Consequences Of Anorexia Nervosa Research Articles

Experiences of eating difficulties in siblings of people with anorexia nervosa: a reflexive thematic analysis

BackgroundSiblings of people with anorexia nervosa (AN) have been found to experience strong emotions, changing family roles and poorer wellbeing as a consequence of experiencing the effects of the illness on their sibling and family system. These factors, combined with genetic influences, may put siblings at an increased risk of developing eating disorder psychopathology in addition to other mental health issues. This research aims to explore the experiences of siblings of people with AN who have had eating difficulties themselves and investigate issues that may be important to the development and prevention of eating difficulties in this population.MethodsThis qualitative study used a reflexive thematic analysis approach. Ten adults who had witnessed a sibling with AN and experienced eating difficulties themselves participated in semi-structured interviews.AnalysisParticipants’ own eating difficulties were affected by the specific experience of witnessing a sibling with AN through mealtimes becoming emotionally charged, an increased focus on body size and diet, and comparisons with their sibling. Difficult experiences, such as marital discord amongst parents were common, as was a difficulty in managing emotions. The onset of AN within the family caused participants to take on caring responsibilities for their sibling and to hide their own difficulties for fear of adding additional burden to their parents. This reduced their perceived ability to access support and for some increased a desire to restrict as a coping mechanism for the stress they were experiencing. Systemic beliefs regarding the value of thinness were prevalent and influential. Protective factors, such as not wanting to become as unwell as a sibling with AN and an understanding of the negative consequences of AN, aided recovery.ConclusionsEating difficulties in siblings of people with AN may be influenced by competition for slimness, increased focus on diet and body size, and a need to manage difficult emotions. The disruption to social connections and a difficulty finding emotional support that may be experienced by people when a sibling develops AN may further influence susceptibility to eating difficulties. Further research is needed into the best ways to support siblings of people with AN.

O-179 Pregnancy outcomes in women with anorexia nervosa: a North American population-based study

Abstract Study question What implications does anorexia nervosa (AN) have on pregnancy outcomes in a North American population (NAP)? Summary answer Anorexia nervosa is associated with substantial increased risk of 500% in SGA, 270% in preterm delivery and 335% in placental abruption in a NAP. What is known already While considered by many a contraindication to fertility treatment, many women with AN do conceive with the help of reproductive medicine and spontaneously. This could be either because of lack of proper screening for anorexia nervosa (as studies show), or this being a lifelong disease. Many fertility specialists are faced with the dilemma of treating women who are undernourished, or if by refusing to do so, possibly preventing these patients the joy of parenthood. Most data regarding the consequences of AN on pregnancy complications, comes from Northern Europe and data from North America is lacking. Study design, size, duration A retrospective population-based study utilizing data from the Healthcare Cost and Utilization Project—Nationwide Inpatient Sample (HCUP-NIS), was performed. A dataset of all deliveries between 2004 and 2014 inclusively, was created. Within this group, all deliveries to women who had a diagnosis of AN during pregnancy were identified as part of the study group (n = 214), and the remaining deliveries comprised the reference group (n = 9,096,574). Participants/materials, setting, methods Descriptive analyses were performed to compare the demographic features among both groups, Chi-squared test or Fisher’s exact test were used when appropriate. Multivariate logistic regression analysis was performed to calculate unadjusted and adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CI). According to Tri-Council Policy statement(2018), IRB approval was not required, given data was anonymous and publicly available. Main results and the role of chance Women diagnosed with AN were more likely to be white, of higher income, to be smokers, have thyroid disease or diagnosed with another psychiatric disorder (p < 0.05 all). No difference was found in the rates of hypertensive diseases of pregnancy, gestational diabetes mellitus, incidence of placenta previa, need for cesarean section, postpartum hemorrhage or chorioamnionitis(P>.05, all). Women with AN had a higher frequency of preterm delivery (aOR 2.70 CI 1.69-4.3, p < 0.001) and placental abruption (aOR 3.35 CI 1.36-8.26, p = 0.009). The incidence of small for gestational age neonates was shockingly higher in the AN group (aOR 5.00 CI 2.93-8.53, p < 0.001). Limitations, reasons for caution The limitations of our study are its retrospective nature and the fact that it relies on an administrative database. The severity of AN could not be assessed, nor could compliance with treatment. Wider implications of the findings Women with AN often conceive through ovulation induction. Fertility specialist should be aware of the magnitude of adverse outcomes related to pregnancy in women with AN, with a 500% increase in SGA 500% compared to a control population, and likely contributing to the increase in preterm delivery. Trial registration number not applicable

Renal dysfunctions and clinical correlates in adolescents with restrictive anorexia nervosa.

The alteration of kidney function in adolescents with anorexia nervosa (AN) is a frequent, but still poorly investigated, consequence of AN. In this study, we analyzed glomerular filtration rate with the Cockroft-Gault formula in a group of 148 adolescents with Anorexia Nervosa and correlated it to clinical and biochemical data collected at admission. A retrospective study was conducted on 148 patients hospitalized from 2016 to 2019 for severe malnutrition due to restrictive AN. We measured glomerular filtration rate and correlated it with the patients' anamnestic history, nutritional status and biochemical data. For the 148 AN patients, 40 (27%) resulted at admission at stage 1 of kidney damage (GFR>90mL/min), 88 patients (59%) at stage 2 (GFR 89-60mL/min), 17 patients (11%) at stage 3A (GFR 59-45mL/min) and 3 patients (2%) at stage 3B (GFR 44-30mL/min). Results outlined a correlation between the entity of kidney damage and BMI at admission and before illness onset, but not with the rapidity and entity of weight loss. Further, more severe renal damages corresponded to major biochemical and hormonal alterations. Results of our study confirm that kidney damage is a frequent condition in adolescents withrestrictive-type AN and support making kidney functionality tests part of routine care in patients with AN.

Clinical, psychopathological, and biological predictors of resumption of menses in subjects with anorexia nervosa: A 4-year follow-up study

IntroductionAmenorrhea is one of the most frequent and serious consequences of Anorexia Nervosa (AN). Resumption of menses (ROM) is considered an important goal and is associated with a better outcome.ObjectivesTo investigate the role of age, Body Mass Index (BMI), diagnostic subtype (restrictive vs binge-purging), history of childhood abuse, duration of illness, psychopathology and sex hormones on ROM in AN.Methods52 patients with AN and amenorrhea were enrolled at the start of treatment. Clinical parameters of interest were collected, and questionnaires were administered for the assessment of general (SCL-90-R) and specific (EDE-Q) psychopathology. Blood samples were taken to assess FSH, LH and estradiol levels. All patients were monitored regularly through psychiatric checkups until ROM, for up to four years.ResultsA total of 30 (57.7%) subjects recovered their menstrual cycle in the follow-up period (mean time: 18.7 ± 14.8 months). Recovery was more frequent in the binge-purging subtype than in the restrictive subtype (82.4% vs 48.6%, p=0.019), and was significantly associated with diagnostic crossover (odds ratio=10.0, p=0.032). Multivariate Cox regression showed an increased likelihood of menstrual recovery for binge-purging subtype (p=0.005) and for those reporting a history of childhood abuse (p=0.025). Early ROM was also associated with baseline SCL-90-R scores (p=0.002) and FSH (p=0.011), while a longer duration of illness (p=0.003) and EDE-Q scores (p=0.009) predicted a later recovery.ConclusionsThis study highlights the role of duration of illness, childhood abuse history and psychopathological characteristics in subjects with AN at the start of treatment in predicting ROM.DisclosureNo significant relationships.

Thirty years after anorexia nervosa onset, serum neurofilament light chain protein concentration indicates neuronal injury

Little is known about the long-term consequences of anorexia nervosa (AN) in terms of possible brain neuronal injury. We aimed at investigating whether women with adolescent-onset AN exhibit increased serum levels of neurofilament light chain protein (NfL), a biomarker for neuronal injury, compared with matched controls at 30-year follow-up. Blood samples were collected from 34 women with adolescent-onset AN and 38 matched healthy comparison women (COMP), at a mean age of 44 years (range 38–48 years). NfL was measured in serum using the in-house single molecule array (Simoa) method. The individuals were asked whether they or their parents had been diagnosed with dementia. The Swedish National Patient Register was searched for diagnoses related to dementia. Serum NfL concentrations were significantly higher in the AN group (AN 27.7 pg/ml; COMP 19.0 pg/ml; p = 0.041). When individuals with medical/neurological disorders in the AN and COMP groups were excluded, there was a statistically non-significant trend towards higher concentrations in the AN group (AN 27.4 pg/ml; COMP 18.8 pg/ml; p = 0.060). None of the participants had been diagnosed with dementia. There was no significant correlation between serum NfL and AN duration (r = 0.15). There was a moderate negative correlation between the serum NfL concentration and the current BMI in the AN group (r = 0.44). This is the first time that serum NfL has been assessed in middle-aged women with a history of adolescent-onset AN. The results suggest that there might be increased axonal degeneration as a sequel of AN. Individuals remaining underweight had higher serum NfL concentrations than those with a normal/high BMI. Additional studies are needed to confirm increased serum NfL concentrations in individuals recovered from AN. There is a need for further study of axonal degeneration as a consequence of AN.

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Incontinence and constipation in adolescent patients with anorexia nervosa-Results of a multicenter study from a German web-based registry for children and adolescents with anorexia nervosa.

Nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood and are frequently accompanied by comorbid psychiatric disorders. Despite a high association between urinary and fecal incontinence with psychiatric and neurodevelopmental disorders, research on comorbidity between incontinence and anorexia nervosa (AN) remains scarce. Yet, it is well known that somatic consequences of AN include metabolic and gastrointestinal disorders. The study sought to assess the prevalence of incontinence and constipation in children and adolescents with AN and to examine associations of these two symptoms with body weight at admission and with BMI changes during inpatient treatment. Data collected between 2015 and 2017 by a multicenter German web-based registry for AN were analyzed. Three hundred and forty-eight patients with AN (96.3% female, mean age = 15.1 ± 1.8 years) were assessed regarding AN subtype, psychiatric comorbidity, body weight, incontinence, and constipation. Overall, 27.6% of patients had constipation, 1.8% had NE and 1.8% DUI. Prevalence of constipation did not significantly differ between AN subtypes. Constipation did not lead to any significant differences in weight/BMI changes during inpatient treatment. This is the largest study of incontinence and constipation in patients with AN, so far. Our results indicate that constipation is highly prevalent in adolescent patients with AN and reflects a clinically relevant condition. Despite, patients with AN do not have an increased prevalence of incontinence compared with the general population. Future studies should include medical examinations like ultrasound and physical examination of the lower abdomen to evaluate the severity of constipation.

Psychological Impairment as a Predictor of Suicide Ideation in Individuals with Anorexia Nervosa.

Anorexia nervosa (AN) is an eating disorder characterized by severe food restriction resulting in low body weight and an intense fear of gaining weight. This disorder has one of the highest suicide rates of any psychiatric illness; however, few studies have investigated prospective predictors of suicide ideation (SI) in this population. Quality-of-life impairment may be particularly relevant for understanding suicide risk in AN, given associations with SI in other psychiatric disorders and associations with chronicity and severity in AN. This study explored associations between eating disorder-related impairment and SI in individuals with AN (n=113) who completed assessments at treatment discharge and 3, 6, and 12months after discharge. Greater psychological impairment predicted future occurrence of SI controlling for age, depression, history of SI, and eating disorder variables. Associations were specific to psychological impairment as other domains of impairment did not predict SI over time. Findings highlight the potential importance of targeting interpersonal-psychological consequences of AN to decrease future suicide risk.

Caregiver burden and illness perceptions in caregivers of medically hospitalized youth with anorexia nervosa

Caregiver burden is common in caregivers of youth with anorexia nervosa (AN) and could impede the successful implementation of family-based therapy (FBT). Thus, it is important to better understand mechanisms by which caregiver burden is developed and maintained. This study aimed to examine the relation between caregiver illness perceptions about AN, symptom severity indicators, and caregiver burden in a sample of medically hospitalized youth with AN. Fifty-one youth with AN (N = 34) or Atypical AN (AAN; N = 17; mean age = 14.85, SD = 1.41; 76% female) and their primary caregivers (N = 47 mothers and N = 4 fathers) completed self-report questionnaires at hospital admission. Collected data included caregiver and youth illness perceptions about AN, caregiver burden, and youth self-reports of psychological symptoms. Physiological data regarding symptom severity included admitting percent of expected body weight (%EBW) and minimum heart rate during admission. Findings indicated that caregiver beliefs about negative consequences of AN were associated with caregiver burden, independent of youth age, sex, illness duration, and diagnosis. Youth reports of symptom severity, %EBW, and low heart rate were not associated with increased caregiver burden. Findings suggest that the subjective experience of having a youth with AN are a greater determinant of caregiver burden than objective indicators of illness severity. Further, these findings provide support for the FBT clinician to strike a balance between providing information about the potential consequences of AN, while instilling hope for recovery and bolstering parent self-efficacy.

Exposure to activity-based anorexia impairs contextual learning in weight-restored rats without affecting spatial learning, taste, anxiety, or dietary-fat preference.

Relapse rates are high amongst cases of anorexia nervosa (AN) suggesting that some alterations induced by AN may remain after weight restoration. To study the consequences of AN without confounds of environmental variability, a rodent model of activity-based anorexia (ABA) can be employed. We hypothesized that exposure to ABA during adolescence may have long-term consequences in taste function, cognition, and anxiety-like behavior after weight restoration. To test this hypothesis, we exposed adolescent female rats to ABA (1.5 h food access, combined with voluntary running wheel access) and compared their behavior to that of control rats after weight restoration was achieved. The rats were tested for learning/memory, anxiety, food preference, and taste in a set of behavioral tests performed during the light period. Our data show that ABA exposure leads to reduced performance during the novel object recognition task, a test for contextual learning, without altering performance in the novel place recognition task or the Barnes maze, both tasks that test spatial learning. Furthermore, we do not observe alterations in unconditioned lick responses to sucrose nor quinine (described by humans as "sweet" and "bitter," respectively). Nor Do we find alterations in anxiety-like behavior during an elevated plus maze or an open field test. Finally, preference for a diet high in fat is not altered. Overall, our data suggest that ABA exposure during adolescence impairs contextual learning in adulthood without altering spatial leaning, taste, anxiety, or fat preference.

State of the art systematic review of bone disease in anorexia nervosa.

Low bone mineral density (BMD) is a known consequence of anorexia nervosa (AN) and is particularly concerning during adolescence, a critical time for bone accrual. A comprehensive synthesis of available data regarding impaired bone health, its determinants, and associated management strategies in AN is currently lacking. This systematic review aims to synthesize information from key physiologic and prospective studies and trials, and provide a thorough understanding of impaired bone health in AN and its management. Search terms included "anorexia nervosa" AND "bone density" for the period 1995-2015, limited to articles in English. Papers were screened manually based on journal impact factor, sample size, age of participants, and inclusion of a control group. When necessary, we included seminal papers published before 1995. AN leads to low BMD, impaired bone quality and increased fracture risk. Important determinants are low lean mass, hypogonadism, IGF-1 deficiency, and alterations in other hormones that impact bone health. Weight gain and menses restoration are critical for improving bone outcomes in AN. Physiologic estrogen replacement as the transdermal patch was shown to increase bone accrual in one study in adolescent females with AN; however, residual deficits persist. Bisphosphonates are potentially useful in adults with AN. To date, evidence suggests that the safest and most effective strategy to improve bone health in AN is normalization of weight with restoration of menses. Pharmacotherapies that show promise include physiologic estradiol replacement (as the transdermal estradiol patch), and in adults, bisphosphonates. Further studies are necessary to determine the best strategies to normalize BMD in AN.

Evidence of a link between resting energy expenditure and bone remodelling, glucose homeostasis and adipokine variations in adolescent girls with anorexia nervosa.

Low bone mass is a consequence of anorexia nervosa (AN). This study assessed the effects of energy deficiency on various bone and hormonal parameters. The interrelationships between energy deficiency and bone remodelling, glucose homeostasis and adipokines underscore the importance of preventing energy deficiency to limit demineralisation and hormonal alterations in AN patients. Low areal bone mineral density (aBMD) is a well-known consequence of AN. However, the impact of reduced energy expenditure on bone metabolism is unknown. This study assessed the effects of energy deficiency on bone remodelling and its potential interactions with glucose homeostasis and adipose tissue-derived hormones in AN, a clinical model for reduced energy expenditure. Fifty women with AN and 50 age-matched controls (mean age 18.1 ± 2.7 and 18.0 ± 2.1 years, respectively) were enrolled. aBMD was determined with DXA. Resting energy expenditure (REEm), a marker of energy status, was indirectly assessed by calorimetry. Bone turnover markers, undercarboxylated osteocalcin (ucOC), parameters of glucose homeostasis, adipokines and growth factors were concomitantly evaluated. AN patients presented low aBMD at all bone sites. REEm, bone formation markers, ucOC, glucose, insulin, HOMA-IR, leptin and IGF-1 were significantly reduced, whereas the bone resorption marker, leptin receptor (sOB-R) and adiponectin were elevated in AN compared with CON. In AN patients, REEm was positively correlated with weight, BMI, whole body (WB) fat mass, WB fat-free soft tissue, markers of bone formation, glucose, insulin, HOMA-IR, leptin and IGF-1 and negatively correlated with the bone resorption marker and sOB-R. Biological parameters, aBMD excepted, appeared more affected by the weight variation in the last 6 months than by the disease duration. The strong interrelationships between REEm and bone remodelling, glucose homeostasis and adipokines underscore the importance of preventing energy deficiency to limit short- and long-term bone demineralisation and hormonal alterations in AN patients.

Girls Growing Up: A Feasibility and Acceptability Study to Explore the Antecedents of Anorexia Nervosa in Girls Aged 7 to 17

Abstract Objective: Prospective longitudinal research into the antecedents of anorexia nervosa (AN) is required to identify targets for prevention, early detection and treatment. Such research is hampered by the low natural incidence of AN, and the ethical complexities of research with children. A number of risk factors have been identified, but the relationship between these and the development and maintenance of AN remains unclear. To date, prospective studies have had insufficient power to differentiate risk factors from consequences of AN. The proposed “Girls Growing Up: The Antecedents of Anorexia Nervosa” study aims to identify predictors of AN and protective factors by prospectively tracking the progress of healthy genetically high risk individuals and controls. A proposed pilot study will first discover whether a series of likely physical and psychometric measures are acceptable to subjects and their families and will additionally assess whether high risk and control subjects differ at baseline on any of these measures. The present study assesses the feasibility and acceptability of the proposed research protocol by use of buzz-groups to ascertain perceptions, opinions and ideas of potential recruits. Method: Seven buzz-groups (focus groups) were held with schoolgirls aged seven to 17, parents and teachers recruited from a co-educational school. The proposed protocol was presented as a narrated storyboard demonstrating an example research day of a fictional study participant. Group discussions were audio-recorded, transcribed and analysed in terms of study location, acceptability of measurements, recruitment and retention. Results: The proposed protocol was broadly acceptable to all participants. Participants provided collaborative input to the study design, including: a strong preference for female researchers; discussion about the acceptability of proposed physical and psychosocial measures; a preference for a choice of study location; the suggestion of provision of a detailed timetable to reduce anxiety; and agreement that it is appropriate to advertise to parents of under-12s, but to 12 to 17 year olds in their own right. They also renamed the study and suggested means of recruitment. Conclusion: The proposed methodology was deemed acceptable to the target group. Buzz-groups proved invaluable in exploring opinions, influencing the proposed research protocol and highlighting the value of involvement of potential participants in preparatory stages of research, particularly into the sensitive field of eating disorders.

Partner distress in the context of adult anorexia nervosa: the role of patients' perceived negative consequences of AN and partner behaviors.

Romantic partners can play an important role in the recovery from anorexia nervosa (AN). It is important to understand partners' behaviors and variables associated with their own distress. The aim was to examine associations of patients' perceived negative consequences of AN, behavioral strategies employed by partners, and partner distress. We used a cross-sectional design to assess associations between self-reports of patients' perceived negative consequences of AN, partners' caregiver distress, negative affect, relationship satisfaction, and observational coding measures of partners' behavioral strategies of change promotion and acceptance/validation. Sixteen adult patient-partner dyads in committed relationships were assessed at baseline of a couple-based intervention for AN. Partners' change promotion moderated the association between patients' perceived negative consequences of AN and partners' caregiver distress. Partners' acceptance/validation was associated with partners' negative affect. This report represents the first description of specific partner behaviors in the context of AN. Partners who reported the least distress were those who were trying to promote changes in AN behaviors in patients who reported high negative consequences of AN, and partners who were trying to show understanding of the patients' experience. Future studies should examine the impact of partner behaviors on AN treatment outcome.

Set‐shifting among adolescents with anorexia nervosa

Set-shifting difficulties are documented for adults with anorexia nervosa (AN). However, AN typically onsets in adolescents and it is unclear if set-shifting difficulties are a result of chronic AN or present earlier in its course. This study examined whether adolescents with short duration AN demonstrated set-shifting difficulties compared to healthy controls (HC). Data on set-shifting collected from the Delis-Kaplan executive functioning system and Wisconsin card sort task (WCST) as well as eating psychopathology were collected from 32 adolescent inpatients with AN and compared with those from 22 HCs. There were no differences in set-shifting in adolescents with AN compared to HCs on most measures. The findings suggest that set-shifting difficulties in AN may be a consequence of AN. Future studies should explore set-shifting difficulties in a larger sample of adolescents with the AN to determine if there is sub-set of adolescents with these difficulties and determine any relationship of set-shifting to the development of a chronic from of AN.

P-553 - Anorexia nervosa and osteoporosis risk, a case report series

Anorexia nervosa (AN) is a mental health disorder whose features are deliberate weight loss, disordered body image, and intrusive overvalued fears of gaining weight. Long term consequences of AN include endocrine dysfunctions resulting in low levels of gonadotropins and estrogens, secondary amenorrhea, bone loss and/or osteoporosis. Bone reabsorption is related with the exposure to low levels of estrogens leading to an increased risk of bone fractures as it happens in late postmenopausal period and young women with AN may develop a risk for pathological fractures comparable to that of menopausal women. In our case report series we examined the influence of AN related amenorrhea on bone mineral density (BMD). We evaluated BMD with computerised bone mineralometry (CBM) in 10 women with diagnosis of AN, hospitalized in the Psychiatric Clinic of University of Pisa. All the patients showed a lumbar and femoral bone loss or osteoporosis with an increased fracture risk in comparison with peers and comparable to that of menopausal women. Our data support the hypothesis that lower estrogenic levels associated with AN have an impact on BMD. Although osteoporotic complications and fracture risk are underdiagnosed, underestimated and potential cause of permanent disability is a predictable and treatable condition in AN patients. Therefore we recommend a more accurate evaluation of BMD with CBM in all patients with prolonged amenorrhoea.

In vivo evidence of global and focal brain alterations in anorexia nervosa

Brain alterations are known to be associated with anorexia nervosa (AN) and tend to be distributed across brain structures, with only a few reports describing focal damage. Magnetic resonance images of 21 anorexic patients with different disease duration and 27 control subjects were acquired and compared using voxel-based morphometry (VBM). Patients had a significant reduction of total white matter (WM) volume and focal gray matter (GM) atrophy in cerebellum, hypothalamus, caudate nucleus and frontal, parietal and temporal areas. The cerebellum was more affected in patients with longer disease duration, whereas the hypothalamic alterations were more pronounced in patients with shorter food restriction. A correlation with body mass index (BMI) and GM was found in the hypothalamus. Our data demonstrate a diffuse reduction of WM together with focal areas of GM atrophy in AN. The finding of a hypothalamic focal atrophy points to hormonal dysfunction and opens the possibility for a central dysregulation of homeostasis. The involvement of temporoparietal areas could account for body image distortion. Finally, the cerebellar GM atrophy confirms previous findings and seems to be a late consequence of AN that could play a role in the chronic phase of the disease.

Personality and anorexia nervosa

We provided a selective review of the relationship between anorexia nervosa (AN) and personality. They reviewed the existing empirical literature examining the relationship between AN and personality. In spite of continued methodologic challenges related to personality assessment, there appears to be a relatively common phenotype in restricting-type AN characterized by high degrees of obsessionality, restraint, and perfectionism. However, there is also evidence of variability within the AN diagnostic category that is related to personality variables. Importantly, personality variables may significantly predict the course and outcome of AN. Personality variables may be risk factors for AN, consequences of AN, share a common cause with AN, or affect the course and outcome of AN. This literature would be enhanced by the articulation of conceptual models of these relationships that can be empirically tested.

The Long Term Biological Consequences of Anorexia Nervosa

The long-term psychiatric and psychological outcome of the anorexia nervosa (AN) has been well described. Less is known about the long-term physiological effects of the illness and this article reviews the findings to date. Having a history of AN does not appear to increase the risk of infertility, but may increase the risk of birth complications and of having a low birth weight infant. Although evidence on the reversibility of bone mineral density loss in AN is conflicting, osteoporosis-related fracture rates are higher in women with previous AN. Animal models of energy restriction and two studies in AN suggest that AN may confer protection against breast cancer, however data are preliminary. Furthermore, it is theoretically possible, that deficiencies of chemoprotective nutrients, chronic constipation, laxative abuse, and selfinduced vomiting may increase the risk of other, and in particular, gastrointestinal tract, pathology. This risk remains to be investigated. The metabolic and endocrine effects of the illness are largely reversed with recovery, but various disturbances in pancreatic hormone secretion have been described and require further clarification. As cohorts of women with a history of AN mature, well controlled studies are recommended to provide further information on the long-term health consequences of AN. Keywords: anorexia nervosa, long-term outcome, health

Effects of Anorexia Nervosa on Clinical, Hematologic, Biochemical, and Bone Density Parameters in Community-Dwelling Adolescent Girls

Anorexia nervosa (AN) is an eating disorder that leads to a number of medical sequelae in adult women and has a mortality rate of 5.6% per decade; known complications include effects on hematologic, biochemical, bone density, and body composition parameters. Few data regarding medical and developmental consequences of AN are available for adolescents, in particular for an outpatient community-dwelling population of girls who have this disorder. The prevalence of AN is increasing in adolescents, and it is the third most common chronic disease in adolescent girls. Therefore, it is important to determine the medical effects of this disorder in this young population. We examined clinical characteristics and performed hematologic, biochemical, hormonal, and bone density evaluations in 60 adolescent girls with AN (mean age: 15.8 +/- 1.6 years) and 58 healthy adolescent girls (mean age: 15.2 +/- 1.8 years) of comparable maturity. Nutritional and pubertal status; vital signs; a complete blood count; potassium levels; hormonal profiles; bone density at the lumbar and lateral spine; total body, hip, and femoral neck (by dual-energy x-ray absorptiometry) and body composition (by dual-energy x-ray absorptiometry) were determined. All measures of nutritional status such as weight, percentage of ideal body weight, body mass index, lean body mass, fat mass, and percentage of fat mass were significantly lower in girls with AN than in control subjects. Girls with AN had significantly lower heart rates, lower systolic blood pressure, and lower body temperature compared with control subjects. Total red cell and white cell counts were lower in AN than in control subjects. Among girls with AN, 22% were anemic and 22% were leukopenic. None were hypokalemic. Mean age at menarche did not differ between the groups. However, the proportion of girls who had AN and were premenarchal was significantly higher compared with healthy control subjects who were premenarchal, despite comparable maturity as determined by bone age. Ninety-four percent of premenarchal girls with AN versus 28% of premenarchal control subjects were above the mean age at menarche for white girls, and 35% of premenarchal AN girls versus 0% of healthy adolescents were delayed >2 SD above the mean. The ratio of bone age to chronological age, a measure of delayed maturity, was significantly lower in girls with AN versus control subjects and correlated positively with duration of illness and markers of nutritional status. Serum estradiol values were lower in girls with AN than in control subjects, and luteinizing hormone values trended lower in AN. Levels of insulin-like growth factor-I were also significantly lower in girls with AN. Estradiol values correlated positively with insulin-like growth factor-I, a measure of nutritional status essential for growth (r = 0.28). All measures of bone mineral density (z scores) were lower in girls with AN than in control subjects, with lean body mass, body mass index, and age at menarche emerging as the most important predictors of bone density. Bone density z scores of <-1 at any one site were noted in 41% of girls with AN, and an additional 11% had bone density z scores of <-2. A high prevalence of hemodynamic, hematologic, endocrine, and bone density abnormalities are reported in this large group of community-dwelling adolescent girls with AN. Although a number of these consequences of AN are known to occur in hospitalized adolescents, the occurrence of these findings, including significant bradycardia, low blood pressure, and pubertal delay, in girls who are treated for AN on an outpatient basis is of concern and suggests the need for vigilant clinical monitoring, including that of endocrine and bone density parameters.