This research paper is a 2020 case report from 5 various practitioners at Internal Medicine & Addiction Medicine, Waban, MA, United States; Consultant-Ketogenic Diet Therapy LLC, Elm Grove, WI, United States; Innovative Psychiatry, South Windsor, CT, United States; Center for Neural Sciences, New York University, New York, NY, United States; The Neuroscience Institute, NYU Langone Medical Center, New York, NY, United States; Center of Excellence in Eating and Weight Disorders, Icahn School of Medicine at Mount Sinai, New York, NY, United States. The authors report the case of a 29-year-old woman who struggled with severe and enduring anorexia nervosa for 15 years, and experienced a complete recovery following a novel treatment of adopting a ketogenic diet followed by ketamine infusions. Her remission has persisted for over 6 months. 

This study is important because complete and sustained remission of chronic anorexia nervosa is quite rare, and the novel use of a ketogenic diet and IV ketamine treatment in this potentially lethal condition suggests avenues for further research, and hope for patients and their families.

The key findings from this study is the treatment paradigm essentially involved three modalities, and not just two treatment arms: first the patients adoption and reconsideration of anorexia nervosa as a disorder whose symptoms are predominately metabolically driven, which was an enormous paradigm shift for the patient; secondly adopting the ketogenic diet and contextualizing ketosis as helpful for her brain rather than as a weight loss or weight control method for her body; and third IV ketamine infusions at a dose and titration schedule not previously reported. 

Clinical implication from of this study is a reminder that the ketogenic diet has an impressive record of safety and efficacy for treating seizure disorders in children and has been used continuously since the 1920s. It is an emerging therapy for treatment of other neurological and psychiatric disorders such as Parkinson’s, early Alzheimer’s, and bipolar disorder. Ketogenic diet use in combination with new paradigm, such as “Adaptation to Flee Famine Hypothesis” and the dissociation effect of an old medicine, Ketamine, may be able to reverse the unrelenting suffering and lethality of eating disorders, particularly anorexia nervosa.1   

Scolnick B, Zupec-Kania B, Calabrese L, Aoki C, Hildebrandt T. Remission from Chronic Anorexia Nervosa With Ketogenic Diet and Ketamine: Case Report. Front Psychiatry. 2020;11:763. Published 2020 Jul 30. doi:10.3389/fpsyt.2020.00763 

Posted by Richard Proudfoot

 

Social media use is increasing in today’s society. This study looked at Facebook use specifically in relation to potential connection between use and eating disorders or behaviors. From this study it was concluded that there was an association between using Facebook and having some form of disordered eating and/or mental health difficulties through appearance comparison and online bullying. This can relate to nutrition because it can be a barrier to treatment or trigger for patients experiencing a form or eating disorder. The study specifically studied college-aged women, but this could be concluded to have an effect on other age groups who use Facebook. When you have a patient that is struggling with social media relating to their eating disorder changing the talk to a more positive light can be helpful or suggesting a social media cleanse for a period of time. The clinical implications of this study are being able to relate or understand more causes of triggers or problems patients may face relating to eating disorders, and their mental health. Making sure to always ask patients more questions to potentially pull out this trigger can be beneficial in starting treatment sooner and getting to the source of potential problems. Additionally, this can affect those who may not have been diagnosed with an eating disorder, thus serving as a screening tool of asking about social media use when meeting with patients.

Walker, M., Thornton, L., De Choudhury, M., Teevan, J., Bulik, C. M., Levinson, C. A., & Zerwas, S. (2015). Facebook Use and Disordered Eating in College-Aged Women. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 57(2), 157–163. https://doi.org/10.1016/j.jadohealth.2015.04.026

 

References:

Gowers, Clark, A., Roberts, C., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N., Byford, S., & Barrett, B. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial. British Journal of Psychiatry, 191(5), 427–435. https://doi.org/10.1192/bjp.bp.107.036764

 

 

I found this article to be interesting as I have had several of my own patients who presented with a high risk of refeeding syndrome due to severe protein-calorie malnutrition, though not specifically due to anorexia nervosa. ASPEN guidelines for refeeding include providing 10 to 20 kcal/kg for the first 24 hours and advancing by 33% of goal every 1 to 2 days. This is a relatively slow advancement and could take 3 to 5 days to achieve goal caloric intake. This does not include the initial time while feeding is held until electrolytes are normalized, and advancement might be slowed if their electrolytes are difficult to correct or drop quickly. I would be curious if an HCR approach could be used safely in these patients.

 

Garber, A. K., Cheng, J., Accurso, E. C., Adams, S. H., Buckelew, S. M., Kapphahn, C. J., Kreiter, A., Le Grange, D., Machen, V. I., Moscicki, A. B., Sy, A., Wilson, L., & Golden, N. H. (2021). Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial. JAMA pediatrics, 175(1), 19–27. https://doi.org/10.1001/jamapediatrics.2020.3359 

This study is important because it tries to shed light on possible triggers of eating disorders that are rooted in changes in physiological systems and could be mitigated by other methods besides cognitive behavioral therapy alone. They are difficult disorders to treat and have a significant relapse rate, so it seems worthwhile to explore every avenue for treatment. 

Although there are many interesting findings, like different types of stressors (infectious, mental stress, etc) can change the gut (“leaky gut”) and blood-brain barrier functions causing your body to make antibodies against microbial compounds which then cross-react with human neuropeptides and neurotransmitters regulating appetite and eating behaviors, I will focus on the changes in the gut microbiome they discussed. 
They found significant microbiota changes in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Since the microbiota produce neuroactive compounds like serotonin, dopamine, and GABA, they are important for mood regulation. In this review they pointed out a study that found lower levels of serotonin, dopamine, and GABA in fecal samples of women with AN compared to healthy women (among changes in the makeup of the gut flora). It’s relation to nutritional science is that maybe by utilizing pre-or-probiotics as part of a nutritional plan for AN patients, it can make a difference in mood and depressive-like behaviors that are part of what keeps AN patients in the cycle of disordered eating. 

Clinically, it provides another way to look at the mechanisms that underlie AN, or other eating disorders. It is interesting to think that adding on a therapy focused modulating the gut microbiome, in addition to the multi-disciplinary treatment courses for AN, could make a difference in the success rate of existing treatments. 

 

Hartmann, A. S., Greenberg, J. L., & Wilhelm, S. (2013). The relationship between anorexia nervosa and body dysmorphic disorder. Clinical psychology review, 33(5), 675–685. https://doi.org/10.1016/j.cpr.2013.04.002

This study is important because it focuses on the prominence of potential comorbidities of Anorexia nervosa (AN), such as depression and vitamin D deficiency. Patients with AN were assessed at admission, discharge, and one year post-admission for vitamin D levels and depressive symptoms. These levels were compared to see if there was correlation between the comorbidities. This study found that vitamin D levels did not show deficiency as frequently at admission, as it did at discharge and follow up. This shows that vitamin D levels dropped during treatment without supplementation. This relates to nutritional sciences because it emphasizes the importance of employing supplements in AN treatments due to the high levels of nutrient deficiency. Although the study did not find a correlation between vitamin D levels and depressive systems, it highlights the importance of physicians to consistently observe vitamin D levels in AN patients. Vitamin D supplements should be utilized by physicians when treating AN patients to lower their chance of vitamin D deficiency when they are discharged and one year post-admission.

Föcker, Manuel et al. “Vitamin D Level Trajectories of Adolescent Patients with Anorexia Nervosa at Inpatient Admission, during Treatment, and at One Year Follow Up: Association with Depressive Symptoms.” Nutrients vol. 13,7 2356. 9 Jul. 2021, doi:10.3390/nu13072356

This study, published through the European Journal of Nutrition, was conducted to evaluate vitamin d status along with BMI, body composition of fat mass, and bone mineral density on patients with severe anorexia nervosa that were receiving an intensive nutritional therapy via high energy diet.  Reduced bone mass is associated with anorexia nervosa and can develop to osteoporosis and an increase risk of fractures. Nutrition and vitamin D are two factors that determine bone modeling and remodeling in adolescence. Vitamin D deficiency leads to a reduction in bone mass and decreased bone mineralization. Patients with anorexia nervosa can have decreased bone mass density and have seen 38%-50% prevalence of osteoporosis. The Endocrine Society suggests children and adults maintain Serum 25-hydroxyvitamin D levels above 50 nmol/L to prevent osteomalacia and above 75nmol/L to maximize the effect on calcium bone and muscle metabolism. The researchers found that even with the high energy diet, patient Vitamin D levels decreased overall. At the start of the study, the median Serum 25 levels were adequate at 84nmol/L but decreased after the nutritional intervention. There findings could indicate the need to increase vitamin D in patients with severe anorexia nervosa who are undergoing intensive nutritional therapy to prevent the decrease of levels. 

Svedlund, A., Pettersson, C., Tubic, B., Magnusson, P., & Swolin-Eide, D. (2017). Vitamin D status in young Swedish women with anorexia nervosa during intensive weight gain therapy. European journal of nutrition, 56(6), 2061-2067.

 

Hay P. (2020). Current approach to eating disorders: a clinical update. Internal medicine journal, 50(1), 24–29. https://doi.org/10.1111/imj.14691