The role of wearable sensors and wireless technologies for the assessment of heart rate variability in anorexia nervosa

  • Lucia BilleciEmail author
  • Gennaro Tartarisco
  • Elena Brunori
  • Giulia Crifaci
  • Silvia Scardigli
  • Rita Balocchi
  • Giovanni Pioggia
  • Sandra Maestro
  • Maria Aurora Morales
Original Article



Bradycardia and abnormal cardiac autonomic function are related to increased mortality in anorexia nervosa (AN). The aim of this study was to assess heart rate (HR) and HR variability of young adolescents with AN as compared to controls by means of wearable sensors and wireless technologies.


The ECG signal was recorded in 27 AN girls and 15 healthy girls at rest using a wearable chest strap. The tachogram, the mean intervals between R peaks (meanRR), the root mean square of successive differences (RMSSD), the power of low-frequency (LF) and high-frequency (HF) bands and the LF/HF ratio were assessed.


All AN girls showed a reduced HR and an increased meanRR and RMSSD. An HF increase, a LF decrease, and a LF/HF reduction indicated a prevalence of the parasympathetic on sympathetic activity.


The instruments used in this pilot study were feasible, unobtrusive and extremely suitable in AN subjects who are burdened by high incidence of cardiovascular mortality; their application could open to new approaches of vital signs monitoring in hospitals as well as in home settings.


Eating disorders Cardiac complications Heart rate variability Monitoring 


Conflict of interest

The authors of this manuscript certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.


  1. 1.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, ArlingtonCrossRefGoogle Scholar
  2. 2.
    Sullivan PF (1995) Mortality in anorexia nervosa. Amer J Psychiatry 152:1073–1074CrossRefGoogle Scholar
  3. 3.
    Birmingham CL, Su J, Hlynsky JA, Goldner EM, Gao M (2005) The mortality rate from anorexia nervosa. Int J Eat Disord 38:143–146. doi: 10.1002/eat.20164 CrossRefPubMedGoogle Scholar
  4. 4.
    Polli N, Blengino S, Moro M, Zappulli D, Scacchi M, Cavagnini F (2006) Pericardial effusion requiring pericardiocentesis in a girl with anorexia nervosa. Int J Eat Disord 39(7):609–611. doi: 10.1002/eat.20307 CrossRefPubMedGoogle Scholar
  5. 5.
    Casiero D, Frishman WH (2006) Cardiovascular complications of eating disorders. Cardiol Rev 14(5):227–231. doi: 10.1097/01.crd.0000216745.96062.7c CrossRefPubMedGoogle Scholar
  6. 6.
    Neumarker KJ (1997) Mortality and sudden death in anorexia nervosa. Int J Eat Disord 21(3):205–212. doi: 10.1002/(SICI)1098-108X(199704)21:3<205:AID-EAT1>3.0.CO;2-O CrossRefPubMedGoogle Scholar
  7. 7.
    Nussinovitch M, Gur E, Kaminer K, Volovitz B, Nussinovitch N, Nussinovitch U (2012) QT variability among weight-restored patients with anorexia nervosa. Gen Hosp Psychiatry 34(1):62–65. doi: 10.1016/j.genhosppsych.2011.06.012 CrossRefPubMedGoogle Scholar
  8. 8.
    Kollai M, Bonyhay I, Jokkel G, Szonyi L (1994) Cardiac vagal hyperactivity in adolescent anorexia nervosa. Eur Heart J 15(8):1113–1138PubMedGoogle Scholar
  9. 9.
    Kreipe RE, Goldstein B, De King DE, Tipton R, Kempski MH (1994) Heart rate power spectrum analysis of autonomic dysfunction in adolescents with anorexia nervosa. Int J Eat Disord 16(2):159–165. doi: 10.1002/1098-108X(199409)16:2<159:AID-EAT2260160207>3.0.CO;2-H CrossRefPubMedGoogle Scholar
  10. 10.
    Petretta M, Bonaduce D, Scalfi L, de Filippo E, Marciano F, Migaux ML, Themistoclakis S, Ianniciello A, Contaldo F (1997) Heart rate variability as a measure of autonomic nervous system function in anorexia nervosa. Clin Cardiol 20(3):219–224. doi: 10.1002/clc.4960200307 CrossRefPubMedGoogle Scholar
  11. 11.
    Rechlin T, Weis M, Ott C, Blechner F, Joraschky P (1998) Alterations of autonomic cardiac control in anorexia nervosa. Biol Psychiatry 43(5):358–363. doi: 10.1016/S0006-3223(97)00026-7 CrossRefPubMedGoogle Scholar
  12. 12.
    Casu M, Patrone V, Gianelli MV, Marchegiani A, Ragni G, Murialdo G, Polleri A (2002) Spectral analysis of R–R interval variability by short-term recording in anorexia nervosa. Eat Weight Disord 7(3):239–243. doi: 10.1007/BF03327462 CrossRefPubMedGoogle Scholar
  13. 13.
    Galetta F, Franzoni F, Prattichizzo F, Rolla M, Santoro G, Pentimone F (2003) Heart rate variability and left ventricular diastolic function in anorexia nervosa. J Adolesc Health 32(6):416–421. doi: 10.1016/S1054-139X(03)00048-X CrossRefPubMedGoogle Scholar
  14. 14.
    Cong ND, Saikawa R, Ogawa R, Hara M, Takahashi N, Sakata T (2004) Reduced 24 h ambulatory blood pressure and abnormal heart rate variability in patients with dysorexia nervosa. Heart 90(5):563–564. doi: 10.1136/hrt.2003.024356 CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Melanson EL, Donahoo WT, Krantz MJ, Poirier P, Mehler PS (2004) Resting and ambulatory heart rate variability in chronic anorexia nervosa. Amer J Cardiol 94(9):1217–1220. doi: 10.1016/j.amjcard.2004.07.103 CrossRefPubMedGoogle Scholar
  16. 16.
    Roche F, Barthelemy JC, Garet M, Costes F, Pichot V, Duverney D, Kadem M, Millot L, Estour B (2004) Chronotropic incompetence to exercise separates low body weight from established anorexia nervosa. Clin Physiol Funct Imaging 24(5):270–275. doi: 10.1111/j.1475-097X.2004.00561.x CrossRefPubMedGoogle Scholar
  17. 17.
    Platisa MM, Nestorovic Z, Damjanovic S, Gal V (2006) Linear and non-linear heart rate variability measures in chronic and acute phase of anorexia nervosa. Clin Physiol Funct Imaging 26(1):54–60. doi: 10.1111/j.1475-097X.2005.00653.x CrossRefPubMedGoogle Scholar
  18. 18.
    Murialdo G, Casu M, Falchero M, Brugnolo A, Patrone V, Cerro PF, Ameri P, Andraghetti G, Briatore L, Copello F, Cordera R, Rodriguez G, Ferro AM (2007) Alterations in the autonomic control of heart rate variability in patients with anorexia or bulimia nervosa: correlations between sympathovagal activity, clinical features, and leptin levels. J Endocrinol Invest 30(5):356–362. doi: 10.1007/BF03346310 CrossRefPubMedGoogle Scholar
  19. 19.
    Vigo DE, Castro MN, Dörpinghaus A, Weidema H, Cardinali DP, Siri LN et al (2008) Nonlinear analysis of heart rate variability in patients with eating disorders. World J Biol Psychiatry 9:183–189. doi: 10.1080/15622970701261604 CrossRefPubMedGoogle Scholar
  20. 20.
    Ishizawa T, Yoshiuchi K, Takimoto Y, Yamamoto Y, Akabayashi A (2008) Heart rate and blood pressure variability and baroreflex sensitivity in patients with anorexia nervosa. Psychosom Med 70(6):695–700. doi: 10.1097/PSY.0b013e31817bb090 CrossRefPubMedGoogle Scholar
  21. 21.
    Jacoangeli F, Mezzasalma FS, Canto G, Jacoangeli F, Colica C, de Lorenzo A, Iellamo F (2013) Baroreflex sensitivity and heart rate variability are enhanced in patients with anorexia nervosa. Int J Cardiol 162(3):263–264. doi: 10.1016/j.ijcard.2012.10.073 CrossRefPubMedGoogle Scholar
  22. 22.
    Bomba M, Corbetta F, Gambera A, Nicosia F, Bonini L, Neri F, Tremolizzo L, Nacinovich R (2014) Heart rate variability in adolescents with functional hypothalamic amenorrhea and anorexia nervosa. Psychiatry Res 215(2):406–409. doi: 10.1016/j.psychres.2013.11.012 CrossRefPubMedGoogle Scholar
  23. 23.
    Jarrett ME, Burr RL, Cain KC, Hertig V, Weisman P, Heitkemper MM (2003) Anxiety and depression are related to autonomic nervous system function in women with irritable bowel syndrome. Dig Dis Sci 48:386–394. doi: 10.1023/A:1021904216312 CrossRefPubMedGoogle Scholar
  24. 24.
    Mazurak N, Enck P, Muth E, Teufel M, Zipfel S (2011) Heart rate variability as a measure of cardiac autonomic function in anorexia nervosa: a review of the literature. Eur Eating Disord Rev 19:87–99. doi: 10.1002/erv.1081 CrossRefGoogle Scholar
  25. 25.
    Smink FR, van Hoeken D, Hoek HW (2012) Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep 14(4):406–414. doi: 10.1007/s11920-012-0282-y CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Yilmaz T, Foster R, Hao Y (2010) Detecting vital signs with wearable wireless sensors. Sensors 10(12):10837–10862. doi: 10.3390/s101210837 CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA et al (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18(12):1440–1463. doi: 10.1016/j.echo.2005.10.005 CrossRefPubMedGoogle Scholar
  28. 28.
    Schiller NB, Acquatella H, Ports TA, Drew D, Goerke J, Ringertz H et al (1979) Left ventricular volume from paired biplane two-dimensional echocardiography. Circulation 60(3):547–555. doi: 10.1161/01.CIR.60.3.547 CrossRefPubMedGoogle Scholar
  29. 29.
    Burns A, Greene BR, McGrath MJ, O’Shea TJ, Kuris B, Ayer SM, Stroiescu F, Cionca V (2010) SHIMMER™: a wireless sensor platform for noninvasive biomedical research. IEEE Sens J 10(9):1527–1534. doi: 10.1109/JSEN.2010.2045498 CrossRefGoogle Scholar
  30. 30.
    Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology (1996) Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation 93(5):1043–1065. doi: 10.1161/01.CIR.93.5.1043 CrossRefGoogle Scholar
  31. 31.
    Merri M, Farden DC, Mottley JG, Titlebaum EL (1990) Sampling frequency of the electrocardiogram for the spectral analysis of heart rate variability. IEEE Trans Biomed Eng 37(1):99–106. doi: 10.1109/CIC.1988.72585 CrossRefPubMedGoogle Scholar
  32. 32.
    Bianchi AM, Mainardi LT, Petrucci E, Signorini MG, Mainardi M, Cerutti S (1993) Time-variant power spectrum analysis for the detection of transient episodes in HRV signal. IEEE Trans Biomed Eng 40(2):136–144. doi: 10.1109/10.212067 CrossRefPubMedGoogle Scholar
  33. 33.
    Solar H, Fernández E, Tartarisco G, Pioggia G, Cvetković B, Kozina S, Luštrek M, Lampe J (2012) A non invasive, wearable sensor platform for multi-parametric remote monitoring in CHF patients impact analysis of solutions for chronic disease prevention and management. Lect Notes Comput Sci 7251:140–147. doi: 10.1007/978-3-642-30779-9_18 CrossRefGoogle Scholar
  34. 34.
    Tartarisco G, Baldus G, Corda D, Raso R, Arnao A, Ferro M, Gaggioli A, Pioggia G (2012) Personal health system architecture for stress monitoring and support to clinical decisions. Comput Commun 35(11):1296–1305. doi: 10.1016/j.comcom.2011.11.015 CrossRefGoogle Scholar
  35. 35.
    Solar H, Fernández E, Tartarisco G, Pioggia G, Cvetković B, Kozina S, Luštrek M, Lampe J (2013) A non invasive, wearable sensor platform for multi-parametric remote monitoring in CHF patients. Health Technol 3(2):99–109. doi: 10.1007/978-3-642-30779-9_18 CrossRefGoogle Scholar
  36. 36.
    Pan J, Tompkins WJ (1985) A real-time QRS detection algorithm. IEEE Trans Biomed Eng BME 32(3):230–236. doi: 10.1109/TBME.1985.325532 CrossRefGoogle Scholar
  37. 37.
    Yule GU (1927) On a method of investigating periodicities in disturbed series, with special reference to Wolfer’s sunspot numbers. Philos Trans Roy Soc Lond Ser A 226:267–298. doi: 10.1098/rsta.1927.0007 CrossRefGoogle Scholar
  38. 38.
    Walker G (1931) On periodicity in series of related terms. Proc Roy Soc Lond Ser A 131:518–532. doi: 10.1098/rspa.1931.0069 CrossRefGoogle Scholar
  39. 39.
    IBM Corp. Released (2012) IBM SPSS statistics for Windows, Version 21.0. IBM Corp, ArmonkGoogle Scholar
  40. 40.
    Lesinskiene S, Barkus A, Ranceva N, Dembinskas A (2008) A meta-analysis of heart rate and QT interval alteration in anorexia nervosa. World J Biol Psychiatry 9(2):86–91. doi: 10.1080/15622970701230963 CrossRefPubMedGoogle Scholar
  41. 41.
    Olivares JL, Vázquez M, Fleta J, Moreno LA, Pérez-González JM, Bueno M (2005) Cardiac findings in adolescents with anorexia nervosa at diagnosis and after weight restoration. Eur J Pediatr 164(6):383–386. doi: 10.1007/s00431-005-1647-6 CrossRefPubMedGoogle Scholar
  42. 42.
    De Simone G, Scalfi L, Galderisi M, Celentano A, Di Biase G, Tammaro P, Garofalo M, Mureddu GF, de Divitiis O, Contaldo F (1994) Cardiac abnormalities in young women with anorexia nervosa. Br Heart J 71(3):287–292. doi: 10.1136/hrt.71.3.287 CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    Bai X, Li J, Zhou L, Li X (2009) Influence of the menstrual cycle on non linear properties of heart rate variability in young women. Amer J Physiol Heart Circul Physiol 297(2):H765–H774. doi: 10.1152/ajpheart.01283.2008 CrossRefGoogle Scholar
  44. 44.
    Attia E, Roberto CA (2009) Should amenorrhea be a diagnostic criterion for anorexia nervosa? Int J Eat Disord 42(7):581–589. doi: 10.1002/eat.20720 CrossRefPubMedGoogle Scholar
  45. 45.
    Farquharson CA, Struthers AD (2002) Increasing plasma potassium with amiloride shortens the QT interval and reduces ventricular extrasystoles but does not change endothelial function or heart rate variability in chronic heart failure. Heart 88(5):475–480. doi: 10.1136/heart.88.5.475 CrossRefPubMedCentralPubMedGoogle Scholar
  46. 46.
    Yoshida NM, Yoshiuchi K, Kumano H, Sasaki T, Kuboki T (2006) Changes in heart rate with refeeding in anorexia nervosa: a pilot study. J Psychosom Res 61(4):571–575. doi: 10.1016/j.jpsychores.2006.02.009 CrossRefPubMedGoogle Scholar
  47. 47.
    Theorell T, Kjellberg J, Palmblad J (1978) Electrocardiographic changes during total energy deprivation (fasting). Acta Med Scand 203(1–2):13–19. doi: 10.1111/j.0954-6820.1978.tb14824.x PubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Lucia Billeci
    • 1
    Email author
  • Gennaro Tartarisco
    • 2
  • Elena Brunori
    • 3
  • Giulia Crifaci
    • 2
  • Silvia Scardigli
    • 3
  • Rita Balocchi
    • 1
  • Giovanni Pioggia
    • 2
  • Sandra Maestro
    • 3
  • Maria Aurora Morales
    • 1
  1. 1.Institute of Clinical PhysiologyNational Research Council of Italy (CNR)PisaItaly
  2. 2.Institute of Clinical PhysiologyNational Research Council of Italy (CNR)MessinaItaly
  3. 3.IRCCS Stella Maris Scientific FoundationPisaItaly

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