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Effect of dexamethasone on appetite regulation in anorexia nervosa
F e b r u a r y 1997
POSTER PRESENTATIONS
PREDICTORS OF BINGE EATING IN OBESE ADOLESCENTS. Christine M. Forke, B.A., Robert 1. Berkowitz, M.D., Stanley E. Hemsley, Jr., M.D., Abbas F. Jawad, Ph.D., Gail B. Slap, M.D. The CraigDalsimer Program in Adolescent Medicine, Departments of Medicine and Pediatrics; Department of Psychiatry, University of Pennsylvania School of Medicine and The Children's Hospital of Philadelphia, Philadelphia, PA. There is increasing evidence that the subgroup of obese adolescents with binge-eating behavior is both difficult to recognize and treat. OBJECTIVE: The objective of this study was to determine if a set of clinical factors can help differentiate obese adolescents who binge from those who do not. DESIGN: Thirty-eight patients >130% ideal body weight (IBW) aged 12-16 years were studied prior to beginning a weight-reduction program. All patients completed questionnaires, structured interviews, and physical examinations for the collection of sociodemographic, psychosocial, and anthropometric data. The Child Depression Inventory, Piers-Harris Self-Concept Scale, and Stunkard-Messick Earing Inventory were used to assess depression; selfesteem; and disinhibirion, cognitive restraint, and hunger. Body fat was measured by Total Body Electrical Conductivity (TOBEC). Height (Holtain Limited stadiometer) and weight (Scale-tronix 5005 stand-on scale) were each measured three rimes and averaged. One psychiatrist (RIB) interviewed all adolescents regarding their earing behavior. Binge earing was defined according to DSM-IV criteria. Patients were divided by frequency of binge episodes: none, < twice/week (2/wk), _>2/wk. The tluee groups were compared on all variables using the chi-squared test for categorical variables and the ANOVA test for continuous variables. No significant differences were found between binge earing < 2/wk and binge earing _>2/wk; these two groups therefore were merged into a combined binge group, The no-binge and combined-binge groups were compared using the chisquared and Student's t-tests, and all variables significant @ p<0.05 were eligible for stepwise logistic regression analysis to predict binge eating. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated, a receiver-operator characteristic (ROC) curve was drawn; and the area under the curve (AUC) was computed. RESULTS: The study sample had a mean age of 14.5 _+0.2 years and was 186.3 + 5.7% IBW (range: 130-317%). Twenty-nine (76%) patients were female, 24 (63%) were White, 12 (31%) were Black, and two (6%) were Latino. Of the 38 patients in the study sample, binge eating occurred < 2/wk in 9 (24%) and _>2/wk in 8 (21%). The no-binge and combined-binge groups did not differ significantly on age, race, sex, SES, BMI, % IBW, or % body fat. Compared to the no-binge group, the combined-binge group had higher scores for depression (5.6 + 0.8 vs 9.5 + 1.2, p=0.01), disinhibition (5.5 + 0.6 vs 8.8 _+0.7, p=0.002), and hunger (5.0 + 0.6 vs 9.6 + 0.6, p<0.0005) and lower scores for cognitive restraint (11.0 + 1.0 vs 6.5 + 0.8, p=0.002) and self-esteem (62.2 + 2.2 vs 53.6 + 3.1, p=0.03). Two variables comprised the logistic regression model predicting binge eating: hunger (OR=2.1, CI: 1.3 - 3.5, p=0.004) and depression (OR=l.3, CI: 0.99 - 1.6, p=0.06). The model correctly identified 82% of patients with binge eating (sensitivity) and 86% of patients without binge eating (specificity). The AUC was 0.94 (p<0.00005). CONCLUSIONS: Obese adolescents with binge eating have more hunger and depression than obese adolescents without binge eating and may require a different psychotherapeutic approach as part of their weight-reduction regimen.
EFFECT OF DEXAMETHASONE ON APPETITE REGULATION IN ANOREXIA NERVOSA. Catherine M. Gordon. M.D.1,2, S. Jean Emans, M.D.1 Robert H. DuRant, Ph.D.1, Estherann Grace, M.D. 1 Gordon P. Harper, M.D.3, Joseph A. Majzoub, M.D.2, Division of Adolescent/Young Adult Medicine 1, Division of Endocrinology2,Dept. of Psychiatry3,Children's Hospital, Harvard Medical School,Boston, MA. OBJECTIVE: Patients with anorexia nervosa (AN) have an overactive hypothalamic-pimitaryadrenal (HPA) axis, with marked elevations of serum cortisol possibly due to oversecretion of corticotropin-releasing hormone (CRH). We examined if a 1-week course of dexamethasone (DEX), a known appetite stimulant, would cause a reduction in HPA axis hormones and anorexic behavior. METHODS: For this pilot study, 4 females with AN (ages 18-20 years, by DSM-IV criteria) and 5 healthy female controls (ages 18-26 years) were recruited from our hospital adolescent clinic. For AN patients: after 7 days of placebo, the group received DEX at 2mg/m2/day po for 7 days; appetite visual analog scales were administered daily (N=I4); on days 1 and 14, the State of the Mind Questionnaire (SOMQ, including Beck Depression Inventory, BDI and Anorexia Nervosa Subtest, ANS) and an overnight inpatient hormonal evaluation were completed. For controls: the group received the same dose of DEX for 1 week; appetite analog scales were administered daily (N-7); on day 1 and 7, the SOMQ and a hormonal evaluation were completed. Before and after DEX, 24-hour urinary free cortisol (UFC) and weights were measured. Data were analyzed with paired t-tests and repeated measures analysis of variance, as appropriate. RESULTS: All participants completed the study. After DEX, as expected, the 24-hour UFCs were suppressed (p=0.006) in both groups. On DEX, the mean weights of both the AN group (-1.08 kg) and the controls (+0.56 kg) increased, although not significantly. The AN group had a lower ANS score (p=0.040) after DEX. Both groups had lower Beck scores after DEX (p=0.046). However, the AN group had increased (p=0.041) feelings of sadness on DEX. Other trends included increased feelings of inefficiency (p=0.072) and anxiety (p 0.062) by both groups. Significant correlations for both groups included: baseline UFC and both pretest and posttest ANS scores (r-.70, p=0.035; r=.69, p=0.04); baseline weight and pretest ANS score (r=-.75, p=0.02); follow-up weight and posttest ANS score r--.70, p=0.037); baseline BDI score and both ANS scores (r=.92, p_<0.001; F- .95, p_<0.001);and final BDI score and both ANS scores (r-.89, p=.001;r-.96, p<_0.001). CONCLUSIONS: While conclusions are limited by the sample size of this pilot study, a week of DEX appeared to improve attitudes toward eating and body image, evidenced by responses on the SOMQ, but this improvement was accompanied by feelings of sadness, inefficiency and anxiety. While these results suggest that such therapy may point to a new pharmacologic treatment of AN, close attention must be paid to accompanying psychological and endocrinological issues.
153
POSTER PRESENTATIONS
PREDICTORS OF BINGE EATING IN OBESE ADOLESCENTS. Christine M. Forke, B.A., Robert 1. Berkowitz, M.D., Stanley E. Hemsley, Jr., M.D., Abbas F. Jawad, Ph.D., Gail B. Slap, M.D. The CraigDalsimer Program in Adolescent Medicine, Departments of Medicine and Pediatrics; Department of Psychiatry, University of Pennsylvania School of Medicine and The Children's Hospital of Philadelphia, Philadelphia, PA. There is increasing evidence that the subgroup of obese adolescents with binge-eating behavior is both difficult to recognize and treat. OBJECTIVE: The objective of this study was to determine if a set of clinical factors can help differentiate obese adolescents who binge from those who do not. DESIGN: Thirty-eight patients >130% ideal body weight (IBW) aged 12-16 years were studied prior to beginning a weight-reduction program. All patients completed questionnaires, structured interviews, and physical examinations for the collection of sociodemographic, psychosocial, and anthropometric data. The Child Depression Inventory, Piers-Harris Self-Concept Scale, and Stunkard-Messick Earing Inventory were used to assess depression; selfesteem; and disinhibirion, cognitive restraint, and hunger. Body fat was measured by Total Body Electrical Conductivity (TOBEC). Height (Holtain Limited stadiometer) and weight (Scale-tronix 5005 stand-on scale) were each measured three rimes and averaged. One psychiatrist (RIB) interviewed all adolescents regarding their earing behavior. Binge earing was defined according to DSM-IV criteria. Patients were divided by frequency of binge episodes: none, < twice/week (2/wk), _>2/wk. The tluee groups were compared on all variables using the chi-squared test for categorical variables and the ANOVA test for continuous variables. No significant differences were found between binge earing < 2/wk and binge earing _>2/wk; these two groups therefore were merged into a combined binge group, The no-binge and combined-binge groups were compared using the chisquared and Student's t-tests, and all variables significant @ p<0.05 were eligible for stepwise logistic regression analysis to predict binge eating. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated, a receiver-operator characteristic (ROC) curve was drawn; and the area under the curve (AUC) was computed. RESULTS: The study sample had a mean age of 14.5 _+0.2 years and was 186.3 + 5.7% IBW (range: 130-317%). Twenty-nine (76%) patients were female, 24 (63%) were White, 12 (31%) were Black, and two (6%) were Latino. Of the 38 patients in the study sample, binge eating occurred < 2/wk in 9 (24%) and _>2/wk in 8 (21%). The no-binge and combined-binge groups did not differ significantly on age, race, sex, SES, BMI, % IBW, or % body fat. Compared to the no-binge group, the combined-binge group had higher scores for depression (5.6 + 0.8 vs 9.5 + 1.2, p=0.01), disinhibition (5.5 + 0.6 vs 8.8 _+0.7, p=0.002), and hunger (5.0 + 0.6 vs 9.6 + 0.6, p<0.0005) and lower scores for cognitive restraint (11.0 + 1.0 vs 6.5 + 0.8, p=0.002) and self-esteem (62.2 + 2.2 vs 53.6 + 3.1, p=0.03). Two variables comprised the logistic regression model predicting binge eating: hunger (OR=2.1, CI: 1.3 - 3.5, p=0.004) and depression (OR=l.3, CI: 0.99 - 1.6, p=0.06). The model correctly identified 82% of patients with binge eating (sensitivity) and 86% of patients without binge eating (specificity). The AUC was 0.94 (p<0.00005). CONCLUSIONS: Obese adolescents with binge eating have more hunger and depression than obese adolescents without binge eating and may require a different psychotherapeutic approach as part of their weight-reduction regimen.
EFFECT OF DEXAMETHASONE ON APPETITE REGULATION IN ANOREXIA NERVOSA. Catherine M. Gordon. M.D.1,2, S. Jean Emans, M.D.1 Robert H. DuRant, Ph.D.1, Estherann Grace, M.D. 1 Gordon P. Harper, M.D.3, Joseph A. Majzoub, M.D.2, Division of Adolescent/Young Adult Medicine 1, Division of Endocrinology2,Dept. of Psychiatry3,Children's Hospital, Harvard Medical School,Boston, MA. OBJECTIVE: Patients with anorexia nervosa (AN) have an overactive hypothalamic-pimitaryadrenal (HPA) axis, with marked elevations of serum cortisol possibly due to oversecretion of corticotropin-releasing hormone (CRH). We examined if a 1-week course of dexamethasone (DEX), a known appetite stimulant, would cause a reduction in HPA axis hormones and anorexic behavior. METHODS: For this pilot study, 4 females with AN (ages 18-20 years, by DSM-IV criteria) and 5 healthy female controls (ages 18-26 years) were recruited from our hospital adolescent clinic. For AN patients: after 7 days of placebo, the group received DEX at 2mg/m2/day po for 7 days; appetite visual analog scales were administered daily (N=I4); on days 1 and 14, the State of the Mind Questionnaire (SOMQ, including Beck Depression Inventory, BDI and Anorexia Nervosa Subtest, ANS) and an overnight inpatient hormonal evaluation were completed. For controls: the group received the same dose of DEX for 1 week; appetite analog scales were administered daily (N-7); on day 1 and 7, the SOMQ and a hormonal evaluation were completed. Before and after DEX, 24-hour urinary free cortisol (UFC) and weights were measured. Data were analyzed with paired t-tests and repeated measures analysis of variance, as appropriate. RESULTS: All participants completed the study. After DEX, as expected, the 24-hour UFCs were suppressed (p=0.006) in both groups. On DEX, the mean weights of both the AN group (-1.08 kg) and the controls (+0.56 kg) increased, although not significantly. The AN group had a lower ANS score (p=0.040) after DEX. Both groups had lower Beck scores after DEX (p=0.046). However, the AN group had increased (p=0.041) feelings of sadness on DEX. Other trends included increased feelings of inefficiency (p=0.072) and anxiety (p 0.062) by both groups. Significant correlations for both groups included: baseline UFC and both pretest and posttest ANS scores (r-.70, p=0.035; r=.69, p=0.04); baseline weight and pretest ANS score (r=-.75, p=0.02); follow-up weight and posttest ANS score r--.70, p=0.037); baseline BDI score and both ANS scores (r=.92, p_<0.001; F- .95, p_<0.001);and final BDI score and both ANS scores (r-.89, p=.001;r-.96, p<_0.001). CONCLUSIONS: While conclusions are limited by the sample size of this pilot study, a week of DEX appeared to improve attitudes toward eating and body image, evidenced by responses on the SOMQ, but this improvement was accompanied by feelings of sadness, inefficiency and anxiety. While these results suggest that such therapy may point to a new pharmacologic treatment of AN, close attention must be paid to accompanying psychological and endocrinological issues.
153