Eating disorders are complicated illnesses that come with significant morbidity and mortality.
Eating disorders put individuals at risk for many medical complications, including electrolyte disorders, dehydration, chronic nausea, and delayed gastric empting. These tend to be transient and normalize with weight restoration and eating disorder treatment.
Another medical complication that can occur with eating disorders is bone loss. This occurs as a result of being underweight for long periods of time.
Bone loss and eating disorders
Patients with anorexia nervosa, restricting subtype and purging subtype, are at particularly high risk for bone loss because weight loss puts them far below their ideal body weight.
Being underweight causes women to stop menstruating due to underproduction of endogenous estrogen. Being underweight causes men to under-produce testosterone. These hormones are critical for bone health as they help to encourage the body to make normal healthy bone and to keep natural bone destruction under control.
Bone loss does not always improve with treatment. And, bone loss can have long-lasting and devastating effects — long after a patient is in recovery from their eating disorder.
Testing bone health
Bone health in patients with eating disorders is often overlooked by doctors, but the time to diagnosis is critical.
A patient’s loss of bone mineral density, or overall bone health, can be determined with an imaging study called a DEXA bone exam. This study typically examines bone density at the level of spine and hip and generates scores (z-scores) that are based on comparisons to the bones of same-aged healthy individuals.
Although women who are premenopausal are not typically given a definitive diagnosis, it can be inferred based on their z-scores that they are in one of these categories:
Normal
Osteopenia (mild to moderate thinning of the bones)
Osteoporosis (moderate to severe thinning of the bones)
Osteoporosis is not just a disease of our grandmothers. Osteoporosis is a serious condition that puts patients at risk for future fractures that can happen spontaneously (non-traumatic fractures) and cause significant loss of normal function.
Often, patients with non-traumatic fractures need complicated orthopedic surgeries, have ongoing chronic pain, and thus are limited in their abilities to lead normal lives. It’s not a matter to take lightly.
Treatment options
Currently, the best option to improve bone health in patients with eating disorders is weight restoration and (for females) resumption of menses. In females, this will raise endogenous estrogen production and improve bone deposition and maintenance.
For males, weight restoration alone typically normalizes testosterone levels and thus directly treats bone loss. (Younger men with eating disorders often have low blood testosterone levels). Supplementing with testosterone is a viable treatment option.
Medications can be used to treat osteoporosis, but only one is currently FDA-approved for the treatment of premenopausal osteoporosis.
Alendronate, a bisphosphonate, is taken orally once weekly, helping to reduce bone resorption and turnover.
Teriparatide is not yet FDA-approved for premenopausal women. In post-menopausal women, it has been shown to be an effective medication in treating bone loss. This medication works to both bolster the cells that build new bone and helps to slow the activity of the cells that break down bone. This medication effectively approaches osteoporosis of anorexia nervosa from two different vantage points. It is an intra-muscular injection that the patient self-administers daily.
Lastly, Denosumab is a medication that is an intra-muscular injection given every 6 months. It tends to be the most expensive of the three and is not yet approved for treating premenopausal osteoporosis.
Studies are ongoing on all three of these medications with the hope that all will be viable cost-effective choices for younger women with osteoporosis and anorexia nervosa.
On a side note, there is a myth that birth control pills can be used in females to “give back” lost estrogen and thus prevent bone loss in this at-risk population. This is false. Studies have shown that birth control pills are not effective for this use. Interestingly though, some studies are now showing that estrogen patches may play a beneficial role in the treatment of premenopausal bone loss.
Ongoing research and improved awareness among providers who care for patients with eating disorders are helping to ensure that recovery from eating disorders means true psychological and medical recovery and the hope of future lives well-lived.
Jennifer Watts, MD is the Medical Director of Outpatient Services for Eating Recovery Center.
The post Sticks and Stones: The Importance of Bone Health in Patients with Eating Disorders – Dr. Jennifer Watts appeared first on Eating Recovery Center.