Elsevier

Metabolism

Volume 64, Issue 9, September 2015, Pages 943-951
Metabolism

Review
Skeletal complications of eating disorders

https://doi.org/10.1016/j.metabol.2015.06.007Get rights and content

Abstract

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. In this review of skeletal complications associated with eating disorders, we discuss the epidemiology, neuroendocrine changes, adolescent vs. adult skeletal considerations, orthopedic concerns, assessment of bone health, and treatment options for individuals with AN. 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. The review presents updates to the field of bone health in AN, and also suggests knowledge gaps and areas for future investigation.

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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