Classification of feeding and eating disorders: review of evidence and proposals for ICD-11

Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier "with dangerously low body weight" should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.     

Longitudinal course of eating disorders after transsexual treatment: a report of two cases

Background

Several reports have been published on patients with gender dysphoria and eating disorders. However, there have been few reports on the longitudinal course of eating disorders after gender reassignment surgery (GRS)/gender confirmation surgery (GCS).

Case presentation

We report two Japanese cases of transsexual persons with eating disorders who underwent GRS/GCS, one male-to-female (MtF) and one female-to-male (FtM). Case 1 was a 35-year MtF person who had a 14-year-course of bulimia nervosa that developed after GRS. Case 2 was a 35-year FtM person with anorexia nervosa who underwent GCS 9 years before.

Conclusions

We found that the treatment of our transsexual patients influenced the course of their eating disorders for a long period, which could be attributable partly to the cultural situation in Japan, an East Asian country. It is possible that many gender identity problems and identity problems in general persist even after surgery and treatment; therefore, continual clinical support should be provided for patients with gender dysphoria and eating disorders even after hormonal therapy or GRS/GCS.

     

Not Your “Typical Island Woman”: Anorexia Nervosa is Reported Only in Subcultures in Curaçao

Anorexia nervosa (AN), once thought to be a problem of wealthier, Western countries has now been documented in survey studies and case reports across geographic and economic groups; however, few epidemiological studies including interview have been done on these populations. We report on a comprehensive study on Curaçao, a Caribbean island in economic transition, where the majority of the population is of predominantly black African origin. As part of an epidemiological study on the island of Curaçao indigenous cases of AN were identified. Participants were interviewed and asked to complete standardized measures of eating behaviors and cultural attitudes. In addition, matched controls completed the same measures and were seen in a focus group to assess their knowledge of eating disorders and perceived current and future challenges to young Curaçao women. Six of the nine indigenous cases of AN were successfully traced; all were of mixed race. No cases of anorexia were found among the majority black population. The women with AN were from the high-education and high-income sectors of the society and the majority had spent time overseas. The women with a history of anorexia reported higher levels of perfectionism and anxiety than the matched controls. All of the women reported challenges to maintaining an active professional and personal life and viewed themselves as different from the norm. Women who presented with AN evidenced vulnerability to a triple threat to identity formation: (1) they were of mixed race, aspiring to fit into the mobile elite (and mostly white) subgroup while distancing themselves from the black majority; (2) they had the means for education and travel that left them caught between modern and traditional constructs of femininity; and (3) they had lived overseas, and therefore struggled upon reentry with the frustrations of what was possible within the island culture. The race, class and overseas exposures of the women with anorexia were anything but typical on the island. Cases of anorexia in other developing countries may similarly be limited to specific subgroups, which require specialized treatment and planning efforts.     

Integrated circuits and molecular components for stress and feeding: implications for eating disorders

Eating disorders are complex brain disorders that afflict millions of individuals worldwide. The etiology of these diseases is not fully understood, but a growing body of literature suggests that stress and anxiety may play a critical role in their development. As our understanding of the genetic and environmental factors that contribute to disease in clinical populations like anorexia nervosa, bulimia nervosa and binge eating disorder continue to grow, neuroscientists are using animal models to understand the neurobiology of stress and feeding. We hypothesize that eating disorder clinical phenotypes may result from stress‐induced maladaptive alterations in neural circuits that regulate feeding, and that these circuits can be neurochemically isolated using animal model of eating disorders.     

The Human Obesity Gene Map: The 2000 Update

This report constitutes the seventh update of the human obesity gene map incorporating published results up to the end of October 2000. Evidence from the rodent and human obesity cases caused by single‐gene mutations, Mendelian disorders exhibiting obesity as a clinical feature, quantitative trait loci uncovered in human genome‐wide scans and in cross‐breeding experiments in various animal models, and association and linkage studies with candidate genes and other markers are reviewed. Forty‐seven human cases of obesity caused by single‐gene mutations in six different genes have been reported in the literature to date. Twenty‐four Mendelian disorders exhibiting obesity as one of their clinical manifestations have now been mapped. The number of different quantitative trait loci reported from animal models currently reaches 115. Attempts to relate DNA sequence variation in specific genes to obesity phenotypes continue to grow, with 130 studies reporting positive associations with 48 candidate genes. Finally, 59 loci have been linked to obesity indicators in genomic scans and other linkage study designs. The obesity gene map reveals that putative loci affecting obesity‐related phenotypes can be found on all chromosomes except chromosome Y. A total of 54 new loci have been added to the map in the past 12 months and the number of genes, markers, and chromosomal regions that have been associated or linked with human obesity phenotypes is now above 250. Likewise, the number of negative studies, which are only partially reviewed here, is also on the rise.     

Non-clinical assessment of cell therapy products: the perspective from five Asian countries/regions based on regulatory guidelines and the underpinning rationales

Background aimsCell-based regenerative medicine is an innovative field that can potentially alter the overall survival and quality of life of patients with devastating diseases. Several cell therapy products (CTPs) have been approved within the last two decades, and more are under development. The establishment of an effective developmental strategy in accordance with the regulatory bodies of each country/region is crucial for fast delivery of each respective CTP. In particular, facilitating investigational new drug (IND) approval is important for accelerating the transition from non-clinical to clinical research/trial phases.MethodsHere the authors compared the non-clinical prerequisites for initiating clinical studies in five Asian countries/regions (India, China, Korea, Taiwan and Japan) from an industry viewpoint. The authors first identified the differences and tried to clarify the perspectives/considerations underpinning the different requirements.ResultsThe authors’ findings revealed that differences in regulations and development experiences, especially with CTPs, have led to clear differences in the non-clinical study package and its corresponding study design.ConclusionsBy sharing experiences of the research and development of CTPs among Asian countries/regions and including not only industry but also regulatory authorities, we will be able to expedite cross-border IND approval and eventually contribute to the early delivery of innovative CTPs to many Asian patients.     

Neuroendocrine dysregulation of food intake in eating disorders

Anorexia nervosa (AN) and bulimia nervosa (BN) are psychiatric disorders characterized by abnormal eating behaviors and imbalance of energy homeostasis. Changes of both central and peripheral neuroendocrine substances involved in the modulation of food intake and energy expenditure have been described in acutely ill patients with eating disorders. This review selectively focuses on the most recent findings supporting abnormal changes in the physiology of some peripheral adipokines and gut-secreted peptides, brain-derived neurotrophic factor and endocannabinoids in patients with AN or BN. Literature data do suggest a dysregulation of these neuroendocrine feeding regulators but, at the moment, they do not allow to establish the state or trait-dependent nature of those aberrations. It has been proposed, although not definitively proved, that neuroendocrine alterations, even when secondary to malnutrition and/or to aberrant eating behaviors, might contribute to the genesis and the maintenance of some symptomatic aspects of AN and BN, thus affecting the course and the prognosis of these disorders. Future studies should clarify whether neuroendocrine alterations are part of the genetically transmitted biological vulnerability to eating disorders.     

Serum leptin levels, body fat deposition, and weight in females with anorexia or bulimia nervosa.

The objective of this retrospective study was to investigate the relation between serum leptin level and fat deposition in patients with eating disorders. 40 female inpatients with anorexia (n=24) or bulimia nervosa (n=16) were assessed for leptin level, body mass index (BMI), and percentage body fat by dual-energy X-ray absorbometry (DXA). The results show that percentage body fat is a better predictor for leptin level and clinical findings in eating disordered patients than BMI. We discuss the necessity for DXA measurements in anorectic patients for prognostic and research purposes.     

Eating disorder behaviors are increasing: findings from two sequential community surveys in South Australia

Background

Evidence for an increase in the prevalence of eating disorders is inconsistent. Our aim was to determine change in the population point prevalence of eating disorder behaviors over a 10-year period.

Methodology/Principal Findings

Eating disorder behaviors were assessed in consecutive general population surveys of men and women conducted in 1995 (n = 3001, 72% respondents) and 2005 (n = 3047, 63.1% respondents). Participants were randomly sampled from households in rural and metropolitan South Australia. There was a significant (all p<0.01) and over two-fold increase in the prevalence of binge eating, purging (self-induced vomiting and/or laxative or diuretic misuse) and strict dieting or fasting for weight or shape control among both genders. The most common diagnosis in 2005 was either binge eating disorder or other “eating disorders not otherwise specified” (EDNOS; n = 119, 4.2%).

Conclusions/Significance

In this population sample the point prevalence of eating disorder behaviors increased over the past decade. Cases of anorexia nervosa and bulimia nervosa, as currently defined, remain uncommon.     

Effect of management of patients with Anorexia and Bulimia nervosa on symptoms and impulsive behavior

The aim of the study was to provide further and up to date information on the evaluation of the management of Anorexia and Bulimia nervosa at the Eating Disorders Unit (EDU) of the Ljubljana Psychiatric Clinic, based upon detailed assessment of the eating disorders specific and non specific symptoms of impulsive behaviors, highly correlated with these entities. 34 female patients with anorexia (restrictive or purgative type) and 38 female patients with Bulimia nervosa (purgative or non-purgative type) undergoing hospital treatment at the EDU were evaluated upon admission, as well as upon discharge and three and six months after discharge, using the Eating Disorder Questionnaire. Upon discharge a marked decrease in the overall symptoms was noted. The differences in symptoms incidences between the two groups were significantly specific for the individual form of eating disorder, especially upon admission, and were more pronounced in anorexia group. In later measurements, performed during the period of three and six months after discharge, a mild trend of increase in the disorder specific symptoms was detected in both groups, but was not statistically significant. In addition to binging on food, striking, quarreling and spending sprees are characteristics of patients with eating disorders, which in particular apply to the Bulimia nervosa group. Apart from the disorder specific symptoms, impulsive behavior was also reduced during study period, while the difference in its occurrence between the two groups gradually became non-significant. The management of patients with eating disorders at the EDU was successful in both groups, confirmed by an intense reduction of the disorder specific symptoms, impulsive behavior and increased stability recorded three and six months after discharge. The study strongly suggests that the effect of treatment regime for eating disorders can be predicted by careful assessment of the relevant symptoms and impulsive behavioral patterns.     

Clinically apparent eating disorders in young diabetic women: associations with painful neuropathy and other complications.

Of 208 young women with insulin dependent diabetes, 15 (7%) had a clinically apparent eating disorder (anorexia nervosa or bulimia), a much higher prevalence than reported in non-diabetic women. Most, but not all, of these patients had a long history of poor glycaemic control. In contrast with previous suggestions, control did not deteriorate after the onset of the eating disorder. There was a high incidence and an early onset of diabetic complications. Eleven of the 15 patients had retinopathy, six with proliferative changes; six had nephropathy; and six neuropathy. Most strikingly, four patients with anorexia nervosa developed acute painful polyneuropathy. In each case pain started when the eating disorder developed, almost coinciding with the peak of weight reduction. Remission of pain occurred as weight was regained. The symptoms were accompanied by abnormalities in peripheral nerve electrophysiology and autonomic nerve function, some improvements in which accompanied weight recovery. It is suggested that nutritional factors may contribute to the high rate of early onset diabetic complications, particularly neuropathy.     

Anorexia nervosa and bulimia nervosa.

No definitive therapy exists for anorexia nervosa (AN) or bulimia nervosa (BN). Nevertheless, biologic and psychologic research into these disorders has increased over the last decade. We examine the various drugs available for treatment. Advances in pharmacotherapy for AN have been modest and have reflected efforts either to stimulate hunger and weight gain or to control complications of the starvation process. Food remains the "drug" of choice. Antidepressants have been found to be beneficial in the treatment of BN. The meaning of this in the context of a relation between BN and mood disorders remains unclear, since coexistent depression does not predict a positive response to these drugs. Pharmacotherapy represents a single but important dimension of the management of patients with eating disorders. The optimal integration of drug therapy and psychotherapy and the identification of predictors of a positive response to drugs have yet to be addressed by clinical research.     

Salient components of a comprehensive service for eating disorders

Eating disorders are challenging and difficult to treat, because of the necessity of a multidisciplinary treatment team for effective outcomes and the high mortality rate of anorexia nervosa. An adequate initial assessment and evaluation requires a psychiatric assessment, a medical history and medical examination, a social history and an interview of family members or collateral informants. A comprehensive eating disorder treatment team includes a psychiatrist coordinating the treatment and appropriate medical physician specialists, nutritionists, and psychotherapists. An adequate outpatient eating disorder clinic needs to provide individual psychotherapy with cognitive behavioral techniques specific for anorexia nervosa and bulimia nervosa, family therapy, pharmacological treatment and the resources to obtain appropriate laboratory tests. Eating disorder patients requiring inpatient care are best treated in a specialized eating disorder inpatient unit. A cognitive behavioral framework is most useful for the overall unit milieu. Medical management and nutritional rehabilitation are the primary goals for inpatient treatment. Various group therapies can cover common core eating disorder psychopathology problems and dialectical behavior therapy groups can be useful for managing emotional dysregulation. Residential, partial hospitalization and day treatment programs are useful for transitioning patients from an inpatient program or for patients needing some monitoring. In these programs, at least one structured meal is advisable as well as nutritional counseling, group therapy or individual counseling sessions. Group therapies usually address issues such as social skills training, social anxiety, body image distortion or maturity fears. Unfortunately there is s paucity of evidence based randomized control trials to recommend the salient components for a comprehensive service for eating disorders. Experienced eating disorder clinicians have come to the conclusion that a multidisciplinary team approach provides the most effective treatment.     

Possible involvement of brain-derived neurotrophic factor in eating disorders

Eating disorders (EDs) manifest as abnormal patterns of eating behavior and weight regulation driven by low self-esteem due to weight preoccupation and perceptions toward body weight and shape. Two major groups of such disorders are anorexia nervosa (AN) and bulimia nervosa (BN). The etiology of EDs is complex and evidence indicates that both biological/genetic and psychosocial factors are involved. Several lines of evidence indicate that brain-derived neurotrophic factor (BDNF) plays a critical role in regulating eating behaviors and cognitive impairments in the EDs. BDNF is involved in neuronal proliferation, differentiation, and survival during development. BDNF and its tyrosine kinase receptor (TrkB) are expressed in hypothalamic nuclei associated with eating behaviors. A series of studies using BDNF knockout mice and the human BDNF gene indicate an association of BDNF and EDs with predisposition and vulnerability. In the previous studies, serum BDNF levels in subjects with EDs are reduced significantly compared with healthy controls, hence, we proposed that levels of serum BDNF would be a useful diagnostic indicator for EDs.     

Radiotherapy in small countries

AimTo examine the availability of radiotherapy in small countries.MethodsA small country was defined as a country with a population less than one million persons. The economic status of each country was defined using the World Bank Classification. The number of cancers in each country was obtained from GLOBOCAN 2012. The number of cancer cases with an indication or radiotherapy was calculated using the CCORE model.ResultsThere were 41 countries with a population of under 1 million; 15 were classified as High Income, 15 Upper Middle Income, 10 Lower Middle Income and one Low Income. 28 countries were islands. Populations ranged from 799 (Holy See) to 886450 (Fiji) and the total number of cancer cases occurring in small countries was 21,043 (range by country from 4 to 2476). Overall the total number of radiotherapy cases in small countries was 10982 (range by country from 2 to 1239). Radiotherapy was available in all HIC islands with 80 or more new cases of cancer in 2012 but was not available in any LMIC island. Fiji was the only LMIC island with a large radiotherapy caseload. Similar caseloads in non-island LMIC all had radiotherapy services. Most non-island HIC did not have radiotherapy services presumably because of the easy access to radiotherapy in neighbouring countries.ConclusionThere are no radiotherapy services in any LMIC islands.     

Urinary steroids in young women with eating disorders

Urinary steroid components were measured after enzyme hydrolysis and methoxym-silyl derivatization by capillary gas chromatography in young women with eating disorders. Using three internal standards, programmed temperature from 50 to 300 degrees C and flame ionization detection, on ULTRA-1 capillary column the separation of 28 steroid components is possible. Fifteen young women with different eating disorders, i.e. anorexia nervosa, bulimia nervosa and bulimarexia (aged 16-28 years) and 15 healthy women (aged 22-26 years) collected 24-h urine. A significant decrease of dehydroepiandrosterone (p<0.05) and a significant elevation of the stress marker allo-tetrahydrocorticosterone (p<0.05) were observed in the patients with compared to the controls. Among the patients two groups were defined due to a significant difference in the content of the cortisol metabolites compared to each other and to controls (p<0.01). The results confirm the role of dehydroepiandrosterone in eating disorders. The increased level of the stress marker allo-tetrahydrocorticosterone refers to the involvement of stress in these diseases, but the relevance of hormone alteration to the pathophysiology of eating disorders remains to be elucidated. The reason of the differences in cortisol metabolites levels in some patients needs further investigations.     

High proportion of mannosidosis and fucosidosis among lysosomal storage diseases in Cuba

Although lysosomal storage disorders (LSDs) are considered individually rare, as a group they present a non-negligible frequency. Few studies have been made of populational occurrence of LSDs; they have been conducted predominantly on Caucasian populations. We studied the occurrence of LSDs in Cuba. Data from individuals who had been referred to the Institute of Neurology and Neurosurgery in Havana from hospitals all over the country between January 1990 and December 2005 were analyzed. This institute was the only laboratory to provide enzyme-based diagnostic testing for 19 LSDs in Cuba during this period. Occurrence rates were calculated by dividing the number of postnatal diagnoses by the number of births during the study period. The combined occurrence of LSDs in Cuba was 5.6 per 100,000, lower than that reported in other studies conducted on Caucasian populations. The most frequent individual LSDs were: mucopolysaccharidosis type I (1.01 per 100,000) and, surprisingly, alpha-mannosidosis (0.72 per 100,000) and fucosidosis (0.62 per 100,000). These findings may be related to specific genetic characteristics and admixture of the Cuban population. This is the first comprehensive study of the occurrence of LSDs in Cuba. We conclude that the epidemiology of these diseases can vary regionally, and we stress the need for similar surveys in other Latin American countries.     

Between Difference and Belonging: Configuring Self and Others in Inpatient Treatment for Eating Disorders

Dedicated inpatient care for eating disorders has profound impact on patients'' embodied practices and lived realities. Analyses of inpatients'' accounts have shown that participants endorse complex and conflicting attitudes toward their experiences in eating disorders wards, yet the apparent ambivalence that characterizes inpatient experiences has not been subject to critical examination. This paper examines the narrated experiences of 13 participants (12 women and one man; age 18–38 years at first interview) with past or present anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified, who had been hospitalized in an inpatient eating disorders ward for adults in central Israel. The interviews, which took place in 2005–2006, and again in 2011, were part of a larger longitudinal study exploring the subjective experiences of eating disorders and recovery among Israeli adults. Employing qualitative analysis, this study finds that the participants'' accounts were concerned with dynamics of difference and belonging, as they played out in various aspects of inpatient care, including diagnosis, treatment, relationships with fellow patients and staff, and everyday life in hospital. Notably, participants simultaneously defined themselves as connected to, but also distinct from, the eating disordered others who formed their reference group at the ward. Through negotiating a protectively ambivalent positioning, participants recognized their eating disordered identities and connected with others on the ward, while also asserting their non-disordered individuality and distancing themselves from the potential dangers posed by ‘excessive’ belonging. The paper suggests that this ambivalent positioning can usefully be understood through the anthropological concept of liminality: being both a part of and apart from one''s community.     

Anorexia nervosa

Anorexia nervosa is an eating disorder characterized by conscious restriction of food intake, which causes numerous metabolic and hormonal disorders. Knowledge of these changes is important due to growing morbidity and mortality of anorexia. Treatment is difficult and requires cooperation of a group of specialists, including an endocrinologist. The authors presented a clinical picture, view of etiopathogenesis and typical disorders found in patients with this illness. Furthermore, treatment methods were also discussed.     

The human obesity gene map: the 2005 update

This paper presents the 12th update of the human obesity gene map, which incorporates published results up to the end of October 2005. Evidence from single-gene mutation obesity cases, Mendelian disorders exhibiting obesity as a clinical feature, transgenic and knockout murine models relevant to obesity, quantitative trait loci (QTL) from animal cross-breeding experiments, association studies with candidate genes, and linkages from genome scans is reviewed. As of October 2005, 176 human obesity cases due to single-gene mutations in 11 different genes have been reported, 50 loci related to Mendelian syndromes relevant to human obesity have been mapped to a genomic region, and causal genes or strong candidates have been identified for most of these syndromes. There are 244 genes that, when mutated or expressed as transgenes in the mouse, result in phenotypes that affect body weight and adiposity. The number of QTLs reported from animal models currently reaches 408. The number of human obesity QTLs derived from genome scans continues to grow, and we now have 253 QTLs for obesity-related phenotypes from 61 genome-wide scans. A total of 52 genomic regions harbor QTLs supported by two or more studies. The number of studies reporting associations between DNA sequence variation in specific genes and obesity phenotypes has also increased considerably, with 426 findings of positive associations with 127 candidate genes. A promising observation is that 22 genes are each supported by at least five positive studies. The obesity gene map shows putative loci on all chromosomes except Y. The electronic version of the map with links to useful publications and relevant sites can be found at http://obesitygene.pbrc.edu.