The Importance of Restoring Body Fat Mass in the Treatment of Anorexia Nervosa An Expert Commentary
Main Article Content
Keywords
anorexia nervosa, body fat percentage, endocrine, metabolic
Abstract
Anorexia nervosa is a severe mental disorder that is characterised by dietary restriction, low weight and wide spread endocrine abnormalities. Whilst the importance of weight restoration has been recognised in recent guidelines, the significance of normalising body fat mass has received less attention. Traboulsi et al systematic review and meta-analysis found that a minimum of 20.5% body fat mass is necessary for regular menses in women of reproductive age. This has significant implications for treatment as well as for research. In psychological treatment, this information should be included in the initial psycho-education at the beginning of treatment and also when addressing body image distortion. It is important to help the patient recognise that certain level of body fat percentage is essential for optimal health, such as the return of menstruation. The benefit of the return of menstruation goes beyond improved fertility: it signals the normalisation of sexual hormones, which have a widespread impact on the body and multiple pathways in the brain. Given the complex functions of adipocytes in various organs of the body, the metabolic effects of the normal body fat tissue should not be underestimated. Further research is needed to elucidate the mechanisms behind the link between minimum body fat mass, menstruation, bone and brain health in anorexia nervosa.
References
1. WHO. The ICD-10 classification of mental and behavioural disorders. Geneva: WHO; 2016.
2. Whalen R, Harrold J, Child S, et al. The health halo trend in UK television food advertising viewed by children: The rise of implicit and explicit health messaging in the promotion of unhealthy foods. Int J Environ Res Public Health 2018;15(3). doi: 10.3390/ijerph15030560
3. Hanachi M, Dicembre M, Rives-Lange C, et al. Micronutrients deficiencies in 374 severely mal-nourished anorexia nervosa inpatients. Nutrients 2019;11(4). doi: 10.3390/nu11040792
4. Mustelin L, Silen Y, Raevuori A, et al. The DSM-5 diagnostic criteria for anorexia nervosa may change its population prevalence and prognostic value. J Psychiatr Res 2016;77:85–91. doi: 10.1016/ j.jpsychires.2016.03.003
5. Stoving RK. Mechanisms in endocrinology: Anorexia nervosa and endocrinology: A clinical update. Eur J Endocrinol 2019;180(1):R9–27. doi: 10.1530/EJE-18-0596
6. Berner LA, Brown TA, Lavender JM, et al. Neuroendocrinology of reward in anorexia ner-vosa and bulimia nervosa: Beyond leptin and ghrelin. Mol Cell Endocrinol 2018. doi: 10.1016/ j.mce.2018.10.018
7. NICE. NICE Guidance 69. Eating disorders: Recognition and treatment. NICE; 2017. Available from: https://www.nice.org.uk/guidance/ng69
8. van den Berg E, Houtzager L, de Vos J, et al. Meta-analysis on the efficacy of psychological treatments for anorexia nervosa. Eur Eat Disord Rev 2019;27(4):331–51. doi: 10.1002/erv.2683
9. Zeeck A, Herpertz-Dahlmann B, Friederich HC, et al. Psychotherapeutic treatment for anorexia nervosa: A systematic review and network meta-analysis. Front Psychiatry 2018;9:158. doi: 10.3389/ fpsyt.2018.00158
10. Khalsa SS, Portnoff LC, McCurdy-McKinnon D, et al. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. J Eat Disord 2017;5:20. doi: 10.1186/s40337-017-0145-3
11. Bardone-Cone AM, Hunt RA, Watson HJ. An overview of conceptualizations of eating disorder recovery, recent findings, and future directions. Curr Psychiatry Rep 2018;20(9):79. doi: 10.1007/ s11920-018-0932-9
12. Gaudiani JL, Brinton JT, Sabel AL, et al. Medical outcomes for adults hospitalized with severe anorexia nervosa: An analysis by age group. Int J Eat Disord 2016;49(4):378–85. doi: 10.1002/eat.22437
13. Goddard E, Hibbs R, Raenker S, et al. A multi-centre cohort study of short term outcomes of hospital treatment for anorexia nervosa in the UK. BMC Psychiatry 2013;13:287.
14. Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: A “trans-diagnostic” theory and treatment. Behav Res Ther 2003;41(5):509–28.
15. Schmidt U, Ryan EG, Bartholdy S, et al. Two-year follow-up of the MOSAIC trial: A multicenter ran-domized controlled trial comparing two psycho-logical treatments in adult outpatients with broadly defined anorexia nervosa. Int J Eat Disord 2016;49(8):793–800. doi: 10.1002/eat.22523
16. Funcke JB, Scherer PE. Beyond adiponectin and leptIn: Adipose tissue-derived mediators of inter-organ communication. J Lipid Res 2019. doi: 10.1194/jlr.R094060
17. Friedman J. The long road to leptin. J Clin Invest 2016;126(12):4727–34. doi: 10.1172/JCI91578
18. Francisco V, Pino J, Campos-Cabaleiro V, et al. Obesity, fat mass and immune system: Role for leptin. Front Physiol 2018;9:640. doi: 10.3389/ fphys.2018.00640
19. Hasan TF, Hasan H. Anorexia nervosa: A unified neurological perspective. Int J Med Sci 2011;8(8): 679–703. doi: 10.7150/ijms.8.679
20. Sadie-Van Gijsen H, Crowther NJ, Hough FS, et al. The interrelationship between bone and fat: From cellular see-saw to endocrine reciprocity. Cell Mol Life Sci 2013;70(13):2331–49. doi: 10.1007/s00018-012-1211-2
21. Ecklund K, Vajapeyam S, Mulkern RV, et al. Bone marrow fat content in 70 adolescent girls with anorexia nervosa: Magnetic resonance imaging and magnetic resonance spectroscopy assessment. Pediatr Radiol 2017;47(8):952–62. doi: 10.1007/ s00247-017-3856-3
22. Watson HJ, Yilmaz Z, Thornton LM, et al. Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nat Genet 2019 doi: 10.1038/ s41588-019-0439-2
23. Yilmaz Z, Gottfredson NC, Zerwas SC, et al. Developmental premorbid body mass index tra-jectories of adolescents with eating disorders in a longitudinal population cohort. J Am Acad Child Adolesc Psychiatry 2019;58(2):191–99. doi: 10.1016/j.jaac.2018.11.008
24. El Ghoch M, Pourhassan M, Milanese C, et al. Changes in lean and skeletal muscle body mass in adult females with anorexia nervosa before and after weight restoration. Clin Nutr 2017;36(1):170–78. doi: 10.1016/j.clnu. 2015.10.006
25. El Ghoch M, Calugi S, Milanese C, et al. Body composition in men with anorexia nervosa: Longitudinal study. Int J Eat Disord 2017;50(7): 856–60. doi: 10.1002/eat.22721
26. El Ghoch M, Calugi S, Chignola E, et al. Body mass index, body fat and risk factor of relapse in anorexia nervosa. Eur J Clin Nutr 2016;70(2): 194–8. doi: 10.1038/ejcn.2015.164
27. El Ghoch M, Calugi S, Chignola E, et al. Body fat and menstrual resumption in adult females with anorexia nervosa: A 1-year longitudinal study. J Hum Nutr Diet 2016;29(5):662–6. doi: 10.1111/ jhn.12373
28. El Ghoch M, Pourhassan M, Milanese C, et al. Changes in lean and skeletal muscle body mass in adult females with anorexia nervosa before and after weight restoration. Clin Nutr 2015;28:28. doi: 10.1016/j.clnu.2015.10.006
29. El Ghoch M, Calugi S, Lamburghini S, et al. Anorexia nervosa and body fat distribution: A systematic review. Nutrients 2014;6(9):3895–912. doi: 10.3390/nu6093895
30. Easter A, Naumann U, Northstone K, et al. A longitudinal investigation of nutrition and dietary patterns in children of mothers with eating disorders. J Pediatr 2013;163(1):173–8.e1. doi: 10.1016/j.jpeds.2012.11.092
31. Mantzoros CS, Magkos F, Brinkoetter M, et al. Leptin in human physiology and pathophysiol-ogy. Am J Physiol Endocrinol Metab 2011; 301(4):E567–84. doi: 10.1152/ajpendo.00315. 2011
32. Misra M, Klibanski A. Bone metabolism in ado-lescents with anorexia nervosa. J Endocrinol Invest 2011;34(4):324–32. doi: 10.3275/7505
33. Le Moene O, Agmo A. The neuroendocrinology of sexual attraction. Front Neuroendocrinol 2018;51:46–67. doi: 10.1016/j.yfrne.2017.12.006
34. Habib P, Beyer C. Regulation of brain microglia by female gonadal steroids. J Steroid Biochem Mol Biol 2015;146:3–14. doi: 10.1016/j.jsbmb. 2014.02.018
35. Hausmann M. Why sex hormones matter for neu-roscience: A very short review on sex, sex hormones, and functional brain asymmetries. J Neurosci Res 2017;95(1–2):40–9. doi: 10.1002/jnr.23857
2. Whalen R, Harrold J, Child S, et al. The health halo trend in UK television food advertising viewed by children: The rise of implicit and explicit health messaging in the promotion of unhealthy foods. Int J Environ Res Public Health 2018;15(3). doi: 10.3390/ijerph15030560
3. Hanachi M, Dicembre M, Rives-Lange C, et al. Micronutrients deficiencies in 374 severely mal-nourished anorexia nervosa inpatients. Nutrients 2019;11(4). doi: 10.3390/nu11040792
4. Mustelin L, Silen Y, Raevuori A, et al. The DSM-5 diagnostic criteria for anorexia nervosa may change its population prevalence and prognostic value. J Psychiatr Res 2016;77:85–91. doi: 10.1016/ j.jpsychires.2016.03.003
5. Stoving RK. Mechanisms in endocrinology: Anorexia nervosa and endocrinology: A clinical update. Eur J Endocrinol 2019;180(1):R9–27. doi: 10.1530/EJE-18-0596
6. Berner LA, Brown TA, Lavender JM, et al. Neuroendocrinology of reward in anorexia ner-vosa and bulimia nervosa: Beyond leptin and ghrelin. Mol Cell Endocrinol 2018. doi: 10.1016/ j.mce.2018.10.018
7. NICE. NICE Guidance 69. Eating disorders: Recognition and treatment. NICE; 2017. Available from: https://www.nice.org.uk/guidance/ng69
8. van den Berg E, Houtzager L, de Vos J, et al. Meta-analysis on the efficacy of psychological treatments for anorexia nervosa. Eur Eat Disord Rev 2019;27(4):331–51. doi: 10.1002/erv.2683
9. Zeeck A, Herpertz-Dahlmann B, Friederich HC, et al. Psychotherapeutic treatment for anorexia nervosa: A systematic review and network meta-analysis. Front Psychiatry 2018;9:158. doi: 10.3389/ fpsyt.2018.00158
10. Khalsa SS, Portnoff LC, McCurdy-McKinnon D, et al. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. J Eat Disord 2017;5:20. doi: 10.1186/s40337-017-0145-3
11. Bardone-Cone AM, Hunt RA, Watson HJ. An overview of conceptualizations of eating disorder recovery, recent findings, and future directions. Curr Psychiatry Rep 2018;20(9):79. doi: 10.1007/ s11920-018-0932-9
12. Gaudiani JL, Brinton JT, Sabel AL, et al. Medical outcomes for adults hospitalized with severe anorexia nervosa: An analysis by age group. Int J Eat Disord 2016;49(4):378–85. doi: 10.1002/eat.22437
13. Goddard E, Hibbs R, Raenker S, et al. A multi-centre cohort study of short term outcomes of hospital treatment for anorexia nervosa in the UK. BMC Psychiatry 2013;13:287.
14. Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: A “trans-diagnostic” theory and treatment. Behav Res Ther 2003;41(5):509–28.
15. Schmidt U, Ryan EG, Bartholdy S, et al. Two-year follow-up of the MOSAIC trial: A multicenter ran-domized controlled trial comparing two psycho-logical treatments in adult outpatients with broadly defined anorexia nervosa. Int J Eat Disord 2016;49(8):793–800. doi: 10.1002/eat.22523
16. Funcke JB, Scherer PE. Beyond adiponectin and leptIn: Adipose tissue-derived mediators of inter-organ communication. J Lipid Res 2019. doi: 10.1194/jlr.R094060
17. Friedman J. The long road to leptin. J Clin Invest 2016;126(12):4727–34. doi: 10.1172/JCI91578
18. Francisco V, Pino J, Campos-Cabaleiro V, et al. Obesity, fat mass and immune system: Role for leptin. Front Physiol 2018;9:640. doi: 10.3389/ fphys.2018.00640
19. Hasan TF, Hasan H. Anorexia nervosa: A unified neurological perspective. Int J Med Sci 2011;8(8): 679–703. doi: 10.7150/ijms.8.679
20. Sadie-Van Gijsen H, Crowther NJ, Hough FS, et al. The interrelationship between bone and fat: From cellular see-saw to endocrine reciprocity. Cell Mol Life Sci 2013;70(13):2331–49. doi: 10.1007/s00018-012-1211-2
21. Ecklund K, Vajapeyam S, Mulkern RV, et al. Bone marrow fat content in 70 adolescent girls with anorexia nervosa: Magnetic resonance imaging and magnetic resonance spectroscopy assessment. Pediatr Radiol 2017;47(8):952–62. doi: 10.1007/ s00247-017-3856-3
22. Watson HJ, Yilmaz Z, Thornton LM, et al. Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nat Genet 2019 doi: 10.1038/ s41588-019-0439-2
23. Yilmaz Z, Gottfredson NC, Zerwas SC, et al. Developmental premorbid body mass index tra-jectories of adolescents with eating disorders in a longitudinal population cohort. J Am Acad Child Adolesc Psychiatry 2019;58(2):191–99. doi: 10.1016/j.jaac.2018.11.008
24. El Ghoch M, Pourhassan M, Milanese C, et al. Changes in lean and skeletal muscle body mass in adult females with anorexia nervosa before and after weight restoration. Clin Nutr 2017;36(1):170–78. doi: 10.1016/j.clnu. 2015.10.006
25. El Ghoch M, Calugi S, Milanese C, et al. Body composition in men with anorexia nervosa: Longitudinal study. Int J Eat Disord 2017;50(7): 856–60. doi: 10.1002/eat.22721
26. El Ghoch M, Calugi S, Chignola E, et al. Body mass index, body fat and risk factor of relapse in anorexia nervosa. Eur J Clin Nutr 2016;70(2): 194–8. doi: 10.1038/ejcn.2015.164
27. El Ghoch M, Calugi S, Chignola E, et al. Body fat and menstrual resumption in adult females with anorexia nervosa: A 1-year longitudinal study. J Hum Nutr Diet 2016;29(5):662–6. doi: 10.1111/ jhn.12373
28. El Ghoch M, Pourhassan M, Milanese C, et al. Changes in lean and skeletal muscle body mass in adult females with anorexia nervosa before and after weight restoration. Clin Nutr 2015;28:28. doi: 10.1016/j.clnu.2015.10.006
29. El Ghoch M, Calugi S, Lamburghini S, et al. Anorexia nervosa and body fat distribution: A systematic review. Nutrients 2014;6(9):3895–912. doi: 10.3390/nu6093895
30. Easter A, Naumann U, Northstone K, et al. A longitudinal investigation of nutrition and dietary patterns in children of mothers with eating disorders. J Pediatr 2013;163(1):173–8.e1. doi: 10.1016/j.jpeds.2012.11.092
31. Mantzoros CS, Magkos F, Brinkoetter M, et al. Leptin in human physiology and pathophysiol-ogy. Am J Physiol Endocrinol Metab 2011; 301(4):E567–84. doi: 10.1152/ajpendo.00315. 2011
32. Misra M, Klibanski A. Bone metabolism in ado-lescents with anorexia nervosa. J Endocrinol Invest 2011;34(4):324–32. doi: 10.3275/7505
33. Le Moene O, Agmo A. The neuroendocrinology of sexual attraction. Front Neuroendocrinol 2018;51:46–67. doi: 10.1016/j.yfrne.2017.12.006
34. Habib P, Beyer C. Regulation of brain microglia by female gonadal steroids. J Steroid Biochem Mol Biol 2015;146:3–14. doi: 10.1016/j.jsbmb. 2014.02.018
35. Hausmann M. Why sex hormones matter for neu-roscience: A very short review on sex, sex hormones, and functional brain asymmetries. J Neurosci Res 2017;95(1–2):40–9. doi: 10.1002/jnr.23857
Article Sidebar
Published
Sep 4, 2019
Article Details
How to Cite
Ayton, A. (2019). The Importance of Restoring Body Fat Mass in the Treatment of Anorexia Nervosa : An Expert Commentary. Journal of Population Therapeutics and Clinical Pharmacology, 26(3), e9-e13. https://doi.org/10.15586/jptcp.v26i3.629
Section
Editorial
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles published in JPTCP are licensed under Copyright Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Ayton, A. (2019). The Importance of Restoring Body Fat Mass in the Treatment of Anorexia Nervosa : An Expert Commentary. Journal of Population Therapeutics and Clinical Pharmacology, 26(3), e9-e13. https://doi.org/10.15586/jptcp.v26i3.629