Screening for osteoporosis in anorexia nervosa: prevalence and predictors of reduced bone mineral density

Absence of relationships between depression and anxiety and bone mineral density in patients hospitalized for severe anorexia nervosa

INTRODUCTION

Low BMD is frequent in anorexia nervosa (AN), depression, and during SSRI treatment but relation between these elements in AN is not established. The aims of this study were to assess the relationships between depression and anxiety, SSRI prescription, and (1) low BMD during inpatient treatment and (2) BMD change 1 year after hospital discharge.

METHODS

From 2009 to 2011, 212 women with severe AN have been included in the EVHAN study (EValuation of Hospitalisation for AN). Depression, anxiety and obsessive-compulsive symptoms and comorbidity were evaluated using psychometric scales and CIDI-SF. BMD was measured by dual-energy X-ray absorptiometry.

RESULTS

According to the CIDI-SF, 56% of participants (n = 70) had a lifetime major depressive disorder, 27.2% (n = 34) had a lifetime obsessive-compulsive disorder, 32.8% (n = 41) had a lifetime generalized anxiety disorder and 25.6% (n = 32) had a lifetime social phobia disorder. Half of the sample (50.7%; n = 72) had a low BMD (Z score ≤ - 2). In multivariate analysis, lifetime lowest BMI was the only determinant significantly associated with low BMD (OR = 0.56, p = 0.0008) during hospitalization. A long duration of AN (OR = 1.40 (0.003-3.92), p = 0.03), the AN-R subtype (OR = 4.95 (1.11-26.82), p = 0.04), an increase of BMI between the admission and 1 year (OR = 1.69 (1.21-2.60), p = 0.005) and a gain of BMD 1 year after the discharge explained BMD change.

CONCLUSION

We did not find any association between depression and anxiety or SSRI treatment and a low BMD or variation of BMD.

LEVEL OF EVIDENCE

Level III, cohort study.

Assessment of fracture risk in women with eating disorders: The utility of dual-energy x-ray absorptiometry (DXA)-Clinical cohort study

OBJECTIVE

Eating disorders (EDs) are associated with decreased bone mineral density (BMD) and increased fracture risk. The association between BMD and fracture risk in EDs is not well elucidated. We aimed to assess BMD in an ED cohort of patients with active disease and patients in remission, and to assess the predictive value of BMD on incidence of fractures.

METHOD

We included 344 female patients (median age 19, IQR 16; 24) referred to ED treatment. Later, patients were invited to follow-up including assessment of remission status and a dual-energy x-ray absorptiometry (DXA)-scan. Information on fractures was obtained through the Danish National Registry of Patients.

RESULTS

Patients with current anorexia nervosa (AN) had significantly lower BMD compared to controls at lumbar spine (16% lower, p < .0001), femoral neck (18% lower, p < .0001), and total hip (23% lower, p < .0001). Recovered AN patients had higher BMD compared to those with current disease (p < .0001 for all measures), but lower BMD compared to controls at lumbar spine (p < .01) and hip (p < .001). BMD did not differ between BN patients and controls. In patients with active eating disorders not otherwise specified, BMD was lower only at the total hip (p < .005). We found no association between BMD and fracture risk.

CONCLUSION

We confirm that AN is associated with low BMD, whereas BN is not. Remission is associated with higher BMD compared to patients with active AN, but a deficit remains. We found no significant association between BMD and fracture risk, challenging the benefit of the widespread use of DXA scans in young women with ED.

CLINICAL TRIAL REGISTRATION

The study is registered in ClinicalTrials.gov, number NCT00267228.

Predictors of outcomes in outpatients with anorexia nervosa - Results from the ANTOP study

This study aimed to determine predictors of BMI and recovery for outpatients with anorexia nervosa (AN). Patients were participants of the ANTOP (Anorexia Nervosa Treatment of Out-Patients) trial and randomized to focal psychodynamic therapy (FPT), enhanced cognitive behavior therapy (CBT-E), or optimized treatment as usual (TAU-O). N=169 patients participated in the one-year follow-up (T4). Outcomes were the BMI and global outcome (recovery/partial syndrome/full syndrome) at T4. We examined the following baseline variables as possible predictors: age, BMI, duration of illness, subtype of AN, various axis I diagnoses, quality of life, self-esteem, and psychological characteristics relevant to AN. Linear and logistic regression analyses were conducted to identify the predictors of the BMI and global outcome. The strongest positive predictor for BMI and recovery at T4 was a higher baseline BMI of the patients. Negative predictors for BMI and recovery were a duration of illness >6 years and a lifetime depression diagnosis at baseline. Additionally, higher bodily pain was significantly associated with a lower BMI and self-esteem was a positive predictor for recovery at T4. A higher baseline BMI and shorter illness duration led to a better outcome. Further research is necessary to investigate whether or not AN patients with lifetime depression, higher bodily pain, and lower self-esteem may benefit from specific treatment approaches.

Diets High in Fiber and Vegetable Protein Are Associated with Low Lumbar Bone Mineral Density in Young Athletes with Oligoamenorrhea

BACKGROUND

Associations of bone mineral density (BMD) with specific food components, including dietary fiber and isoflavones (that have a negative association with serum estrogen), are unclear and need to be determined, particularly in populations more likely to consume large amounts of these nutrients (such as young athletes).

OBJECTIVE

To determine dietary intake of specific food components in athletes with oligoamenorrhea (OA) compared to athletes with eumenorrhea (EA) and nonathletes (NA), and associations of the dietary intake of these nutrients with lumbar spine BMD.

DESIGN AND SUBJECTS

This cross-sectional study evaluated 68 OA, 24 EA, and 26 NA individuals aged 14 to 23 years. Measurements included 4-day food records, a dual x-ray absorptiometry scan evaluating lumbar spine BMD and body composition, and hormone levels. Multivariate analysis was used to estimate associations of nutrients with lumbar spine BMD.

RESULTS

Compared with EA and NA, OA had higher intake of fiber, phytic acid, and vegetable protein (all P values <0.0001). Intake of isoflavones, genistein, and daidzein was higher in OA than NA (P=0.003 and P=0.0002, respectively). OA had lower consumption of energy from saturated fatty acids than NA (P=0.002). After controlling for confounders such as body weight, menstrual status (indicative of estrogen status), calcium intake, and serum vitamin D (known BMD determinants), lumbar spine BMD z scores were inversely associated with dietary fiber (β=-.30; P=0.01), vegetable protein (β= -.28; P=0.02), phytic acid (β=-.27; P=0.02), genistein (β=-.25; P=0.01), and daidzein (β=-.24; P=0.01), and positively associated with percent energy from fatty acids (β=.32; P=0.0006).

CONCLUSIONS

Compared with EA and NA, OA had a higher dietary intake of fiber, vegetable protein, and phytic acid, which were inversely associated with lumbar spine BMD z scores. Further studies are needed to assess dietary recommendations for OA to optimize bone accrual.

Bone disease in anorexia nervosa

Anorexia nervosa is a serious psychiatric disorder accompanied by high morbidity and mortality. It is characterized by emaciation due to self-starvation and displays a unique hormonal profile. Alterations in gonadal axis, growth hormone resistance with low insulin-like growth factor I levels, hypercortisolemia and low triiodothyronine levels are almost universally present and constitute an adaptive response to malnutrition. Bone metabolism is likewise affected resulting in low bone mineral density, reduced bone accrual and increased fracture risk. Skeletal deficits often persist even after recovery from the disease with serious implications for future skeletal health. The pathogenetic mechanisms underlying bone disease are quite complicated and treatment is a particularly challenging task.

Medical findings in women with anorexia nervosa in a korean population

OBJECTIVE

Eating disorders are a common clinical problem among young women in Asian countries. The aim of this study is to determine the medical effects of anorexia nervosa (AN) in the Korean population.

METHODS

We comprehensively investigated medical complications including haemodynamic, haematologic, endocrine, and bone density abnormalities in 67 Korean women with AN, together with 194 healthy Korean women of comparable age with a cross-sectional design.

RESULTS

In AN, 36.9% were anaemic, 50.8% were leukopenic, 35.5% were hypoproteinemic, 7.9% were hypokalemic, 9.5% had increased alanine aminotransferase, 6.3% were hyperbilirubinemia, 14.5% were hypercholesterolemia, 14.8% had decreased triiodothyronine. Osteopenia at any one site was identified in 43.3% and an additional 13.4% had osteoporosis. The lowest-ever body mass index was the main determinant of bone mineral density.

CONCLUSION

Our data in Korean patients with AN show high frequencies of laboratory abnormalities for medical complications. This study emphasizes the importance of recognizing AN as a medical risk in young Korean women.

Two diagnoses become one? Rare case report of anorexia nervosa and Cushing's syndrome

Hypothalamic-pituitary-adrenal axis impairment in anorexia nervosa is marked by hypercortisolemia, and psychiatric disorders occur in the majority of patients with Cushing's syndrome. Here we report a patient diagnosed with anorexia nervosa who also developed Cushing's syndrome. A 26-year-old female had been treated for anorexia nervosa since she was 17 years old, and also developed depression and paranoid schizophrenia. She was admitted to the Department of Endocrinology, Metabolism, and Internal Medicine with a preliminary diagnosis of Cushing's syndrome. Computed tomography revealed a 27 mm left adrenal tumor, and she underwent laparoscopic adrenalectomy. She was admitted to hospital 6 months after this procedure, at which time she did not report any eating or mood disorder. This is a rare case report of a patient with anorexia nervosa in whom Cushing's syndrome was subsequently diagnosed. Diagnostic difficulties were caused by the signs and symptoms presenting in the course of both disorders, ie, hypercortisolemia, osteoporosis, secondary amenorrhea, striae, hypokalemia, muscle weakness, and depression.

The clinical biochemistry of anorexia nervosa

In anorexia nervosa, under-nutrition and weight regulatory behaviours such as vomiting and laxative abuse can lead to a range of biochemical problems. Hypokalaemia is the most common electrolyte abnormality. Metabolic alkalosis occurs in patients who vomit or abuse diuretics and acidosis in those misusing laxatives. Hyponatraemia is often due to excessive water ingestion, but may also occur in chronic energy deprivation or diuretic misuse. Urea and creatinine are generally low and normal concentrations may mask dehydration or renal dysfunction. Abnormalities of liver enzymes are predominantly characterized by elevation of aminotransferases, which may occur before or during refeeding. The serum albumin is usually normal, even in severely malnourished patients. Amenorrhoea is due to hypogonadotrophic hypogonadism. Reduced concentrations of free T4 and free T3 are frequently reported and T4 is preferentially converted to reverse T3. Cortisol is elevated but the response to adrenocorticotrophic hormone is normal. Hypoglycaemia is common. Hypercholesterolaemia is a common finding but its significance for cardiovascular risk is uncertain. A number of micronutrient deficiencies can occur. Other abnormalities include hyperamylasaemia, hypercarotenaemia and elevated creatine kinase. There is an increased prevalence of eating disorders in type 1 diabetes and the intentional omission of insulin is associated with impaired metabolic control. Refeeding may produce electrolyte abnormalities, hyper- and hypoglycaemia, acute thiamin depletion and fluid balance disturbance; careful biochemical monitoring and thiamin replacement are therefore essential during refeeding. Future research should address the management of electrolyte problems, the role of leptin and micronutrients, and the possible use of biochemical markers in risk stratification.

Severe anorexia nervosa: outcomes from a medical stabilization unit

OBJECTIVE

We report data from the medical stabilization and refeeding of patients with severe anorexia nervosa admitted over a 15-month period.

METHOD

Through chart review and computerized data collection, we evaluated demographic and clinical data from 25 consecutive patients admitted to our medical stabilization unit from October 2008 to January 2010.

RESULTS

In this adult-patient population with a median body mass index (BMI) of 13.1 kg/m(2) (interquartile range, 11.0-14.4), 44% developed hypoglycemia, 76% had abnormal liver function, 83% had abnormal bone density, 45% developed refeeding hypophosphatemia, and 92% were hypothermic. Severe liver function abnormality predicted the development of hypoglycemia (p = 0.02, OR 9.78, CI: 1.55-61.65). No clinical features predicted hypophosphatemia, including admission BMI (p = 0.19), serum glucose level (p = 0.21), elevated liver function tests (p = 0.39 for AST), or initial amount of kilocalories consumed (p = 0.06).

DISCUSSION

Patients with the most severe cases of anorexia nervosa have a high prevalence of serious medical complications during initial refeeding.

Osteoporosis in anorexia nervosa

Osteoporosis is common in anorexia nervosa. It places these patients at increased lifetime risk for fractures. Bone loss may never recover completely even once weight is restored. The strongest predictors of osteoporosis include low body weight and amenorrhea. Loss of bone density can occur rapidly and very early in the course of anorexia nervosa. The etiology of bone loss in the patient with anorexia nervosa is multifactorial. In addition to reduced estrogen and progesterone, excess cortisol levels and low levels of insulin growth factor (IGF-1), a correlate for bone formation, are observed. Dual energy x-ray absorptiometry screening is important to assess bone density. However, successful treatments to reverse bone loss, in those with anorexia nervosa, are lacking. Early diagnosis and treatment of anorexia nervosa are paramount to prevent initial weight loss and subsequent loss of bone.

Bone mineral density in partially recovered early onset anorexic patients - a follow-up investigation

BACKGROUND AND AIMS

There still is a lack of prospective studies on bone mineral development in patients with a history of early onset Anorexia nervosa (AN). Therefore we assessed associations between bone mass accrual and clinical outcomes in a former clinical sample. In addition to an expected influence of regular physical activity and hormone replacement therapy, we explored correlations with nutritionally dependent hormones.

METHODS

3-9 years (mean 5.2 +/- 1.7) after hospital discharge, we re-investigated 52 female subjects with a history of early onset AN. By means of a standardized approach, we evaluated the general outcome of AN. Moreover, bone mineral content (BMC) and bone mineral density (BMD) as well as lean and fat mass were measured by dual-energy x-ray absorptiometry (DXA). In a substudy, we measured the serum concentrations of leptin and insulin-like growth factor-I (IGF-I).

RESULTS

The general outcome of anorexia nervosa was good in 50% of the subjects (BMI >/= 17.5 kg/m2, resumption of menses). Clinical improvement was correlated with BMC and BMD accrual (chi2 = 5.62/chi2 = 6.65, p = 0.06 / p = 0.036). The duration of amenorrhea had a negative correlation with BMD (r = -.362; p < 0.01), but not with BMC. Regular physical activity tended to show a positive effect on bone recovery, but the effect of hormone replacement therapy was not significant. Using age-related standards, the post-discharge sample for the substudy presented IGF-I levels below the 5th percentile. IGF-I serum concentrations corresponded to the general outcome of AN. By contrast, leptin serum concentrations showed great variability. They correlated with BMC and current body composition parameters.

CONCLUSIONS

Our results from the main study indicate a certain adaptability of bone mineral accrual which is dependent on a speedy and ongoing recovery. While leptin levels in the substudy tended to respond immediately to current nutritional status, IGF-I serum concentrations corresponded to the individual's age and general outcome of AN.

Association of macrophage inhibitory cytokine-1 with nutritional status, body composition and bone mineral density in patients with anorexia nervosa: the influence of partial realimentation

Background

Macrophage inhibitory cytokine-1 (MIC-1) is a key inducer of cancer-related anorexia and weight loss. However, its possible role in the etiopathogenesis of nutritional disorders of other etiology such as anorexia nervosa (AN) is currently unknown.

Methods

We measured fasting serum concentrations of MIC-1 in patients with AN before and after 2-month nutritional treatment and explored its relationship with nutritional status, metabolic and biochemical parameters. Sixteen previously untreated women with AN and twenty-five normal-weight age-matched control women participated in the study. We measured serum concentrations of MIC-1 and leptin by ELISA, free fatty acids by enzymatic colorimetric assay, and biochemical parameters by standard laboratory methods; determined resting energy expenditure by indirect calorimetry; and assessed bone mineral density and body fat content by dual-energy X-ray absorptiometry. ANOVA, unpaired t-test or Mann-Whitney test were used for groups comparison as appropriate. The comparisons of serum MIC-1 levels and other studied parameters in patients with AN before and after partial realimentation were assessed by paired t-test or Wilcoxon Signed Rank Test as appropriate.

Results

At baseline, fasting serum MIC-1 concentrations were significantly higher in patients with AN relative to controls. Partial realimentation significantly reduced serum MIC-1 concentrations in patients with AN but it still remained significantly higher compared to control group. In AN group, serum MIC-1 was inversely related to Buzby nutritional risk index, serum insulin-like growth factor-1, serum glucose, serum total protein, serum albumin, and lumbar bone mineral density and it significantly positively correlated with the duration of AN and age.

Conclusions

MIC-1 concentrations in AN patients are significantly higher relative to healthy women. Partial realimentation significantly decreased MIC-1 concentration in AN group. Clinical significance of these findings needs to be further clarified.

Laboratory parameters and appetite regulators in patients with anorexia nervosa

Anorexia nervosa (AN) has serious negative effects on multiple organs and systems of the human body. As patients often do not make their eating disorder the subject of discussion, the physician is forced to rely on the physical examination and laboratory parameters as diagnostic hints. Obvious signs of AN are a body mass index (BMI) below 17.5 kg/m, dry and scaly skin, lanugo, edema, acrocyanosis, petechias, dental problems, and low blood pressure. However, because the often complex laboratory alterations can be difficult for the general psychiatrist to interpret, this article presents some useful guidelines. The plasma of patients with AN often shows alterations in laboratory parameters and appetite regulators, including electrolytes, liver enzymes, leukocyte count, hemoglobin (Hb), leptin, neuropeptide Y (NPY), triiodothyronine (T3), follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen, ghrelin, pancreatic polypeptide (PP), tumor necrosis factor-alpha (TNF-alpha), and cortisol. Medical problems secondary to AN or due to the treatment itself may lead to further laboratory abnormalities. To date, despite these associated laboratory alterations, the diagnosis of anorexia is a clinical one, based on weight and specific psychopathology.

Exercise-induced amenorrhea and bone health in the adolescent athlete

Female participation in high school athletics has increased 800% in the last 30 years. The problem of exercise-induced amenorrhea was initially thought to be analogous to hypoestrogenism, but recent studies suggest that nutritional issues underlie most of the pathophysiology and that the mechanism is different from that seen in the primary hypogonadal state. Exercise-induced amenorrhea can be an indicator of an energy drain, and the presence of the other components of the female athlete triad-bone density loss and eating disorders-must be determined as well. Addressing skeletal problems related to nutritional and hormonal deficiencies in this population is of very high priority.