International Journal of Clinical Medicine, 2011, 2, 509-515
doi:10.4236/ijcm.2011.24085 Published Online September 2011 (http://www.SciRP.org/journal/ijcm)
509
Cholecystokinin in the Pathogenesis of
Bulimia Nervosa
Helena Trebbau López, Rosa María Molina-Ruiz, Laura Reyes Molón, Marina Díaz-Marsá
Instituto de Psiquiatría y Salud Mental, Hospital Clínico San Carlos, Madrid, Spain.
Received January 27th, 2011; revised May 30th, 2011; accepted July 12th, 2011.
ABSTRACT
Objective: This review aims to describe the role of the hormone cholecystokinin (CCK) in the pathogenesis of bulimia
nervosa (BN), the perpetuation of this illness and the possibility of its use as a target for future therapeutic advances.
Methods: Search for cholecystokinin AND bulimia nervosa in Pubmed Central, with no limits, identified 38 articles
published up to the present date. Results: It is well established that CCK is altered in the pathogenesis of BN, and that
its main role is in the perpetuation of the disorder rather than the cause of it. Discussion: Additional studies will be
needed to further understand the mechanisms by which CCK regulates orexigenic pathways. If an orally active, longer
acting analogue of CCK could be developed, it would be of significant interest as an appetite suppressant and a key
adjuvant in the treatment of patients suffering from BN, particularly in refractory cases.
Keywords: Satiety, Cholecystokinin, Bulimia Nervosa
1. Introduction
Food is a complex act in which several factors intervene.
At a biological level, feeding behaviour is determined by
nutritional needs and mechanisms for regulating food
intake. In addition to its nutricional function, food has the
intrinsic capacity to alter mood and activate reward
mechanisms that are key to ensure repetition of activities
that are essential for survival of the individual and the
species [1].
Psychological aspects, both personality traits and fam-
ily dynamics, are very influential in the way of estab-
lishing the link with food and body image: individuals
with Anorexia nervosa (AN) tend to have high constrict-
tion of affect and emotional expressiveness, anhedonia
and asceticism, whereas individuals with Bulimia ner-
vosa (BN) tend to be more impulsive and sensation
seeking. This dysphoric temperament may involve an
inherent dysregulation of emotional and reward pathways,
which also mediates the hedonic aspects of feeding, thus
making these individuals vulnerable to disturbed appeti-
tive behaviours [2].
Comorbid psychiatric conditions, like affective and
anxiety disorders, substance abuse or personality disor-
ders, and sociocultural factors (availability of food, eat-
ing habits determined by the regional economy and so-
cial standards of beauty) also seem to influence eating
behaviour [3].
BN, one of the most common and secretive of these
disorders, is characterized by compulsive binge eating
followed by compensatory efforts, usually vomiting or
laxative abuse, in order to purge calories and avoid
weight gain [4,5]. This disorder is usually a chronic ill-
ness, which has been related to physiological distur-
bances in many neuronal and endocrine systems, espe-
cially the satiety reflex. The mechanisms for controlling
food intake involve a complicated interplay between pe-
ripheral systems (including gustatory stimulation, gas-
trointestinal peptide secretion and vagal afferent nerve
responses) and central nervous system neuropeptides,
such as cholecystokinin (CCK), corticotropin-releasing
hormone, β-endorphin, vasopressin, oxytocin, leptin,
neuropeptide Y (NPY) and peptide YY (PYY) [6,7] and
monoamines like noradrenaline, serotonine and dopa-
mine [8].
The central nervous system (CNS) receives and proc-
esses information from both the physiological state of the
organism and the environmental conditions (eg. organo-
leptic characteristics of foods and the education about
eating received by each individual), which reaches its
integration into the hypothalamus where we can find the
“satiety center” in the ventral-med ial hypo thalamus (para-
ventricular and ventromedial nuclei) and the “appetite

Cholecystokinin in the Pathogenesis of Bulimia Nervosa 510
center” in the lateral hypothalamus [1 ].
The molecular signals that stimulate eating are NPY,
norepinephrine and ®-endorphin, while those producing
an inhibition of these behaviours are melanocyte stimu-
lating hormone, corticotropin-releasing hormone and
serotonine. These all work within the CNS, while the
peptides CCK, leptin and specific cytokines, act at a pe-
ripheral level. This multiplicity of biological systems
involved in eating behaviour ensures proper maintenance
of the body wei ght [9].
Neurotransmitter s and neuropeptides are also involv ed
in circuits related to reward and memory of food experi-
ences. In this way, psychological experiences are con-
nected with eating behaviour [10]. The mesolimbic
dopaminergic pathway is involved in the development of
these gratification behaviours by increasing the release of
dopamine in the nucleus accumbens, which as a cones-
quence, perpetuates the behaviour. These processes are
determinants for “food preferences”. The increase in do-
pamine in the lateral hypothalamus tonically inhibits the
search for food and eating, acting on D2 dopamine re-
ceptors, which in turn inhibit the produ ction of dopamine
in the nucleus accumbens [11]. The postprandial reward
systems are anatomically linked with opioids [12]. This
would explain the self-addiction model described in the
pathophysiology of EDs [13].
CCK is one of the most important substances in con-
trolling volume and size of meals because of its powerful
satiating effect [12], being considered the main negative
regulator of ingestion [14]. Its production takes place at a
gastrointestinal and central level. Its secretion, stimulated
mainly by fat intake, cau ses a sensation of fullness in the
gastrointestinal system and central hypothalamic satiety
sensation by direct action or mediated by leptin. Inter-
estingly, there appears to be substantial evidence of
blunting CCK meal-related release in the pathogenesis of
BN, producing less satiety effect when eating a meal [15].
This review will address the role of CCK, one of the key
neuropeptides, involved in the perpetuation of the patho-
genesis of bulimia nervosa.
2. Cholecystokinin
The peptide hormone CCK was discovered in 1928 by
Ivy and Oldberg because of its ability to induce gall-
bladder contraction. Together with secretin and gastrin,
CCK constitutes the classical gut hormone triad [16-18].
In addition to gallbladder contraction, CCK also regu-
lates pancreatic enzyme secretion and growth, intestinal
motility, inhibition of gastric secretion and satiety sig
naling. CCK is, however, also a transmitter in central and
intestinal neurons.
In humans, CCK gene is located on chromosome 3 and
the processing of proCCK is cell specific. Hence, endo-
crine cells contain a mixture of medium size CCKs,
whereas neurons mainly release CCK-8. This cell-spe-
cific synthesis is essential for function in the different
compartments of the body [17]. Two CCK receptors have
been identified. Both are 7 transmembrane G-proteins
which activate phospholipase C and consequently, via the
intracellular cascade, activate protein kinase C. CCK-A
(alimentary) receptors bind only sulphated CCK-8 pep-
tides, whereas the CCK-B (brain or gastrin) receptors are
less restrictive also binding non-sulphated CCK and gas-
trin peptides [17].
The CCK-A receptor mediates gallbladder con traction,
relaxation of the sphincter of Oddie, pancreatic growth
and enzyme secretion, delay gastric emptying and inhibi-
tion of gastric acid secretion. Moreover it promotes insu-
lin secretion in response to glucose, a property also pre-
sent in other gastrointestinal hormones such as gastric
inhibitory peptide. In this way it participates in the diges-
tion of nutrients and its posterior subsequent metabolism
[10]. Because of its effect in producing pyloric constrict-
tion and inhibition of gastric emptying, it contributes to
bloating and produces sensation of fullness and satiety
[19].
Vagotomy studies indicate that peripheral CCK in-
duces satiety via CCK-A receptors located in the pyloric
sphincter and afferent abdominal vagal branches [17,20,
21]. CCK-A receptors have also been found in the ante-
rior pituitary, the myenteric plexus and areas of the mid-
brain. The stimulation of CCK-A receptors located on
peripheral vagal nerve, causes a signal that, after being
processed in the CNS, results in a decrease of food intake.
This food-related information is initially transmitted to
the solitary tract nucleus, a region of the brainstem that
integrates afferent signals both from gustatory and the
gastrointestinal tract. Then, this information is eventually
transmitted to the hypothalamus and other areas of the
basal forebrain [22].
The CCK-B (brain or gastrin) r eceptor is the predomi-
nant CCK receptor in the brain, but less is known about
its role. They are located mainly in the nucleus of the
solitary tract and area postrema of the brain, modulating
also in this way, the respon se to anx iety and pa in [23,24 ].
Mapping of CCK-sensitive sites also show that the me-
dial pons and lateral medulla in the vicinity of the tractus
solitarius nucleus, significantly suppresses food intake.
CCK has also been identified within the CNS as a hypo-
thalamic neuropep tide and it has been shown to suppress
feeding behaviour whenexogenously applied into the
lateral hypothalamus [16]. In fact, the hindbrain contains
sufficient neural complexity to conv ert the afferent signal
into a behavioural decision to stop eating because CCK
inhibits food intake in chronic decerebrated rats [25].
The satiety response to fat is antagonized by serotonin

Cholecystokinin in the Pathogenesis of Bulimia Nervosa511
blockage, suggesting that serotonin mediates this action
of CCK, possibly through their 5HT2C receptors [26].
CCK has also behavioural effects by inducing postpran-
dial sedation and sleep. Likewise, it has an antidopa-
minergic activity, which decreases the search and interest
in food [10]. CCK also inhibits expression of orexigenic
peptides in the hypothalamus and prevents stimulation of
specialized neurons by gh rel i n [18] .
At a peripheric level, CCK has also been shown that in
the pancreas it increases the proliferation of insulin-
producing beta cells and reduces insulin-induced hyper-
phagia. Elevated CCK levels also decrease appetite and
reduce intestinal inflammation caused by parasites and
bacterial toxins [18]. Furthermore, post-meal CCK re-
lease has been found to correlate with subjective ratings
of satiety [27]. This inhibitory effect is dose related; it
does not show significant degree of tolerance and is rela-
tively specific in that equivalent doses have less effect on
water intake [25]. Regarding its effect in normal and
obese subjects, CCK demonstrated to reduce food intake
in both type of patients.
Dysregulation of CCK in Bulimia Nervo sa
Different alterations have been described in BN disorders:
decreased noradrenergic, serotoninergic and dopaminer-
gic activity, reduced colecistoquinergic action and in-
creased orexigenic action of PYY [28], suggesting that
satiety is altered in patients with BN [1,12]. Hormones
like leptin, glucocorticoids and sexual steroids are also
altered [10].
In 1988, Liddle and Geracioti investigated the hy-
pothesis that abnormalities in CCK secretion and satiety
may occur in patients with BN. Their results showed that
fasting CCK levels were similar in BN patients and con-
trols (approximately 0.8 pmol per liter) [29]. After eating,
however, mean peak plasma CCK levels increased to 4.1
+/– 0.9 pmol per liter in normal controls but to only 2.1
+/– 0.2 pmol per liter in patients with BN (p δ 0.5).
These results led to following studies which supported
the initial hypothesis [30-39]. Thus, in BN patients, the
postprandial release OF CCK is decreased, while in AN
patients, both basal and food induced CCK, is normal or
elevated [40]. This fact has also been also been observed
in the elderly and may also explain their lower appetite
[41].
They also described that gastric emptying at 1 hour is
statistically slower in bulimic patients than in control
subjects, which is also in agreement with following stud-
ies done in this area [4,17,42,43]. Gastric dilation typi-
cally occurs afterbinge-eating and becomes manifest in
upper abdominal pain and sometimes in spontaneous
vomiting [43]. Findings of enlarged gastric capacity in
normal-weight bulimics led to the proposal that repeated
binge eating leads to increased stomach capacity that in
turn leads to delayed gastric emptying and blunted post-
meal CCK release. These effects give rise to an attenua-
tion of the normal pos t-meal satiety response and thereb y
promote further eating, thus completing the cycle [27].
Since the release of CCK is stimulated by the presence
of food in the duodenum after it empties from the stom-
ach, CCK release is therefore partly dependent on gastric
emptying. The whole-gut transit time, measured by ra-
dioisotope techniques, has also been demonstrated to be
significantly delayed in patients with eating disorders
[43]. Therefore, the coexistance of delayed gastric emp-
tying and blunted CCK release suggests, but does not
prove, that attenuated CCK response is caused by the
delayed entry of food in the duodenum. Studies by Rolls
et al. (1997) also demonstrated that consuming a high-fat
diet for 2 weeks results in an increase of daily food in-
take, increase hunger and an increase in postprandial
CCK, suggesting that periods of overeating can lead to a
blunted satiety response due to downregulation of CCK
receptors, thus contributing to further overeating [44].
However, studies done by Devlin et al. (1997) found
no correlation between gastric emptying and CCK re-
lease, suggesting that factors other than the rate of gastric
emptying affect interindividual variability in post-meal
release. Nevertheless, although not all studies have
demonstrated statistical differences in gastric compliance
with controls, it has been well established that patients
with BN exhibit diminished sensitivity to gastric disten-
tion [5].
Finally, these multiple neuroendocrine and neuro-
transmitter changes found in ED patients can be ex-
plained by the nutritional hypothesis. This hypothesis
proposes that a temporary reduction of the incorporation
of calories accompanied by a loss of weight may cause
substantial changes in the levels of certain neurotrans-
mitters and hormones. However, the changes in the dif-
ferent neurotransmitter, neuroendocrine and neuropep-
tidergic systems, seems to get back to normal after
weight recovery [9,35,45]. Therefore, these changes ap-
pear to be adaptations to a temporary state of starvation,
rather than the cause of it [35,45,46].
3. Discussion
The role of CCK in the pathog enesis o f BN seems to be a
very important factor in the perpetuation of the disease,
since it is at this stage when the patient has most prob-
lems in preventing a “normal” meal to convert into a
binge because of lack of physiological satiety feedback.
The patient may continue to eat until physical pain of
fullness stops her/him. The more distended the stomach
is, the longer the patient can keep bingeing. The findings
of slowed gastric emptying and of impaired gastric ac-

Cholecystokinin in the Pathogenesis of Bulimia Nervosa 512
commodation following food ingestion indicate that
stomach function in BN is characterized by a reduction in
meal-related gastric muscular activity. These results
suggest that, in patients with BN, the stomach might also
be more easily distensible, perhaps as a result of repeated
episodes of binge eating [5].
In fact, most of the neuroendocrine and neuropeptide
alterations apparent during symptomatic episodes of ED
tend to normalize after recovery [35,46]. This observa-
tion suggests that most of the disturbances are cones-
quences, rather than causes, of malnutrition and altered
meal patterns [47]. There is, however, some controversy
whether these alterations are secondary to the cones-
quences of psychological conflicts and nutritional deficit
(by restriction or by the binge-purge cycle) or a way of
“self-defence” by the organism to starvation [13]. The
psychological aspects eventually produce a biological
imprinting; therefore the biological, psychological and
social issues are so involved that feed each other con-
tinuously, being the disease, the final result of this inter-
action [13].
Further research of these neuropeptide disturbances
may shed light on why many people w ith ED cannot eas-
ily “reverse” their illness even after having normalized
their eating habits [16]. Substantial psycholog ical, social,
and physiological disturbances are associated with EDs,
and it has been very difficult to disentangle those factors
that may result from the disturbed behaviour from the
factors that may have predisposed individuals to, or pre-
cipitated the development of, the disorder [48] suggest-
ing the need for prolonged treatment [9,49].
Understanding the mechanisms by which CCK regu-
lates orexigenic pathways in the body may lead to new
strategies for controlling appetite-related disorders such
as obesity and bulimia nervosa [18]. In 1973, Gibbs et al.
discovered that exogen ous CCK inhibits fo od intak e. The
effect was dose dependent and specific, i.e.; it mimicked
the satiety induced by food and was not seen with other
gut peptides then known [17,30,31,50,51]. The sulphated
form of CCK-8 was found to be the most potent for in-
hibiting food intak e [20]. Thus, the curren t mechanism of
action appears to be activation of pyloric or vagal recap-
tors by CCK-8, which then produce a propagated action
potential up the afferent vagal fibers to the first central
synapse in the nucleus tractus solitarius. Activation of the
“satiety pathway” also induces release of the hypotha-
lamic neuropeptide CCK, with the final result being in-
hibition of food intake. In fact, using synthetic agonists
of CCK for obese patients experimentally, have shown
that blocking this satiety factor increases the size of the
intake [52].
Unfortunately, despite encouraging results with CCK
in test meal situations, there are significant obstacles to
its therapeutic use. These include the inactivity of orally
administered CCK, no evidence concerning safety of
CCK when administered chronically, just little evidence
about the ability of CCK to inhibit intake of preferred
foods, and the lack of evidence concerning the efficacy
of CCK to produce actual weight loss in humans. If an
orally active, longer acting analogue of CCK could be
developed, it would be of significant interest as an appe-
tite suppressant and a key adjuvant in the multidiscipli-
nary treatment of patients suffering from bulimia nervosa,
particularly in chronic refractory cases [18,25].
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