Contributed by: Melanie Schorr, MD, Endocrinologist at Harvard Medical School/Massachusetts General Hospital
Bone loss is an important health concern in anorexia nervosa because it is common and can be severe. Bone loss is assessed by measuring bone mineral density on a DEXA scan, which is a test similar to an x-ray. A patient’s bone mineral density is typically measured at the spine, hip, and wrist, and is compared to a healthy person of their age, gender, and ethnicity.
Mild to moderate bone loss is called osteopenia, and severe bone loss is called osteoporosis. More than 90% of women with anorexia nervosa have osteopenia and 40% have osteoporosis (Grinspoon et al., 2000), with fewer than 15% of such women having normal bone density at all skeletal sites (Miller et al., 2005).
Bone Loss is an Important Health Concern
Adolescent girls with anorexia nervosa are also at risk for bone loss because they do not experience the sharp increase in bone mineral density that normally occurs during puberty (Soyka et al., 2002). Bone loss is an important health concern because it is associated with an increased fracture risk. Studies have reported that 30% of women with anorexia nervosa have had at least one fracture (Miller et al., 2005), and the risk of fracture is seven times greater than expected for a patient’s age and gender (Rigotti, Neer, Skates, Herzog, & Nussbaum, 1991).
Early Intervention is Important
Early intervention can help prevent and treat bone loss in anorexia nervosa. Since low weight and duration of illness are important contributing factors to bone loss, weight recovery can improve bone density (Herzog et al., 1993), but may not normalize it. Regular menstrual periods are also important for good bone health. For women who are not having regular menstrual periods and therefore have low estrogen levels, regaining menstrual periods has been shown to be critical to skeletal recovery (Miller et al., 2006).
Weight recovery that results in resumption of menstrual periods has been shown to be much more effective in restoring bone than taking oral estrogens in the form of oral contraceptive pills. Adequate calcium and vitamin D intake (the Institute of Medicine recommends 1000mg of calcium and 600IU vitamin D for adult women (Ross et al., 2011)) are also important for proper bone mineralization, but alone cannot reverse bone loss in anorexia nervosa.
Although some weight-bearing activity is good for bones, excessive exercise that results in a negative energy balance and/or loss of menstrual periods can worsen bone loss in women with anorexia nervosa (Waugh, Woodside, Beaton, Coté, & Hawker, 2011). For this reason, any exercise should be individualized with a patient’s treatment team. Early intervention to prevent and treat bone loss is important because patients may not realize that they have bone loss until after they have already broken a bone (osteoporosis is a “silent” illness with no symptoms until a fracture occurs), and osteopenia and osteoporosis are frequently long-term complications of anorexia nervosa.
Boys and Men
Less is known about the effects of anorexia nervosa on bone health in adolescent boys and men, but reports indicate they are also significantly affected by bone loss (Mehler, Sabel, Watson, & Andersen, 2008). The factors contributing to bone loss in adolescent boys and men with anorexia nervosa are similar—low testosterone levels are known to be associated with low bone density just as low estrogen levels are in women (Misra et al., 2008). Weight gain and normalization of reproductive function are important treatment goals in men as they are in women, although there are fewer studies on bone loss in adolescent boys and men with anorexia nervosa.
Further studies are needed to determine how to optimize bone mineral density in anorexia nervosa. Currently, there are no Federal Drug Administration (FDA)- approved medications to treat bone loss in anorexia nervosa, but investigations of potential therapeutic medications are ongoing. Improving health, particularly bone health, in patients with anorexia nervosa is a key mission of the Neuroendocrine Unit at Massachusetts Hospital. If you are interested in learning more about our bone health studies, please click on our attached banner. We look forward to hearing from you.
About the author: Dr. Melanie Schorr is an Endocrine Fellow in the Neuroendocrine Unit at Massachusetts General Hospital, which is affiliated with Harvard Medical School. After graduating from Dartmouth College in 2006, she attended Johns Hopkins University School of Medicine, and went on to complete her internal medicine residency at Brigham and Women’s Hospital in 2013. She sees patients in the Neuroendocrine Clinical Center at Massachusetts General Hospital, and her research interests include skeletal health in
women with eating disorders.
References:: Grinspoon, S., Thomas, E., Pitts, S., Gross, E., Mickley, D., Miller, K., … Klibanski, A. (2000). Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Annals of Internal Medicine, 133(10), 790–794.
: Herzog, W., Minne, H., Deter, C., Leidig, G., Schellberg, D., Wüster, C., … Bergmann, G. (1993). Outcome of bone mineral density in anorexia nervosa patients 11.7 years after first admission. Journal of Bone and Mineral Research: The Official Journal of the American Society for Bone and Mineral Research, 8(5), 597–605. http://doi.org/10.1002/jbmr.5650080511
: Mehler, P. S., Sabel, A. L., Watson, T., & Andersen, A. E. (2008). High risk of osteoporosis in male patients with eating disorders. International Journal of Eating Disorders, 41(7), 666–672. http://doi.org/10.1002/eat.20554
: Miller, K. K., Grinspoon, S. K., Ciampa, J., Hier, J., Herzog, D., & Klibanski, A. (2005). Medical findings in outpatients with anorexia nervosa. Archives of Internal Medicine, 165(5), 561–566. http://doi.org/10.1001/archinte.165.5.561
: Miller, K. K., Lee, E. E., Lawson, E. A., Misra, M., Minihan, J., Grinspoon, S. K., … Klibanski, A. (2006). Determinants of skeletal loss and recovery in anorexia nervosa. The Journal of Clinical Endocrinology and Metabolism, 91(8), 2931–2937. http://doi.org/10.1210/jc.2005-2818
: Misra, M., Katzman, D. K., Cord, J., Manning, S. J., Mendes, N., Herzog, D. B., … Klibanski, A. (2008). Bone metabolism in adolescent boys with anorexia nervosa. The Journal of Clinical Endocrinology and Metabolism, 93(8), 3029–3036. http://doi.org/10.1210/jc.2008-0170
: Rigotti, N. A., Neer, R. M., Skates, S. J., Herzog, D. B., & Nussbaum, S. R. (1991). The clinical course of osteoporosis in anorexia nervosa. A longitudinal study of cortical bone mass. JAMA, 265(9), 1133–1138.
: Ross, A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., … Shapses, S. A. (2011). The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know. The Journal of Clinical Endocrinology & Metabolism, 96(1), 53–58. http://doi.org/10.1210/jc.2010-2704
: Soyka, L. A., Misra, M., Frenchman, A., Miller, K. K., Grinspoon, S., Schoenfeld, D. A., & Klibanski, A. (2002). Abnormal bone mineral accrual in adolescent girls with anorexia nervosa. The Journal of Clinical Endocrinology and Metabolism, 87(9), 4177–4185. http://doi.org/10.1210/jc.2001-011889
: Waugh, E. J., Woodside, D. B., Beaton, D. E., Coté, P., & Hawker, G. A. (2011). Effects of exercise on bone mass in young women with anorexia nervosa. Medicine and Science in Sports and Exercise, 43(5), 755–763. http://doi.org/10.1249/MSS.0b013e3181ff3961
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Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on April 14, 2016
Published on EatingDisorderHope.com