Bone loss associated with anorexia nervosa

doi:10.1016/j.jbspin.2004.07.011

Joint Bone Spine

Volume 72, Issue 6, December 2005, Pages 489-495

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Abstract

The objective of this study was to evaluate the epidemiology, diagnosis, pathophysiology, and treatment of bone loss related to anorexia nervosa. Earlier onset and longer duration of anorexia nervosa are associated with more severe bone loss. Osteoporosis develops in 38–50% of cases. Bone mineral density measurement by dual-energy X-ray absorptiometry is useful for assessing bone mass, and bone marker assays provide information on bone turnover. Bone loss in anorexia nervosa is probably multifactorial. Estrogen deficiency was long felt to be the major factor. However, in contrast to postmenopausal osteoporosis, bone loss associated with anorexia nervosa is related mainly to inadequate bone formation, with only a slight increase in bone resorption. This suggests a role for nutritional factors, such as disturbances in the growth hormone–somatomedin C axis (GH/IGF-I) related to malnutrition. The best treatment strategy for correcting bone mass in patients with anorexia nervosa is not agreed on. Resumption of menstrual cycles and weight gain seem necessary but not always sufficient. Studies found no benefits with estrogen therapy, but this was usually given as estrogen–progestin contraceptives. No vast studies evaluating hormone replacement therapy have been reported. Bone formation enhancers such as IGF-I seem to provide the best results, most notably when used in combination with estrogens. This suggests that complex treatment strategies combining bone formation enhancers and bone resorption inhibitors may deserve evaluation.

Section snippets

Bone mineral density

Bone mass can be measured by absorptiometry at the spine and femoral neck. Radiation exposure is minimal with this method. The World Health Organization defines osteoporosis in postmenopausal women as a BMD value at least 2.5 S.Ds. below the mean in young women (T-score < −2.5 S.Ds.), at the spine, femoral neck or radius. This definition may be unsatisfactory in adolescents, who may not have achieved their peak bone mass. Studies comparing BMD values at various sites in patients with anorexia

Hormonal factors

A few studies investigated BMD changes in patients with anorexia nervosa [5], [11], [12], [20], [21]. The BMD values were significantly lower in the patients who were younger than 18 years at disease onset, illustrating the impact of anorexia nervosa on peak bone mass achievement. Amenorrhea is a diagnostic criterion for anorexia nervosa, and estrogen deficiency has been described as a major source of bone loss in this condition. The mechanisms underlying this estrogen deficiency remain

Changes in bone mass after weight regain

The BMD changes during recovery from anorexia nervosa have been investigated [3], [10], [12], [16], [20], [22], [24]. Although bone mass increased when weight returned to normal, several studies showed persistent osteopenia in a large proportion of patients [3], [10], [12], [16], [36]. Hartman et al. [37] studied bone mass at in 19 women with a history of anorexia nervosa followed by a full recovery for a mean of 21 years. Although their body weight was normal, their bone mass at the femoral

Weight regain and menstrual cycle recovery

These two factors improved bone mass in several studies [7], [10], [14], [22], [39] but were not sufficient in another study [12]. Although weight regain and menstrual cycle recovery seem to be prerequisites to bone mass gain, they do not allow a return to normal bone mass values.

Physical activity

Conflicting results have been reported [40]. Although physical activity is needed to achieve peak bone mass and to maintain bone stock in adulthood, its ability to protect against osteoporosis in patients with anorexia

Conclusion

Anorexia nervosa is associated with severe bone loss that must be looked for routinely by obtaining absorptiometry measurements of BMD. The mechanism is multifactorial and incompletely understood. Diminished bone formation may play a greater role than increased bone resorption. The best management is not agreed on. Oral contraceptives have been of little help. Hormone replacement therapy has not been investigated in large studies. Bone formation enhancers such as IGF-I may produce the best

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ReviewBone loss associated with anorexia nervosa

Abstract

Section snippets

Bone mineral density

Hormonal factors

Changes in bone mass after weight regain

Weight regain and menstrual cycle recovery

Physical activity

Conclusion

J. Psychiatr. Res.

J. Psychosom. Res.

Mayo Clin. Proc.

J. Adolesc. Health Care

J. Pediatr.

J. Pediatr. Adolesc. Gynecol.

Anorexia nervosa in female adolescents: endocrine and bone mineral density disturbances

Eur. J. Endoc.

Epidemiology of eating disorders

Psychiatric Clin North Am

Outcome of bone mineral density in anorexia nervosa patients 11,7 years after first admission

J. Bone Miner. Res.

Osteoporosis in eating disorders

Eur. Eat. Disord. Rev.

Prevalence and predictive factors for regional osteoporosis in women with anorexia nervosa

Ann. Intern. Med.

Peak bone mass

Osteoporos. Int.

Severity of osteopenia in oestrogen-deficient women with anorexia nervosa and hypothalamic amenorrhea

J. Clin. Endocrinol. Metab.

Mechanisms of osteoporosis in adult and adolescents women with anorexia nervosa

J. Clin. Endocrinol. Metab.

American Psychiatric Association practice guidelines for eating disorders

Am. J. Psychiatry

Recovery from osteopenia in adolescent girls with anorexia nervosa

J. Clin. Endocrinol. Metab.

The effects of anorexia nervosa on bone metabolism in female adolescents

J. Clin. Endocrinol. Metab.

Abnormal bone mineral accrual in adolescent girls with anorexia nervosa

J. Clin. Endocrinol. Metab.

Dissociation of bone turnover in anorexia nervosa

Ann. Clin. Biochem.

Osteoporosis and pathologic fractures in anorexia nervosa

Am. J. Psychiatry

Étude du retentissement osseux dans 33 cas d’anorexie mentale dont 8 avec une ostéoporose fracturaire

Rev. Rhum. Mal. Osteoart.

Medical findings and predictors of long-term physical outcome in anorexia nervosa: a prospective, 12-year follow-up study

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Osteoporosis in eating disorders: a follow-up study of patients with anorexia and bulimia nervosa

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On exposure to anorexia nervosa, the temporal variation in axial and appendicular skeletal development predisposes to site-specific deficits in bone size and density: a cross-sectional study

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Anorexia nervosa: slow regain of bone mass

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Review
Bone loss associated with anorexia nervosa