 girls (31.21%). In the second phase, all risk subjects were reevaluated with a semistructured interview for ED, and they were also weighed and measured. In all, 156 adolescents (53.24%)[103 girls (45.57%) and 53 boys (79.10%)] participated in person. The remaining 137 subjects completed the interview by telephone. Diagnostic and Statistical Manual (DSM)-III-R diagnostic criteria were applied. RESULTS: Five girls (0.69% of the total study population) fulfilled the DSM-III-R criteria for anorexia nervosa, and nine (1.24%), for bulimia nervosa. Two boys (0.36%) had bulimia. Twenty girls (2.76%) and three boys (0.54%) represented partial syndromes. The results of adding the full and partial syndromes showed that 4.7% of the girls and 0.9% of the boys had eating disorders. CONCLUSIONS: This study demonstrates an increase in the prevalence of eating disorders in Madrid, reaching similar levels to those reported in the literature for other developed countries.

Evaluation of nutritional status by immunologic assessment in bulimia nervosa: influence of body mass index and vomiting episodes.

The nutritional status of 21 patients suffering from bulimia nervosa was evaluated by anthropometric and immunologic indexes in comparison with a control group (n = 15). In addition, the influence of body mass index (BMI; in kg/m2) values and vomiting episodes on the nutritional status of bulimic patients was assessed. Anthropometry showed no signs of malnutrition in either group, except for those patients with low weights (BMI < 19). Bulimic patients had lower lymphocyte counts than did control subjects, except for those without vomiting (NVBN). All T lymphocyte subsets tested as well as CD57 cells were lower (22% and 55%, respectively) in bulimic patients than in control subjects, but the CD19 cell subset remained unmodified. The low-weight bulimic group (LWBN) had lower CD4 cell counts than did the normal-weight (BMI > 19) bulimic group. The NVBN group had lymphocyte subpopulations similar to those in the control group, except for CD57, which was lower. The bulimic patients with vomiting had the lowest cell subset values. These results suggest a depleted nutritional status in all bulimic patients studied, even those with normal weights. The LWBN group had the most depleted nutritional status and the NVBN group was least affected at a subclinical level. CD57 can be considered a good marker of nutritional status in this syndrome because it was the only subpopulation altered in all groups.

Interactions between nutrition and immunity in anorexia nervosa: a 1-y follow-up study.

Nutritional status and immunocompetence were evaluated in 15 patients suffering from anorexia nervosa in comparison with a control group (n = 15). After 1 y, data from six phases of the study were evaluated: immediately after admittance to the hospital (AN1), after 1 mo (AN2), after 2 mo (AN3), after 3 mo (AN4), after 6 mo (AN5), and after 1 y, (AN6). Patients recovered weight from AN4 until AN6 although, according to body mass index values, all patients had low weights during the 1-y follow-up. Likewise, leukocyte and lymphocyte values were borderline and lower in patients in all phases tested than in control subjects. All lymphocyte subpopulations were lower in AN1 and AN2 patients (inpatients) than in control subjects, except for CD19 cells, which remained unmodified. There seemed to be a recovery of lymphocyte subsets after hospitalization in AN3 and AN4 patients (outpatients), except for CD57, which remained below control values. However, there was a global decrease of the lymphocyte subsets in AN5 and AN6. Ratios of CD4 to CD8 cells were not altered but the ratio of CD2 to CD19 cells was lower in all phases except AN6. Moreover, cell-mediated immune function was impaired and none of the patients showed normal responses. Thus, despite the slight weight increase found in AN4, AN5, and AN6 and the apparent cell subset recovery after hospitalization, these results suggest a greatly depleted nutritional status that remained during the whole year in all patients.

Multiple endocrine abnormalities of the growth hormone and insulin-like growth factor axis in patients with anorexia nervosa: effect of short- and long-term weight recuperation.

We have studied the GH-insulin-like growth factor (IGF) axis in patients with anorexia nervosa at the time of diagnosis and at two points during weight recuperation. We report their spontaneous GH secretion and IGF-I, free IGF-I (fIGF-I), IGF-II, the IGF-binding proteins (IGFBP-1, IGFBP-2, and IGFBP-3), and GH-binding protein (GHBP) levels at the time of the clinical diagnosis (n = 50) and after recuperation of between 6-8% (n = 42) and 10% or less of the initial weight (n = 20). Two distinct groups were seen, those who significantly hypersecreted GH and those whose GH secretion was reduced significantly. After recuperation of 10% or more of their initial weight, all patients had a normal GH pattern. Independently of GH secretory dynamics, IGF-1, IGFBP-3, and GHBP serum levels were all significantly decreased at diagnosis, and only GHBP returned to normal after weight recuperation. Serum IGFBP-1 and IGFBP-2 levels were significantly increased at the time of diagnosis and decreased after weight recuperation. The body mass index (BMI) correlated positively with fIGF-I levels and negatively with IGFBP-1 and IGFBP-2 levels, but only after weight recuperation in all cases. Contrary to what is seen in normal individuals, no correlation was found between BMI and serum GHBP levels in anorexia nervosa patients. Serum IGFBP-2 levels had a strong negative correlation with fIGF-I, IGF-II, and the sum of IGF-I and IGF-II, but only at the time of diagnosis. In conclusion, the GH-IGF axis is dramatically altered in patients with anorexia nervosa. Changes in the peripheral IGF system however, appear to be independent of modifications in GH secretion and, in contrast to current thought, not all of the observed abnormalities are rapidly reversed with weight recuperation.

Nutritional status and immunocompetence in eating disorders. A comparative study.

Nutritional status and immunocompetence were evaluated in 26 patients suffering from anorexia nervosa (AN) (n = 16) or bulimia nervosa (BN) (n = 10) in comparison with a control group (n = 22). Body mass index (BMI) was lower in all patients than in controls, AN patients having the lowest values. Slight leukopenia together with relative lymphocytosis was shown in both AN and BN. The CD4/CD8 ratio was low in all patients, but more so for BN patients, although cell-mediated immune function was impaired to the same extent for both eating disorders. The complement system appeared to be damaged in all the patients in comparison with controls. These results may mean that the nutritional status of both syndromes was different. Although anthropometric measurements in the BN group may suggest a more acceptable nutritional status, immunological parameters were shown to be depleted at the same level as the AN group and even more impaired when judged by the lower CD4/CD8 values.

Anorexia nerviosa en adolescentes: una aproximación clínica y terapéutica / Anorexia nervosa in adolescents: a clinical and therapeutical approach

En 1974 W. W. Gull describe la anorexia nerviosa (apepsia hysterica, anorexia hysterica). Propone el aislamiento del paciente como condición básica para su tratamiento. Un siglo después y tras haber atendido más de un centenar de casos, los autores redefinen el lugar de aislamiento en el marco terapéutico. Este cumple una función destacada en el establecimiento de una relación médico - paciente y con ello facilita la aplicación de técnicas comportamentales necesarias en el período de hospitalización. El paciente pasa progresivamente de lo psicosomático-conductual a lo cognitivo, y de ahí a la introspección y retrospección. Es un proceso lento que en algunos casos dura años. El aumento de consultas por anorexia nerviosa y cuadros afines en la década de los 80 ha significado un reto para los clínicos especializados en adolescencia. Ha sido necesario adecuar los servicios para atender por tiempos prolongados estas graves patologías. Se han diseñado protocolos de estudio, de hospitalización y de la cura ambulatoria que se extiende por 4 años. El mayor conocimiento de la enfermedad, la sistematización de los tratamientos y la mejor utilización de aproximaciones terapéuticas familiares han sido básicos para obtener resultados favorables en adolescentes

Nutritional status and food habits assessed by dietary intake and anthropometrical parameters in anorexia nervosa.

A nutritional study was carried out on 43 adolescents females (5 hospitalized and 38 ambulatory) suffering from anorexia nervosa and on a control group matched for sex and age. The study consisted of an interview, a "48 h. recall" and anthropometric measurements. The results have demonstrated that the nutritional status of anoretics are characterized by a total energy restriction resulting in a drastically reduced intake of macronutrients and selected micronutrients, an increased proportion of energy derived from protein. Finally, preferences and aversions are conditioned by calories content of food.