Osteoporosis and bone loss are severe physical consequences that can occur quickly in the early stages of an eating disorder. Getting a bone density scan and medical consult can help you identify if this is an issue you need to address.

What is Anorexia?

Anorexia is an eating disorder that usually stems from an irrational fear of gaining weight. People with anorexia are often underweight and restrict food intake through starvation, over-exercising, and sometimes purging behaviors.

Those with anorexia can develop severe physical and medical issues, including decreased bone density and vitamin D deficiencies.

What is Osteoporosis?

Osteoporosis is when the bones are less dense and can fracture, resulting in significant pain and disability. More than 53 million individuals in the U.S. are diagnosed with osteoporosis or are at high risk due to low bone mass. [1]

You may be at a higher risk of developing osteoporosis if you:

Are very thin
Have a family history of osteoporosis
Are female and don’t have a regular menstrual cycle
Have reached menopause
Have low calcium intake
Smoke
Consume a significant amount of alcohol regularly
Do not exercise regularly

Often, bone loss is associated with underweight women, which is why those with anorexia risk developing osteoporosis.

Connecting Anorexia & Osteoporosis

Anorexia has serious physical consequences due to the nutritional and hormonal shifts that impact bone density.

Low body weight in women can stop estrogen production and cause amenorrhea or lack of menstrual cycles. This causes a massive loss in bone density, leading to osteoporosis. [1]

The adrenal hormone cortisol is also excessively produced in those with anorexia, leading to bone loss.

Other factors, such as a decrease in the growth hormone coupled with low body weight, low calcium, and malnutrition, can aid bone loss, resulting in osteoporosis or osteopenia.

Adolescence is a critical time for bone growth, and those who develop osteoporosis may be less likely to reach their optimum bone density. As a result, they may be at higher risk for osteoporosis and fractures throughout life. [2]

How to Protect Bone Health

Almost 40% of bone accrual happens two years before and two years after the final puberty growth spurt. [3] This time is critical for bone development. The longer anorexia continues, the greater the bone loss and decrease in bone minerals, which can affect lifelong bone strength.

Increase Vitamin D Intake

Vitamin D comes into play to help reverse bone loss with anorexia. Consuming high-calcium foods, such as dairy products, dark leafy vegetables, and calcium-fortified foods and beverages, is vital. Other foods that can increase vitamin D include:

Egg yolks
Saltwater fish
Liver

Maintain a Healthy Weight

A study found that vitamin D deficiency is significantly prevalent in teens with an eating disorder. [4] This nutritional lack increases the risk for osteoporosis, estrogen cessation, and cortisol levels, all of which contribute to bone loss.

Another study in Israel found that many participants in their early to late teen years who had anorexia, bulimia, and binge eating had vitamin D levels and bone mineral density lower than 32 ng/ml, which is the level where bone growth is maintained. Researchers also found that their lumbar spine bone mineral density was low.[4]

We know that body changes in low weight or malnutrition affect hormone production. Estrogen is also decreased, which affects women’s menstruation and increases cortisol. With weight loss comes poor nutrition, which can also reduce muscle mass.

Vitamins for Eating Disorders

People with anorexia often arrive in treatment centers severely underweight. Unfortunately, gaining weight isn’t easy, as feeding these people too much too quickly can result in a deadly refeeding syndrome of electrolyte imbalances. So often, doctors turn to supplements instead.

At the onset of treatment, doctors use multivitamins to help correct imbalances. [5] These vitamins for anorexia contain vitamin D along with other critical elements such as:

Thiamine
Potassium
Magnesium
Phosphate

As people improve and begin eating a healthy diet, they receive their vitamin D from food. Unfortunately, most foods with vitamin D don’t have enough to meet people’s daily needs. Most people in the United States don’t get enough of this vitamin from food only. [6]

Doctors often recommend vitamins for anorexia and suggest their patients stay on them during inpatient and outpatient care. [5] This long-term treatment ensures that people have the nutrients they need to rebuild bones and have a healthy recovery.

While a multivitamin for an eating disorder may be a good idea, taking too much vitamin D isn’t always healthy. People can consume too much of this element, and it could become toxic.

Treatment Considerations

Treatment for anorexia includes support from a multidisciplinary team, including a:

Medical provider
Psychiatrist
Individual therapist
Dietitian

Bone density scans and vitamin supplements are often required.

Birth Control

Birth control can also help with estrogen replacement and improving bone density, but it can affect growth levels in children as it can influence the natural process of bone formation and growth. Some researchers say this treatment isn’t effective for all people.[8]

Exercise

It is typically recommended that exercise and weight training are used for strengthening bones, but with anorexia, it is difficult as the goal is weight gain. However, exercise can be utilized once weight is restored with nutritional support and supervision.

It can take years for complex medical conditions to rectify. Many people in recovery from anorexia tend to have a lower bone density in the long term, depending on the duration and severity of the eating disorder.

Final Thoughts

Eating disorders are directly related to bone density concerns and vitamin D and calcium loss. In addition, lack of proper nutrition through starvation, rapid weight loss, and cessation of the menstrual cycle can decrease bone strength.

Even though other eating disorders do not include starvation, lack of proper nutrition and exercise can trigger bone loss. However, by working with your treatment team and following medical recommendations, you can slowly regain bone strength and reverse some of the physical damage from an eating disorder.

References

National Institutes of Health. (2018). What People with Anorexia Nervosa Need to Know About Osteoporosis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Retrieved September 2022.
Misra M, Klibanski A. (2014). Anorexia nervosa and bone. Journal of Endocrinology, 221(3):R163-76.
Cattran AM, Kalkwarf HJ, Pinney SM, Huang B, Biro FM. (2015). Bone Density and Timing of Puberty in a Longitudinal Study of Girls. Journal of Pediatric and Adolescent Gynecology, 28(3):170-2.
Modan-Moses D, Levy-Shraga Y, Pinhas-Hamiel O, Kochavi B, Enoch-Levy A, Vered I, Stein D. (2015). High prevalence of vitamin D deficiency and insufficiency in adolescent inpatients diagnosed with eating disorders. International Journal of Eating Disorders, 48(6):607-14.
National Collaborating Centre for Mental Health (UK). (2004). Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. Leicester (UK): British Psychological Society (UK); 2004. (NICE Clinical Guidelines, No. 9.) 6, Treatment and management of anorexia nervosa.
Vitamin D. (2022). National Institutes of Health. Retrieved September 2022.
Guidelines for the Nutritional Management of Anorexia Nervosa. (July 2005). Royal College of Psychiatrists London. Retrieved September 2022.
Bergström I, Crisby M, Engström A, Hölcke M, Fored M, Jakobsson Kruse P, Sandberg A. (2013). Women With Anorexia Nervosa Should Not Be Treated With Estrogen or Birth Control Pills in a Bone-Sparking Effect. AOGS.

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published on October 10, 2022 and reviewed by: Jacquelyn Ekern, MS, LPC
Published on EatingDisorderHope.com

Anorexia, Bone Density Concerns & Vitamin D