Anu Raevuori

A review of eating disorders in males.

Purpose of review Research in eating disorders in males has been active lately compared to the past. This review aims to provide an overview of the recently published studies of eating disorders in males. Recent findings Publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition has outlined more sex-neutral diagnostic criteria for eating disorders. Data of socioeconomic factors, prenatal influences, clinical characteristics, assessment, and mortality for eating disorders have been reported independently for males. Unlike in females, higher parental education showed no association with eating disorders in males, but twin or triplet status and lower gestational age at birth had an independent association with anorexia nervosa in males. Contrary to earlier suggestions, no differences in eating disorder symptoms such as binging, vomiting, or laxative abuse were observed between the sexes. Yet, males tended to score lower on eating disorder symptom measures than females. High rates of premorbid overweight and higher BMIs at various stages of eating disorders have been confirmed repeatedly. Higher age and lower BMI at admission, and restrictive anorexia nervosa subtype predicted fatal outcome for anorexia nervosa in males. Summary Contemporary research provides grounds for improved recognition, diagnosis, and treatment for males suffering from eating disorders.

Genetic and environmental factors affecting self-esteem from age 14 to 17 : a longitudinal study of Finnish twins

BACKGROUND We analysed genetic and environmental influences on self-esteem and its stability in adolescence. METHOD Finnish twins born in 1983-1987 were assessed by questionnaire at ages 14 (n = 4132 twin individuals) and 17 years (n = 3841 twin individuals). Self-esteem was measured using the Rosenberg global self-esteem scale and analyzed using quantitative genetic methods for twin data in the Mx statistical package. RESULTS The heritability of self-esteem was 0.62 [95% confidence interval (CI) 0.56-0.68] in 14-year-old boys and 0.40 (95% CI 0.26-0.54) in 14-year-old girls, while the corresponding estimates at age 17 were 0.48 (95% CI 0.39-0.56) and 0.29 (95% CI 0.11-0.45). Rosenberg self-esteem scores at ages 14 and 17 were modestly correlated (r = 0.44 in boys, r = 0.46 in girls). In boys, the correlation was mainly (82%) due to genetic factors, with residual co-variation due to unique environment. In girls, genetic (31%) and common environmental (61%) factors largely explained the correlation. CONCLUSIONS In adolescence, self-esteem seems to be differently regulated in boys versus girls. A key challenge for future research is to identify environmental influences contributing to self-esteem during adolescence and determine how these factors interact with genetic influences.

A meta-analysis of temperament in axis I psychiatric disorders.

This article reports on a meta-analysis of Cloningers temperament dimensions (novelty seeking, harm avoidance, reward dependence, and persistence) in individuals with lifetime psychiatric disorders compared with controls and on interdisorder comparisons between these disorders. Nine disorders from 75 studies were included in the meta-analyses. The most consistent feature was elevated harm avoidance: compared with the controls, harm avoidance was higher in all diagnostic groups studied except for those with alcohol use disorders. The increase in effect sizes in harm avoidance scores varied from a very large (d = 2.66) in social phobia to a small effect (effect size, d = 0.29) in alcohol use disorders. In other dimensions, differences between cases and controls were relatively small. However, in pairwise comparisons, notable differences also in other dimensions emerged: in novelty seeking, the lowest scores were in social phobia (d = -0.87) and the highest in bulimia nervosa (d = 0.33); in reward dependence, the lowest scores were in schizophrenia (d = -0.36) and the highest in social phobia (d = 0.12); and in persistence, the lowest scores were in social phobia (d = -0.30) and the highest in anorexia nervosa (d = 0.49). The provided data should be taken into account in the future studies on suggestive vulnerability markers for psychiatric morbidity.

Mortality in eating disorders: A follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010

Elevated mortality risk in anorexia nervosa has been established, but less is known about the outcomes of bulimia nervosa and binge eating disorder. In this follow-up study we determined mortality in adults (N=2450, 95% women) admitted to the eating disorder clinic of the Helsinki University Central Hospital in the period 1995-2010. Most of the patients (80.7%) were outpatients. For each patient four controls were selected and matched for age, sex and place of residence. The matching was taken into account by modelling end-point events using Coxs proportional hazard model. The hazard ratio (HR) for all-cause mortality was 6.51 (95% CI 3.46-12.26) in broad anorexia nervosa (AN), 2.97 (95% CI 1.90-4.65) in broad bulimia nervosa (BN), and 1.77 (95% CI 0.60-5.27) in binge eating disorder (BED). Mortality risk in broad AN was highest during the first years after admission but declined thereafter, while in broad BN the mortality risk started to rise two years after the first admission. The HR for suicide was elevated both in broad AN (HR 5.07; 95% CI 1.37-18.84) and in broad BN (HR 6.07; 95% CI 2.47-14.89). Results show that eating disorders are associated with increased mortality risk even when specialised treatment is available.

Reproductive health outcomes in eating disorders.

OBJECTIVE Eating disorders are common psychiatric disorders in women at childbearing age. Previous research suggests that eating disorders are associated with fertility problems, unplanned pregnancies, and increased risk of induced abortions and miscarriages. The purpose of this study was to assess how eating disorders are related to reproductive health outcomes in a representative patient population. METHOD Female patients (N = 2,257) treated at the eating disorder clinic of Helsinki University Central Hospital during 1995-2010 were compared with matched controls identified from the Central Population Register (N = 9,028). Patients had been diagnosed (ICD-10) with anorexia nervosa (AN), atypical AN, bulimia nervosa (BN), atypical BN, or binge eating disorder (BED, according to DSM-IV research criteria). Register-based data on number of children, pregnancies, childbirths, induced abortions, miscarriages, and infertility treatments were used to measure reproductive health outcomes. RESULTS Patients were more likely to be childless than controls [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.62-2.13, p < .001]. Pregnancy and childbirth rates were lower among patients than among controls. BN was associated with increased risk of induced abortion compared to controls (OR 1.85; 95% CI 1.43-2.38, p < .001), whereas BED was associated with elevated risk of miscarriage (OR 3.18; 95% CI 1.52-6.66, p = .002). DISCUSSION Reproductive health outcomes are compromised in women with a history of eating disorders across all eating disorder types. Our findings emphasize the importance of reproductive health counseling and monitoring among women with eating disorders.

Pregnancy, obstetric, and perinatal health outcomes in eating disorders

OBJECTIVE The purpose of this study was to assess pregnancy, obstetric, and perinatal health outcomes and complications in women with lifetime eating disorders. STUDY DESIGN Female patients (n = 2257) who were treated at the Eating Disorder Clinic of Helsinki University Central Hospital from 1995-2010 were compared with unexposed women from the population (n = 9028). Register-based information on pregnancy, obstetric, and perinatal health outcomes and complications were acquired for all singleton births during the follow-up period among women with broad anorexia nervosa (AN; n = 302 births), broad bulimia nervosa (BN; n = 724), binge eating disorder (BED; n = 52), and unexposed women (n = 6319). RESULTS Women with AN and BN gave birth to babies with lower birthweight compared with unexposed women, but the opposite was observed in women with BED. Maternal AN was related to anemia, slow fetal growth, premature contractions, short duration of the first stage of labor, very premature birth, small for gestational age, low birthweight, and perinatal death. Increased odds of premature contractions, resuscitation of the neonate, and very low Apgar score at 1 minute were observed in mothers with BN. BED was associated positively with maternal hypertension, long duration of the first and second stage of labor, and birth of large-for-gestational-age infants. CONCLUSION Eating disorders appear to be associated with several adverse perinatal outcomes, particularly in offspring. We recommend close monitoring of pregnant women with either a past or current eating disorder. Attention should be paid to children who are born to these mothers.

Genome-Wide Association Analysis of Eating Disorder-Related Symptoms, Behaviors, and Personality Traits

Eating disorders (EDs) are common, complex psychiatric disorders thought to be caused by both genetic and environmental factors. They share many symptoms, behaviors, and personality traits, which may have overlapping heritability. The aim of the present study is to perform a genome‐wide association scan (GWAS) of six ED phenotypes comprising three symptom traits from the Eating Disorders Inventory 2 [Drive for Thinness (DT), Body Dissatisfaction (BD), and Bulimia], Weight Fluctuation symptom, Breakfast Skipping behavior and Childhood Obsessive‐Compulsive Personality Disorder trait (CHIRP). Investigated traits were derived from standardized self‐report questionnaires completed by the TwinsUK population‐based cohort. We tested 283,744 directly typed SNPs across six phenotypes of interest in the TwinsUK discovery dataset and followed‐up signals from various strata using a two‐stage replication strategy in two independent cohorts of European ancestry. We meta‐analyzed a total of 2,698 individuals for DT, 2,680 for BD, 2,789 (821 cases/1,968 controls) for Bulimia, 1,360 (633 cases/727 controls) for Childhood Obsessive‐Compulsive Personality Disorder trait, 2,773 (761 cases/2,012 controls) for Breakfast Skipping, and 2,967 (798 cases/2,169 controls) for Weight Fluctuation symptom. In this GWAS analysis of six ED‐related phenotypes, we detected association of eight genetic variants with P < 10−5. Genetic variants that showed suggestive evidence of association were previously associated with several psychiatric disorders and ED‐related phenotypes. Our study indicates that larger‐scale collaborative studies will be needed to achieve the necessary power to detect loci underlying ED‐related traits.

The DSM-5 diagnostic criteria for anorexia nervosa may change its population prevalence and prognostic value

The definition of anorexia nervosa was revised for the Fifth Edition of the Diagnostic and Statistical Manual (DSM-5). We examined the impact of these changes on the prevalence and prognosis of anorexia nervosa. In a nationwide longitudinal study of Finnish twins born 1975-1979, the women (N = 2825) underwent a 2-stage screening for eating disorders at mean age 24. Fifty-five women fulfilled DSM-IV criteria for lifetime anorexia nervosa. When we recoded the interviews using DSM-5 criteria, we detected 37 new cases. We contrasted new DSM-5 vs. DSM-IV cases to assess their clinical characteristics and prognosis. We also estimated lifetime prevalences and incidences and tested the association of minimum BMI with prognosis. We observed a 60% increase in the lifetime prevalence of anorexia nervosa using the new diagnostic boundaries, from 2.2% to 3.6%. The new cases had a later age of onset (18.8 y vs. 16.5, p = 0.002), higher minimum BMI (16.9 vs. 15.5 kg/m(2), p = 0.0004), a shorter duration of illness (one year vs. three years, p = 0.002), and a higher 5-year probability or recovery (81% vs. 67%, p = 0.002). Minimum BMI was not associated with prognosis. It therefore appears that the substantial increase in prevalence of anorexia nervosa is offset by a more benign course of illness in new cases. Increased diagnostic heterogeneity underscores the need for reliable indicators of disease severity. Our findings indicate that BMI may not be an ideal severity marker, but should be complemented by prognostically informative criteria. Future studies should focus on identifying such factors in prospective settings.

The increased risk for autoimmune diseases in patients with eating disorders.

Objective Research suggests autoimmune processes to be involved in psychiatric disorders. We aimed to address the prevalence and incidence of autoimmune diseases in a large Finnish patient cohort with anorexia nervosa, bulimia nervosa, and binge eating disorder. Methods Patients (N = 2342) treated at the Eating Disorder Unit of Helsinki University Central Hospital between 1995 and 2010 were compared with general population controls (N = 9368) matched for age, sex, and place of residence. Data of 30 autoimmune diseases from the Hospital Discharge Register from 1969 to 2010 were analyzed using conditional and Poisson regression models. Results Of patients, 8.9% vs. 5.4% of control individuals had been diagnosed with one or more autoimmune disease (OR 1.7, 95% CI 1.5–2.0, P<0.001). The increase in endocrinological diseases (OR 2.4, 95% CI 1.8–3.2, P<0.001) was explained by type 1 diabetes, whereas Crohns disease contributed most to the risk of gastroenterological diseases (OR 1.8, 95% CI 1.4–2.5, P<0.001). Higher prevalence of autoimmune diseases among patients with eating disorders was not exclusively due to endocrinological and gastroenterological diseases; when the two categories were excluded, the increase in prevalence was seen in the patients both before the onset of the eating disorder treatment (OR 1.5, 95% CI 1.1–2.1, P = 0.02) and at the end of the follow-up (OR 1.4, 95% CI 1.1–1.8, P = 0.01). Conclusions We observed an association between eating disorders and several autoimmune diseases with different genetic backgrounds. Our findings support the link between immune-mediated mechanisms and development of eating disorders. Future studies are needed to further explore the risk of autoimmune diseases and immunological mechanisms in individuals with eating disorders and their family members.

Highly increased risk of type 2 diabetes in patients with binge eating disorder and bulimia nervosa

OBJECTIVE We aimed to examine the prevalence and incidence of type 2 diabetes (T2D) in a large patient cohort treated for binge eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa. METHOD Patients (N = 2,342) treated at the Eating Disorder Unit of Helsinki University Central Hospital over the period up to 16 years were compared with matched general population controls (N = 9,368) in three stages: before entering to the treatment for an eating disorder, after the entrance until the end of the study period, and combined any time before, during, and after the treatment. The study population was linked with the oral TSD medication data of 17 years from The Medical Reimbursement Register. Data were analyzed using conditional and Poisson regression models. RESULTS Before entering to the treatment for eating disorders, the risk of T2D was substantially increased in patients compared with controls (OR 6.6, 95% CI 4.0-10.7). At the end of the study period, the lifetime prevalence of T2D was 5.2% among patients, 1.7% among controls (OR 3.4, 95% CI 2.6-4.4), and in male patients, it was significantly higher compared with females. Of those treated for BED, every third had T2D by the end of the study period (OR 12.9, 95% CI 7.4-22.5), whereas the same was true for 4.4% of those with BN (OR 2.4, 95% CI 1.7-3.5). DISCUSSION Our findings provide strong support for the association between T2D and clinically significant binge eating. Disturbed glucose metabolism may contribute to the onset and maintenance of BED and BN.