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Plasma Total-Homocysteine in Anorexia Nervosa

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Plasma Total-Homocysteine in Anorexia Nervosa European Journal of Clinical Nutrition (1998) 52, 172±175 ß 1998 Stockton Press. All rights reserved 0954±3007/98 $12.00 Plasma total-homocysteine in anorexia nervosa D Moyano1, MA Vilaseca1. R Artuch1, C Valls1 and N Lambruschini2 1Serveis de BioquõÂmica i, 2Pediatria, Hospital Universitari Sant Joan de DeÂu, Barcelona, Spain Objective: The measurement of plasma total-homocysteine (tHcy) as a marker of folate and cobalamin status in patients with anorexia nervosa. Design: Plasma tHcy, folate, cobalamin and other determinats of tHcy of a random group of patients with anorexia nervosa were compared with our own reference values. Setting: The study was performed at the tertiary children's Hospital Sant Joan de DeÂu. Sujects: All the female adolescents (n 43) coming to the Hospital during a one-year period, who were diagnosed with anorexia nervosa. Reference values for tHcy were simultaneously performed with apparently healthy adolescents (by history and analytical data) who underwent presurgical analysis for minor interventions, and other magnitudes we used our own reference values. Interventions: Plasma tHcy was measured by reverse fase HPLC with ¯uorescence detection of the SBDF derivatives. Folate and cobalamin concentrations were determined by radioimmunoassay. Results: tHcy was signi®cantly increased in anorexic patients compared to reference values (Mann±Whitney, P < 0.0001±0.001). Values were above reference range in 34% of patients, and high-normal range in 53% of patients. tHcy concentrations lowered in 8 and 11 patients after nutritional rehabilitation. Cobalamin and folate were in the reference range except for one case. No signi®cant correlation was found among tHcy, vitamins and other determinants of tHcy concentration. Conclusions: tHcy concentrations appear signi®cantly increased in adolescents with anorexia nervosa, most probably owing to subclinical folate de®ciency. This might be caused by both, intracellular folate de®ciency and impaired availability. Abnormal plasma tHcy values were completely corrected after nutritional rehabilitation. Sponsorship: D Moyano was the recipient of a grant from Hospital Sant Joan de DeÂu, Barcelona. Descriptors: Anorexia nervosa; folate; cobalamin; total-homocysteine; malnutrition Introduction homocysteine (tHcy), the sum of all the homocysteine species that release this amino acid by reduction, increases Anorexia nervosa is a severe nutritional disorder, affecting considerably when there is an intracellular de®ciency of mostly female adolescents, characterized by excessive food folate or cobalamin (Ueland et al, 1993). restriction that results in a marked loss of weight. Although Our aim in this study was the detection of possible diets (self-designed and strictly controlled by the anorectic de®ciencies of folate and cobalamin in anorexia nervosa by patients) are not uniform, as is the case of macrobiotic the measurement of plasma tHcy. Cobalamin and folate nutrition (Schneede et al, 1994), the experience of several concentrations as well as other tHcy determinants (Refsum groups conclude that there is a general trend to a marasmic et al, 1997) were also determined in an attempt to ®nd a malnutrition in anorexia nervosa (Madruga et al, 1993; relationship with tHcy values. Nussbaum, 1992). Therefore, either protein and energy, as well as micronutrients may result defective in this condi- tion. However, in spite of being a severe eating disorder, it Materials and methods is associated with rather mild abnormalities in the classical parameters of malnutrition (Schebendach et al, 1992; Subjects Nussbaum, 1992). Studies of biochemical data on vitamin The female adolescents (n 43) coming to the Department and mineral status found in the literature are fragmentary of Pediatrics of our hospital during a one-year period, who and contradictory and most often reported for adults, were diagnosed of anorexia nervosa according to the however, subclinical vitamin de®ciencies might be consid- criteria of the American Psychiatric Association (1994). ered in this disorder (Fisher et al, 1995). The search for new They were analysed at diagnosis as a part of the biochem- diagnostic tools to detect the defective dietary components ical evaluation of their nutritional status. Body mass index of diet may help to apply the adequate treatment that avoids (BMI) calculated as weight divided by the square of height the neurologic sequelae involved in these vitamin de®cien- (kg=m2) was 17 (12±19) (median (range); normal popula- cies (Carmel, 1989). tion > 20). Renal function was normal in all the patients. Folate and cobalamin (as methylcobalamin) are Reference values for tHcy were simultaneously performed involved as substrate and coenzyme, respectively, in the with apparently healthy adolescents (by history and analy- remethylation of homocysteine to methionine. Plasma total tical data) who underwent presurgical analysis for minor interventions (n 90). For the other biochemical and hematological magnitudes we used our own age-matched reference values. Blood was collected again in a group of Correspondence: Dr MA Vilaseca, Servei de BioquõÂmica, Hospital Universitari Sant Joan de DeÂu, P. Sant Joan de DeÂu 2, 08950 Esplugues 11 patients after six months of nutritional rehabilitation (Barcelona), Spain. without special vitamin supplementation. Samples of Received 4 April 1997; revised 29 August 1997; accepted 5 October 1997 patients and controls used for reference values were Plasma total-homocysteine in anorexia nervosa D Moyano et al 173 obtained in accordance with the Helsinki Declaration of Table 1 Plasma tHcy, folate, cobalamin, methionine, cystine, MCV, 1975, as revised in 1983. hemoglobin, creatinine and BMI in anorexia nervosa Anorexia nervosa Reference values Specimens Fasting venous blood was collected from patients with Units Median (interval) N Median (interval) N anorexia nervosa and controls used for reference values at tHcy mmol=L 8:00 am. The samples were collected in Venoject tubes A (11±15 y) 9.5*** (5.9±24.1) 27 6.6 (4.4±10.8) 59 containing EDTA, placed in melting ice, and centrifuged B (16±18 y) 11.2** (6.3±30.1) 16 8.1 (4.6±11.3) 31 within 15 min (3000 g, 10 min at 4C). The plasma was Folate nmol=L 13.6 (3.2±45) 43 13.8 (5.6±39) 52 Cobalamin pmol=L 350 (186±931) 43 306 (175±809) 52 rapidly separated, frozen at 7 40 C and analysed within Cystine mmol=L 29** (14±84) 43 35 (11±83) 52 the next fortnight. Serum samples collected in parallel for Methionine mmol=L 30* (15±57) 43 23 (8±67) 52 nutritional control were used for cobalamin and folate MCV fL 90 (71±100) 43 88 (74±102) 52 measurements. Hemoglobin g=dL 13.2 (12±15) 43 13.5 (12±16) 52 Creatinine mmol=L 98*** (83±110) 43 67 (42±112) 52 BMI kg=m2 17 (12±19) 43 > 20 30 Methods Plasma samples were analysed for tHcy by reverse fase Mann-Whitney, ***P < 0.0001, **P < 0.001; *P < 0.02. HPLC with ¯uorescence detection of the SBDF derivatives (Vilaseca et al, 1997). Within-run imprecision (n 18): 3% (70.9 Æ 2.2 mmol=L), and 4% (8.9 Æ 0.3 mmol=L); between-day imprecision (n 18): 6% (6.9 Æ 0.4 mmol=L), and 6% (55.4 Æ 3.1 mmol=L). Cobalamin and folate were determined by radioimmunoassay (ICN Phar- maceuticals SimulTRAC, Costa Mesa, CA, USA). Folate within-run imprecision (n 20): 3.7% (5.5 Æ 0.4 nmol=L); between-day imprecision (n 20): 5.2% (5.1 Æ 0.5 nmol=L). Cobalamin within-run imprecision (n 20): 6.4% (318 Æ 40 pmol=L); between-day imprecision (n 20): 4% (320 Æ 54 pmol=L). Hematological indices: median corpuscular volum (MCV fL) and hemoblobin (g=dL), were measured with the autoanalyser Cobas Vega Roche (Diagnostic systems). Creatinine was measured by an automated adaptation (Olympus AU-510, Merck-Igoda S.A.) of Jaffe method (Farre et al, 1991). As an additional study, plasma sulfur amino acids, methionine and cystine, were included in the results (mea- sured by ion exchange chromatography with post-column ninhydrin detection) (Moyano et al, 1996). Statistical analysis Kolmogorov±Smirnov test was applied to study the dis- tribution. Since tHcy, vitamin and amino acid values were Figure 1 tHcy values in anorexia nervosa (AN) distributed in two age not normally distributed, non-parametric Mann±Whitney groups (A) 11±15 y, and (B) 16±18 y, compared with age-matched test was used to compare patient and reference values, and reference values (RVa and b). Horizontal lines indicate the medians in all groups. Wilcoxon test to compare tHcy in the group of patients analysed at diagnosis and after nutritional rehabilitation. The Spearman linear regression coe®cient was used to established the relationship between concentrations of tHcy, folate, cobalamin, creatinine, BMI, methionine, cystine, MCV and hemoglobin in the patient group. Statis- tical analysis was performed with Statgraphics Statistical Graphics System, version 6.0. Results Plasma tHcy increases with age, so patients were distrib- uted in two aged groups: (A) 11±15 y, and (B) 16±18 y, according to our reference values. tHcy was signi®cantly higher in patients in comparison with the age-matched reference population (Mann±Whitney, P < 0.0001±0.001) (Table 1) (Figure 1). In seven patients of group A (26%) and eight of group B (50%) tHcy values were above the reference range. Moreover, 23 and of 43 patients (53%) showed tHcy concentration in the high-normal range of the reference values. tHcy concentrations lowered in 8 and of 11 patients after nutritional rehabilitation (Figure 2). Figure 2 tHcy concentrations at diagnosis (1) of anorexia nervosa. (AN) Folate and cobalamin of patients did not show signi®- and after nutritional rehabilitation (2) in a group of 11 patients. Plasma total-homocysteine in anorexia nervosa D Moyano et al 174 cant differences in comparison with the reference values. Nevertheless, tHcy measurement does not predict the They were in the reference range in patients except for one anorexic group since tHcy values of 63% patients over- case (folate: 3.2 nmol/L), who showed the highest tHcy lapped with reference values, but it proves rather useful to concentration (30 mmol/L).
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