Open Issues in Anorexia Nervosa

Abstract

Anorexia nervosa and diet-induced amenorrhea have an important impact not only on gynecological health but also on bone mass, especially if the disease is not promptly recognized and treated. This is particularly important because these conditions usually arise in adolescence, when peak bone mass is normally achieved. In this article we discuss the therapeutic issues related to bone loss associated with eating disorders.

Eating Disorders in the Obstetric and Gynecologic Patient Population

“…35 Fifty percent of adolescents with anorexia nervosa have low bone density, and bone health can also be impacted in other eating disorders, although studies have not been as consistent. 35,36 Unlike in menopausal bone loss where formation and resorption are both increased, bone resorption is increased but new bone formation is slow with eating disorders. Bone growth is impaired within the first year of anorexia nervosa diagnosis, and anorexia nervosa patients with more than 6 years of amenorrhea have a sevenfold risk of fracture compared with patients without anorexia nervosa.…”

“…Other treatment options for low bone density, including bisphosphonates, dehydroepiandrosterone, recombinant insulin-like growth factor-1, and recombinant leptin, are either experimental or not approved for use in premenopausal patients. 35,36,45 …”

“…Those with primary amenorrhea are at higher risk of fracture than those with secondary amenorrhea, and some studies suggest that anorexia nervosa can lead to permanent bone damage. 35,36 While there has been concern related to the effects of strenuous activity on bone density, studies have shown that regular weight-bearing activity actually increases the amount of bone mass gained during childhood, mainly at the bone sites which are trained. 37,38 Instead, the problem appears to be in young women in whom the combination of intensive training and inadequate energy intake lead to menstrual dysfunction.…”

“…Estrogen replacement may be partially protective of lumbar bone loss in girls who are severely underweight, but it should never be used in isolation. 36 Dietary supplementation of calcium and vitamin D may also be a necessary component of bone rehabilitation. 7,35,36 The Society for Adolescent Medicine supports the recommended daily allowance of 1,300 -1,500 mg/day for calcium and 400 international units/day for vitamin D in anorexia nervosa, although recent literature has highlighted the epidemic of vitamin D insufficiency in the United States and these recommendations may be subject to change.…”

“…36 Dietary supplementation of calcium and vitamin D may also be a necessary component of bone rehabilitation. 7,35,36 The Society for Adolescent Medicine supports the recommended daily allowance of 1,300 -1,500 mg/day for calcium and 400 international units/day for vitamin D in anorexia nervosa, although recent literature has highlighted the epidemic of vitamin D insufficiency in the United States and these recommendations may be subject to change. 7,44 Moderate weight-bearing exercise may be part of the treatment regimen if bone loss is not severe and if excessive exercise has not been part of the disease process.…”