ReviewSkeletal complications of eating disorders
Introduction
Anorexia nervosa (AN) is a psychiatric illness with profound medical consequences. Among the many adverse physical sequelae of AN, bone health is impacted by starvation and can be permanently impaired over the course of the illness [1], [2], [3]. In this review of skeletal complications associated with eating disorders, we discuss both screening and treatment considerations. The focus of the review is the skeletal sequelae associated with anorexia nervosa, but we also briefly consider other eating disorders that may afflict adolescents and young adults. (See Fig. 1.)
Section snippets
Epidemiology
Undernutrition is the primary cause of compromised bone health in AN. However, there are other factors that contribute to diminished bone mass and skeletal strength in this population. Lifestyle choices can be detrimental to bone health, including low physical activity, excess caffeine and/or carbonated beverages, a strict vegetarian diet, high salt diet, and regular cigarette or alcohol use [4], [5]. In addition, genetics explain approximately three quarters of skeletal phenotypic variance, an
Neuroendocrine Changes in Anorexia Nervosa
In the setting of prolonged nutritional restriction, multiple endocrine systems are negatively impacted, and hormonal regulation is altered to preserve essential body functions.
Adolescent vs. Adult Skeletal Considerations
Although bone mineral accumulation takes place throughout childhood, much of the overall growth in skeletal structure occurs during the second decade of life. An estimated 26% of calcium deposition present in adults is established in early adolescence, with peak rates occurring at 12.5 years for girls and 14.0 years for boys [36]; most skeletal growth is complete by early in the third decade of life with the achievement of peak bone mass [4]. Thus, establishment of healthy bones and attainment of
Cartilage
To our knowledge, no studies to date have examined the direct effect of an eating disorder on the risk of sustaining a cartilaginous injury. However, several reports have examined components of the female athlete triad, such as menstrual irregularity on risk of musculoskeletal injuries, which have included anterior cruciate ligament (ACL) tears, patellofemoral disorders, and other diagnoses [43]. One study examined the difference in serum concentrations of testosterone, 17-β estradiol and
Screening for Bone Health
Any individual with an eating disorder, and in particular AN, should be considered at risk for poor bone health. The initial evaluation of bone health in an individual with AN includes a thorough history, exploring the extent of the patient’s nutritional deficiency, past orthopedic injury, and careful review of dietary intake. Genetics is an important determinant of bone health [4]; thus an assessment of family history for fracture or osteoporosis can help to identify AN patients at
Treatment Considerations
Treatment of eating disorders is best accomplished by an interdisciplinary team of experienced providers. Eating disorders are primarily psychiatric illnesses and thus long-term recovery will only be achieved through intensive therapeutic intervention by an experienced therapist. The goal of therapy is to address underlying body dissatisfaction, which motivates the eating disordered patient’s under-nourished state. For some patients, psychopharmacology may play an important role in treating
Future Directions and Considerations
Bone health in individuals with AN may deteriorate substantially during the course of this debilitating disease. Threats to skeletal health can be minimized with early identification of illness, aggressive weight restoration, and ongoing interdisciplinary management of the disease through psychiatric, medical, and nutritional support. However, new contributions to bone assessment technologies and both anabolic and anti-resorptive skeletal agents may help to preserve bone health during the
Authors' Contributions
Both authors materially contributed to the article preparation, and have approved the final article.
Conflict of Interest
The authors declare no conflicts of interest or financial disclosures.
Acknowledgements
Dr. Gordon is supported by NIH grant R01 AR060829.
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2022, BoneCitation Excerpt :Bone marrow composition is an important component of bone strength, as progenitors of osteoblasts and adipocytes are housed within bone marrow. Disordered eating behaviors has been described in transgender youth [5,6], and there is a known impact of restrictive eating on bone health [7,8]. Relative nutritional deficiency may contribute to diminished bone health in this population.
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2018, BoneCitation Excerpt :Increasing evidence suggests that bone marrow activity alternates between osteoblast and adipocyte formation [3,7,8]. Hormonal abnormalities likely mediate the preferential differentiation towards adipocytes, resulting in premature conversion from red marrow (RM) to yellow marrow (YM) and increased marrow fat [9]. Some work has focused on marrow fat composition, defined by relative levels of saturated and unsaturated fat, in adult women with AN [10] or osteoporosis [11,12] and has identified an inverse relationship between saturated fat content in marrow and bone mineral density (BMD).