This article was downloaded by: [New York University] On: 17 April 2015, At: 16:59 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of the American College of Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uacn20
Zinc status before and after zinc supplementation of eating disorder patients. a
a
a
a
a
a
C J McClain , M A Stuart , B Vivian , M McClain , R Talwalker , L Snelling & L a
Humphries a
Department of Medicine, University of Kentucky Medical Center, Lexington 40536-0084. Published online: 02 Sep 2013.
To cite this article: C J McClain, M A Stuart, B Vivian, M McClain, R Talwalker, L Snelling & L Humphries (1992) Zinc status before and after zinc supplementation of eating disorder patients., Journal of the American College of Nutrition, 11:6, 694-700, DOI: 10.1080/07315724.1992.10718269 To link to this article: http://dx.doi.org/10.1080/07315724.1992.10718269
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Zinc Status Before and After Zinc Supplementation of Eating Disorder Patients Craig J. McClain, MD, FACN, Mary A. Stuart, PhD, RD, Beverly Vivian, RD, Marion McClain, MS, Ramesh Talwalker, PhD, Laurel Snelling, MS, and Laurie Humphries, MD Departments of Medicine (C.J.M., R. T.), Psychiatry (L.H.), Nutrition and Food Sciences (M.A.S.), Graduate School of Nutrition (C.J.M., M.A.S., L.S.), and Eating Disorder Unit (C.J.M., M.A.S., B.V., M.M., L.S., L.H.), University of Kentucky Medical Center and Lexington VA Medical Center, Lexington
Downloaded by [New York University] at 16:59 17 April 2015
Key words: zinc, zinc deficiency, eating disorders, anorexia nervosa, bulimia nervosa Reduced food consumption is a major manifestation of zinc (Zn) deficiency. Many manifestations of Zn deficiency are complications of anorexia nervosa and bulimia nervosa. We evaluated serum and 24-hour urinary Zn values in 12 healthy volunteers and 33 eating disorder patients before and after hospitalization which included either Zn supplementation (75 mg Zn/day) or placebo. Bulimics had depressed serum Zn concentrations (p < 0.025). Admission urinary Zn was lower in bulimics (258 ± 44 μg/day), and significantly depressed in anorexics (196 ± 36 Mg/day, p < 0.005) vs controls (376 ± 45 ^g/day). During hospitalization, serum Zn concentrations increased in all supplemented patients vs no change with placebo. Urinary Zn excretion increased in supplemented bulimics (p < 0.001) and placebo (p < 0.05). Urinary Zn excretion markedly increased in supplemented anorexics (179 ± 65 to 1052 ± 242 Mg/day); however, placebo values fell or remained unacceptably low (admission 208 ± 48 μg/day; discharge 160 ± 17 Mg/day). By dietary history, controls consumed the Recommended Dietary Allowance (RDA) for Zn (11.95 ± 1.25 mg/day); anorexics 6.46 ±1.14 mg/day; and bulimics 8.93 ± 1.29 mg/day. We suggest that Zn deficiency may act as a "sustaining" factor for abnormal eating behavior in certain eating disorder patients. Abbreviations: AN = anorexia nervosa, BN = bulimia nervosa, CRC = Clinical Research Center, Cu = copper, RDA = Recommended Dietary Allowance, Zn = zinc
INTRODUCTION
patients, and this is limited to those with AN [9]. We recently reported a high frequency of biochemical Zn deficiency in 86 patients with eating disorders, 62 having BN and 24 with AN [18]. However, subjects were both inpatients and outpatients, and Zn status was evalu ated at varying points in time in relation to the initiation of nutritional intervention and psychotherapy. It was, therefore, the purpose of this study to: 1) evaluate admis sion Zn status in both AN and BN patients requiring hospitalization; 2) determine the effects of Zn supplemen tation vs placebo on Zn status during the period of hospi talization in both AN and BN patients; 3) evaluate possible untoward effects of Zn supplementation in eating disorder patients during the study period; and 4) evaluate the dietary intake of Zn in eating disorder patients as a potential cause ofZn deficiency.
The eating disorders, anorexia nervosa (AN) and buli mia nervosa (BN), manifest many of the same signs and symptoms as zinc (Zn) deficiency including anorexia with a cyclic pattern of food intake, weight loss, amenorrhea in females or impotence in males, gastric distention, altera tions in mood including depression, and in some cases, skin lesions [1-11]. Individual cases have been reported of patients with eating disorders having depressed serum Zn levels, and some patients have had signs and symptoms of Zn deficiency that responded to Zn supplementation [1013]. Few studies have prospectively evaluated Zn status in eating disorder patients, with almost all data being limited to patients with AN [9,14-18]. Furthermore, there is only one prospective study of Zn therapy in eating disorder
Address reprint requests to C.J. McClain, MD, Division of Digestive Diseases and Nutrition, MN654, University of Kentucky Medical Center, Lexington, KY 40536-0084. Journal of the American College of Nutrition, Vol. 11, No. 6, 694-700 (1992) Published by the American College of Nutrition 694
Zn and Eating
METHODS
Downloaded by [New York University] at 16:59 17 April 2015
Patients Thirty-three eating disorder patients and 12 healthy volunteers were included in the study. All patients signed a University of Kentucky Medical Institutional Review Board approved consent form. Eighteen patients had BN and 15 had AN according to DSM-III-R criteria [19]. Of the 15 with AN, 4 also binged and/or purged. Normal volunteers were age- and sex-matched to eating disorder patients. There were 13 female and 2 male AN patients, age range 14-36 years, with a mean age of 19.7 years. BN patients were all female with an age range of 15-33 years and a mean age of 21.1 years. Normal volunteers consisted of 10 females and 2 males who had an age range of 14-28 years and a mean age of 18.1 years. None of these groups is statistically significantly different from the others for mean age or sex. Diet History To assess dietary intake of various nutrients, especially Zn, all patients and volunteers were asked to keep a 3-day food diary prior to the beginning of the study period [20]. All study subjects kept extensive diet diaries which were then analyzed using the Nutritionist III computer program (N2 Computing, Salem, OR). Study Protocol This was a randomized, double-blind, placebo-con trolled, Zn intervention study. Patients were admitted to the Clinical Research Center (CRC) for a 3-day period of intensive metabolic testing at the beginning of their hospitalization and prior to being randomized to either Zn supplementation or placebo intervention. Zn status was assessed by serum and 24-hour urinary Zn values. Patients were then randomized to receive either Zn or placebo. Normal volunteers also underwent an identical 3-day test ing period in the CRC in order to provide comparison information on the metabolic and physiologic parameters studied. After testing in the CRC was completed, patients were admitted to the Eating Disorder Unit for a specified period of psychiatric and dietary intervention (4 weeks for AN and 3 weeks for BN patients). During their stay in the Eating Disorder Unit, patients were given either Zn (25 mg Zn as Zn acetate, t.i.d.) or placebo 30 minutes prior to meals. Zn and placebo solutions looked and tasted the same so staff and patients were blinded as to which sub stance the patients were receiving. Food was presented as single foods (e.g., chicken, beans, etc.) as opposed to com bination foods (e.g., casseroles), so that nutrient content could be assessed. Meals were carefully weighed prior to
Disorders
and after eating so that exact amounts of food and nutrients consumed could be calculated. Patients were allowed onehalf hour to eat, and were monitored carefully to avoid the possibility of discarding food or self-induced vomiting. AN patients were refed aggressively with a nutritious diet to effect weight gain. The diet consisted of 50% carbohydrate, 30% fat and 20% protein. Patient diets were supplemented with Ensure (Ross Laboratories, Columbus, OH) for those patients not consuming enough calories from their hospital diet. Additional privileges (e.g., more TV time) were allowed with increased food consumption. The goal for BN patients was to maintain normal weight through a balanced diet and without binging or purging. Patient bathrooms were locked and patients were ac companied to the bathroom each time to guard against vomiting. Patient activity was also restricted to a minimum necessary to get dressed, eat, watch TV, participate in psychiatric therapy sessions, do homework, etc., as patients were restricted to wheelchairs. Patient room doors were kept open, so that secret exercising could not take place. Patients were weighed in clean hospital gowns daily be tween 7 and 7:30 a.m. after voiding. Patients were involved in group therapy sessions five times/week, and individual counseling three times/week. All patients, regardless of Zn or placebo intervention, participated in the same psychi atric counseling. At the end of the protocol-determined stay in the Eating Disorder Unit, patients were readmitted to the CRC for a repeat 3-day protocol of metabolic testing. These data were used for before-and-after treatment comparisons. Zn Status Zn status was determined from results of fasting serum Zn concentrations and 24-hour urinary Zn levels. Since there was concern about possible untoward effects of Zn supplementation, serum copper (Cu) values also were ex amined. Zn, Cu and Laboratory Determinations Serum Zn and Cu were determined using a PerkinElmer 5000 atomic absorption spectrophotometer as pre viously described [21-25]. Urinary Zn measurements were determined by flame atomic absorption on aliquots of a 24-hour urine specimen collected in the CRC [21]. All other laboratory tests were performed in the hospital clin ical laboratory. Statistical Analysis Group means were compared using Student's t test. Before and after measurements on individual patients were compared using a paired t test. Results were considered significantly different at a p value of 0.05.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
695
Zn and Eating
Disorders
RESULTS
Zlnc Supplementation
Placebo
180y 160··
Serum and Urinary Zn
Downloaded by [New York University] at 16:59 17 April 2015
140··
At admission, mean serum Zn levels were as follows: control 94 ± 3 pg/dl; AN 93 ± 4 pg/dl; and BN 81 ± 4 Mg/dl. Although some individual AN patients were hypozincemic, the mean serum Zn value of the AN group was virtually identical to that of the control group. The mean value for the BN group was significantly (p < 0.025) lower than that of the control group. Admission mean urinary Zn values were as follows: control, 376 ± 45 jig/day; AN, 196 ± /ig/day; and BN 258 ± 44 jig/day. Compared to controls, these values are significantly different for the AN group (p < 0.005), but not significantly different for the BN group. Since this was a Zn intervention study, the main interest was the effect of Zn supplementation on serum and urinary Zn values. Figures 1 and 2 show admission and discharge serum Zn values for AN and BN patients, respectively. The Zn supplemented groups showed significant increases in serum Zn concentrations (AN p < 0.02, BN p < 0.001). Figures 3 and 4 show admission and discharge urinary Zn values for AN and BN patients. The Zn supplemented groups had significant increases in urinary Zn (AN, p < 0.01; BN, p < 0.001). For the AN placebo group, urinary Zn values decreased or remained unacceptably low (
Journal of the American College of Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uacn20
Zinc status before and after zinc supplementation of eating disorder patients. a
a
a
a
a
a
C J McClain , M A Stuart , B Vivian , M McClain , R Talwalker , L Snelling & L a
Humphries a
Department of Medicine, University of Kentucky Medical Center, Lexington 40536-0084. Published online: 02 Sep 2013.
To cite this article: C J McClain, M A Stuart, B Vivian, M McClain, R Talwalker, L Snelling & L Humphries (1992) Zinc status before and after zinc supplementation of eating disorder patients., Journal of the American College of Nutrition, 11:6, 694-700, DOI: 10.1080/07315724.1992.10718269 To link to this article: http://dx.doi.org/10.1080/07315724.1992.10718269
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Zinc Status Before and After Zinc Supplementation of Eating Disorder Patients Craig J. McClain, MD, FACN, Mary A. Stuart, PhD, RD, Beverly Vivian, RD, Marion McClain, MS, Ramesh Talwalker, PhD, Laurel Snelling, MS, and Laurie Humphries, MD Departments of Medicine (C.J.M., R. T.), Psychiatry (L.H.), Nutrition and Food Sciences (M.A.S.), Graduate School of Nutrition (C.J.M., M.A.S., L.S.), and Eating Disorder Unit (C.J.M., M.A.S., B.V., M.M., L.S., L.H.), University of Kentucky Medical Center and Lexington VA Medical Center, Lexington
Downloaded by [New York University] at 16:59 17 April 2015
Key words: zinc, zinc deficiency, eating disorders, anorexia nervosa, bulimia nervosa Reduced food consumption is a major manifestation of zinc (Zn) deficiency. Many manifestations of Zn deficiency are complications of anorexia nervosa and bulimia nervosa. We evaluated serum and 24-hour urinary Zn values in 12 healthy volunteers and 33 eating disorder patients before and after hospitalization which included either Zn supplementation (75 mg Zn/day) or placebo. Bulimics had depressed serum Zn concentrations (p < 0.025). Admission urinary Zn was lower in bulimics (258 ± 44 μg/day), and significantly depressed in anorexics (196 ± 36 Mg/day, p < 0.005) vs controls (376 ± 45 ^g/day). During hospitalization, serum Zn concentrations increased in all supplemented patients vs no change with placebo. Urinary Zn excretion increased in supplemented bulimics (p < 0.001) and placebo (p < 0.05). Urinary Zn excretion markedly increased in supplemented anorexics (179 ± 65 to 1052 ± 242 Mg/day); however, placebo values fell or remained unacceptably low (admission 208 ± 48 μg/day; discharge 160 ± 17 Mg/day). By dietary history, controls consumed the Recommended Dietary Allowance (RDA) for Zn (11.95 ± 1.25 mg/day); anorexics 6.46 ±1.14 mg/day; and bulimics 8.93 ± 1.29 mg/day. We suggest that Zn deficiency may act as a "sustaining" factor for abnormal eating behavior in certain eating disorder patients. Abbreviations: AN = anorexia nervosa, BN = bulimia nervosa, CRC = Clinical Research Center, Cu = copper, RDA = Recommended Dietary Allowance, Zn = zinc
INTRODUCTION
patients, and this is limited to those with AN [9]. We recently reported a high frequency of biochemical Zn deficiency in 86 patients with eating disorders, 62 having BN and 24 with AN [18]. However, subjects were both inpatients and outpatients, and Zn status was evalu ated at varying points in time in relation to the initiation of nutritional intervention and psychotherapy. It was, therefore, the purpose of this study to: 1) evaluate admis sion Zn status in both AN and BN patients requiring hospitalization; 2) determine the effects of Zn supplemen tation vs placebo on Zn status during the period of hospi talization in both AN and BN patients; 3) evaluate possible untoward effects of Zn supplementation in eating disorder patients during the study period; and 4) evaluate the dietary intake of Zn in eating disorder patients as a potential cause ofZn deficiency.
The eating disorders, anorexia nervosa (AN) and buli mia nervosa (BN), manifest many of the same signs and symptoms as zinc (Zn) deficiency including anorexia with a cyclic pattern of food intake, weight loss, amenorrhea in females or impotence in males, gastric distention, altera tions in mood including depression, and in some cases, skin lesions [1-11]. Individual cases have been reported of patients with eating disorders having depressed serum Zn levels, and some patients have had signs and symptoms of Zn deficiency that responded to Zn supplementation [1013]. Few studies have prospectively evaluated Zn status in eating disorder patients, with almost all data being limited to patients with AN [9,14-18]. Furthermore, there is only one prospective study of Zn therapy in eating disorder
Address reprint requests to C.J. McClain, MD, Division of Digestive Diseases and Nutrition, MN654, University of Kentucky Medical Center, Lexington, KY 40536-0084. Journal of the American College of Nutrition, Vol. 11, No. 6, 694-700 (1992) Published by the American College of Nutrition 694
Zn and Eating
METHODS
Downloaded by [New York University] at 16:59 17 April 2015
Patients Thirty-three eating disorder patients and 12 healthy volunteers were included in the study. All patients signed a University of Kentucky Medical Institutional Review Board approved consent form. Eighteen patients had BN and 15 had AN according to DSM-III-R criteria [19]. Of the 15 with AN, 4 also binged and/or purged. Normal volunteers were age- and sex-matched to eating disorder patients. There were 13 female and 2 male AN patients, age range 14-36 years, with a mean age of 19.7 years. BN patients were all female with an age range of 15-33 years and a mean age of 21.1 years. Normal volunteers consisted of 10 females and 2 males who had an age range of 14-28 years and a mean age of 18.1 years. None of these groups is statistically significantly different from the others for mean age or sex. Diet History To assess dietary intake of various nutrients, especially Zn, all patients and volunteers were asked to keep a 3-day food diary prior to the beginning of the study period [20]. All study subjects kept extensive diet diaries which were then analyzed using the Nutritionist III computer program (N2 Computing, Salem, OR). Study Protocol This was a randomized, double-blind, placebo-con trolled, Zn intervention study. Patients were admitted to the Clinical Research Center (CRC) for a 3-day period of intensive metabolic testing at the beginning of their hospitalization and prior to being randomized to either Zn supplementation or placebo intervention. Zn status was assessed by serum and 24-hour urinary Zn values. Patients were then randomized to receive either Zn or placebo. Normal volunteers also underwent an identical 3-day test ing period in the CRC in order to provide comparison information on the metabolic and physiologic parameters studied. After testing in the CRC was completed, patients were admitted to the Eating Disorder Unit for a specified period of psychiatric and dietary intervention (4 weeks for AN and 3 weeks for BN patients). During their stay in the Eating Disorder Unit, patients were given either Zn (25 mg Zn as Zn acetate, t.i.d.) or placebo 30 minutes prior to meals. Zn and placebo solutions looked and tasted the same so staff and patients were blinded as to which sub stance the patients were receiving. Food was presented as single foods (e.g., chicken, beans, etc.) as opposed to com bination foods (e.g., casseroles), so that nutrient content could be assessed. Meals were carefully weighed prior to
Disorders
and after eating so that exact amounts of food and nutrients consumed could be calculated. Patients were allowed onehalf hour to eat, and were monitored carefully to avoid the possibility of discarding food or self-induced vomiting. AN patients were refed aggressively with a nutritious diet to effect weight gain. The diet consisted of 50% carbohydrate, 30% fat and 20% protein. Patient diets were supplemented with Ensure (Ross Laboratories, Columbus, OH) for those patients not consuming enough calories from their hospital diet. Additional privileges (e.g., more TV time) were allowed with increased food consumption. The goal for BN patients was to maintain normal weight through a balanced diet and without binging or purging. Patient bathrooms were locked and patients were ac companied to the bathroom each time to guard against vomiting. Patient activity was also restricted to a minimum necessary to get dressed, eat, watch TV, participate in psychiatric therapy sessions, do homework, etc., as patients were restricted to wheelchairs. Patient room doors were kept open, so that secret exercising could not take place. Patients were weighed in clean hospital gowns daily be tween 7 and 7:30 a.m. after voiding. Patients were involved in group therapy sessions five times/week, and individual counseling three times/week. All patients, regardless of Zn or placebo intervention, participated in the same psychi atric counseling. At the end of the protocol-determined stay in the Eating Disorder Unit, patients were readmitted to the CRC for a repeat 3-day protocol of metabolic testing. These data were used for before-and-after treatment comparisons. Zn Status Zn status was determined from results of fasting serum Zn concentrations and 24-hour urinary Zn levels. Since there was concern about possible untoward effects of Zn supplementation, serum copper (Cu) values also were ex amined. Zn, Cu and Laboratory Determinations Serum Zn and Cu were determined using a PerkinElmer 5000 atomic absorption spectrophotometer as pre viously described [21-25]. Urinary Zn measurements were determined by flame atomic absorption on aliquots of a 24-hour urine specimen collected in the CRC [21]. All other laboratory tests were performed in the hospital clin ical laboratory. Statistical Analysis Group means were compared using Student's t test. Before and after measurements on individual patients were compared using a paired t test. Results were considered significantly different at a p value of 0.05.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
695
Zn and Eating
Disorders
RESULTS
Zlnc Supplementation
Placebo
180y 160··
Serum and Urinary Zn
Downloaded by [New York University] at 16:59 17 April 2015
140··
At admission, mean serum Zn levels were as follows: control 94 ± 3 pg/dl; AN 93 ± 4 pg/dl; and BN 81 ± 4 Mg/dl. Although some individual AN patients were hypozincemic, the mean serum Zn value of the AN group was virtually identical to that of the control group. The mean value for the BN group was significantly (p < 0.025) lower than that of the control group. Admission mean urinary Zn values were as follows: control, 376 ± 45 jig/day; AN, 196 ± /ig/day; and BN 258 ± 44 jig/day. Compared to controls, these values are significantly different for the AN group (p < 0.005), but not significantly different for the BN group. Since this was a Zn intervention study, the main interest was the effect of Zn supplementation on serum and urinary Zn values. Figures 1 and 2 show admission and discharge serum Zn values for AN and BN patients, respectively. The Zn supplemented groups showed significant increases in serum Zn concentrations (AN p < 0.02, BN p < 0.001). Figures 3 and 4 show admission and discharge urinary Zn values for AN and BN patients. The Zn supplemented groups had significant increases in urinary Zn (AN, p < 0.01; BN, p < 0.001). For the AN placebo group, urinary Zn values decreased or remained unacceptably low (
