professor Johannes Hebebrand (Duisburg-Essen University)

“The term 'refusal' should be omitted.” Johannes Hebebrand

Plenary lecture by Johannes Hebebrand, ESCAP 2009 Budapest

Getting weighty issues in anorexia nervosa sorted out

ESCAP 2009 Congress in Budapest, Hungary: original abstract by professor Johannes Hebebrand, University of Duisburg-Essen, Department of Child and Adolescent Psychiatry, Duisburg, Germany – “Getting Weighty Issues in Anorexia Nervosa Sorted Out”, Plenary Session IX., 26 August 2009, 09:00. Chaired by P. Hoekstra (Netherlands).

Unfortunately, body weight in patients with anorexia nervosa is not assessed in the same manner rendering comparisons of clinical data difficult. Currently, both percent average body weight and BMI are being used to assess relative weight. Due to the fact that BMI is used to define different weight categories according to the World Health Organisation, we argue that the same index should be used clinically and in research studies. Because BMI in children and adolescents can only be assessed age-dependently, we recommend the use of BMI centiles for assessing relative weight in AN patients (for USA see The DSM-IV weight criterion roughly corresponds to the 10th BMI centile. Premorbid BMI centile of adolescent patients predicts BMI at referral; the extent of weight loss is also correlated with premorbid BMI centile. Despite inconsistent data, there is evidence to indicate that BMI at referral has prognostic significance for both mortality and future BMI. Due to the loss of fat mass, patients with anorexia nervosa typically present with subnormal leptin levels. The lower the leptin level of an individual patient, the more the adaptation to semi-starvation has progressed.

Low leptin levels are involved in the down-regulation of the hypothalamuspituitary- gonadal axis leading to amenorrhea. Hypoleptinemia is the initial trigger of other semi-starvation related symptoms of AN; both in a rodent model of AN and in patients substantial evidence points to the role of hypoleptinemia in semi-starvation induced hyperactivity. Based on clinical and biological data, we argue that the term "refusal” should be omitted from the first DSM-IV criterion for the diagnosis of anorexia nervosa.