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Thavaraputta S, Ungprasert P, Witchel SF, Fazeli PK. Anorexia nervosa and adrenal hormones: a systematic review and meta-analysis. Eur J Endocrinol 2023; 189:S64-S73. [PMID: 37669399 PMCID: PMC10498414 DOI: 10.1093/ejendo/lvad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/02/2023] [Accepted: 08/08/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE Anorexia nervosa is a primary psychiatric disorder characterized by self-induced negative energy balance. A number of hormonal responses and adaptations occur in response to starvation and low body weight including changes in adrenocortical hormones. Our objective was to systematically review adrenocortical hormone levels in anorexia nervosa. DESIGN/METHODS We searched MEDLINE and EMBASE for studies that reported at least one adrenocortical hormone, including dehydroepiandrosterone (DHEA), DHEA-sulphate (DHEA-S), progesterone, 17-hydroxyprogesterone, pregnenolone, cortisol (serum, urine, cerebrospinal fluid, and hair sample), aldosterone, androstenedione, and testosterone in patients with anorexia nervosa and normal-weight healthy controls from inception until October 2021. Means and standard deviations for each hormone were extracted from the studies to calculate a mean difference (MD). A pooled MD was then calculated by combining MDs of each study using the random-effects model. RESULTS We included a total of 101 studies with over 2500 females with anorexia nervosa. Mean cortisol levels were significantly higher in anorexia nervosa as compared to normal-weight controls for multiple forms of measurement, including morning cortisol, 12-hour and 24-hour pooled serum cortisol, 24-hour urine cortisol, and after an overnight dexamethasone suppression test. In contrast, mean serum total testosterone and DHEA-S levels were significantly lower among patients with anorexia nervosa. CONCLUSIONS Women with anorexia nervosa have higher cortisol levels and lower DHEA-S and testosterone levels compared to women without anorexia nervosa. This finding is important to consider when evaluating low-weight women for disorders involving the adrenal axis, especially Cushing's syndrome.
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Affiliation(s)
- Subhanudh Thavaraputta
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University and Excellence Center in Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Selma F Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
| | - Pouneh K Fazeli
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
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2
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Lopes MP, Robinson L, Stubbs B, Dos Santos Alvarenga M, Araújo Martini L, Campbell IC, Schmidt U. Associations between bone mineral density, body composition and amenorrhoea in females with eating disorders: a systematic review and meta-analysis. J Eat Disord 2022; 10:173. [PMID: 36401318 PMCID: PMC9675098 DOI: 10.1186/s40337-022-00694-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 10/23/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lower bone mineral density (BMD) increases the risk of osteoporosis in individuals with eating disorders (EDs), particularly women with anorexia nervosa (AN), making them susceptible to pain and fractures throughout adulthood. In AN, low weight, hypothalamic amenorrhoea, and longer illness duration are established risk factors for low BMD, and in people with other EDs a history of AN seems to be an important risk factor for low BMD. PURPOSE To conduct a systematic review and meta-analysis of BMD in individuals with EDs, including AN, bulimia nervosa (BN), binge-eating disorder (BED) and other specified feeding or eating disorders (OSFED) compared to healthy controls (HC). METHODS Following PRISMA guidelines, electronic databases were reviewed and supplemented with a literature search until 2/2022 of publications measuring BMD (dual-energy X-ray absorptiometry or dual photon absorptiometry) in females with any current ED diagnosis and a HC group. Primary outcomes were spine, hip, femur and total body BMD. Explanatory variables were fat mass, lean mass and ED clinical characteristics (age, illness duration, body mass index (BMI), amenorrhoea occurrence and duration, and oral contraceptives use). RESULTS Forty-three studies were identified (N = 4163 women, mean age 23.4 years, min: 14.0, max: 37.4). No study with individuals with BED met the inclusion criteria. BMD in individuals with AN (total body, spine, hip, and femur), with BN (total body and spine) and with OSFED (spine) was lower than in HC. Meta-regression analyses of women with any ED (AN, BN or OSFED) (N = 2058) showed low BMI, low fat mass, low lean mass and being amenorrhoeic significantly associated with lower total body and spine BMD. In AN, only low fat mass was significantly associated with low total body BMD. CONCLUSION Predictors of low BMD were low BMI, low fat mass, low lean mass and amenorrhoea, but not age or illness duration. In people with EDs, body composition measurement and menstrual status, in addition to BMI, are likely to provide a more accurate assessment of individual risk to low BMD and osteoporosis.
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Affiliation(s)
- Mariana P Lopes
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil. .,Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.
| | - Lauren Robinson
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK
| | - Brendon Stubbs
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.,Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
| | - Marle Dos Santos Alvarenga
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil
| | - Ligia Araújo Martini
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil
| | - Iain C Campbell
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.,Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
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3
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Butler MGK, Ambrosi TH, Murphy MP, Chan CKF. Aging of Skeletal Stem Cells. ADVANCES IN GERIATRIC MEDICINE AND RESEARCH 2022; 4:e220006. [PMID: 36037035 PMCID: PMC9409336 DOI: 10.20900/agmr20220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The skeletal system is generated and maintained by its progenitors, skeletal stem cells (SSCs), across the duration of life. Gradual changes associated with aging result in significant differences in functionality of SSCs. Declines in bone and cartilage production, increase of bone marrow adipose tissue, compositional changes of cellular microenvironments, and subsequent deterioration of external and internal structures culminate in the aged and weakened skeleton. The features and mechanisms of skeletal aging, and of its stem and progenitor cells in particular, are topics of recent investigation. The discovery of functionally homogeneous SSC populations with a defined cell surface phenotype has allowed for closer inspection of aging in terms of its effects on transcriptional regulation, cell function, and identity. Here, we review the aspects of SSC aging on both micro- and macroscopic levels. Up-to-date knowledge of SSC biology and aging is presented, and directions for future research and potential therapies are discussed. The realm of SSC-mediated bone aging remains an important component of global health and a necessary facet in our understanding of human aging.
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Affiliation(s)
- M. Gohazrua K. Butler
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Thomas H. Ambrosi
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Matthew P. Murphy
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Charles K. F. Chan
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
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4
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Hung C, Muñoz M, Shibli-Rahhal A. Anorexia Nervosa and Osteoporosis. Calcif Tissue Int 2022; 110:562-575. [PMID: 33666707 DOI: 10.1007/s00223-021-00826-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/14/2021] [Indexed: 12/12/2022]
Abstract
Patients with anorexia nervosa (AN) often experience low bone mineral density (BMD) and increased fracture risk, with low body weight and decreased gonadal function being the strongest predictors of the observed bone mineral deficit and fractures. Other metabolic disturbances have also been linked to bone loss in this group of patients, including growth hormone resistance, low insulin-like growth factor-1 (IGF-1) concentrations, low leptin concentrations, and hypercortisolemia. However, these correlations lack definitive evidence of causality. Weight restoration and resumption of menstrual function have the strongest impact on increasing BMD. Other potential treatment options include bisphosphonates and teriparatide, supported by data from small clinical trials, but these agents are not approved for the treatment of low BMD in adolescents or premenopausal women with AN.
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Affiliation(s)
- Chermaine Hung
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Marcus Muñoz
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Amal Shibli-Rahhal
- Division of Endocrinology, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
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5
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Estrogen for the Treatment of Low Bone Mineral Density in Anorexia Nervosa. JOURNAL OF PSYCHIATRY AND BRAIN SCIENCE 2022; 7. [PMID: 35874115 PMCID: PMC9302594 DOI: 10.20900/jpbs.20220004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anorexia nervosa is a disorder of chronic, self-induced negative energy balance which typically results in a low body weight. Functional hypothalamic amenorrhea is an adaptive response to states of negative energy balance and chronic undernutrition. A majority of women with anorexia nervosa are amenorrheic with resultant hypoestrogenemia, and longer durations of amenorrhea are associated with lower bone mineral density in this population. In this review, we highlight studies that have investigated the effects of estrogen replacement on bone mineral density in anorexia nervosa, including prospective and randomized studies that show no benefit to treatment with oral estrogen with respect to bone mineral density in either adolescent girls or women with anorexia nervosa. We also review data from a randomized, placebo-controlled study in adolescent girls and a prospective, open-label pilot study in women with anorexia nervosa suggesting that transdermal estrogen may have beneficial effects with respect to bone mineral density in this population.
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6
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Merki-Feld GS, Bitzer J. Contraception in adolescents with anorexia nervosa. Is there evidence for a negative impact of combined hormonal contraceptives on bone mineral density and the course of the disease? EUR J CONTRACEP REPR 2020; 25:213-220. [PMID: 32336145 DOI: 10.1080/13625187.2020.1743826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective: Adolescents with anorexia nervosa (AN) are at increased risk of unplanned pregnancies and bone loss, due to low oestrogen levels and low use of efficient contraception. The negative impact of combined hormonal contraceptives (CHC) on peak bone mass during adolescence might limit wider use in anorexic women. Another issue limiting CHC use is the concern, that CHC-induced cyclic bleeding reduces the motivation for further weight gain and thus exerts a negative impact on recovery. We wanted to find evidence based answers about the impact of CHC use on bone health and course of the disease in adolescents with AN.Methods: We performed a narrative review of the current literature investigating the effect of CHC or progestin-only contraceptives on bone density, body shape and course of disease in young women with anorexia.Results: There is no evidence that CHC use aggravates the bone loss associated with AN. In long-term users CHC exert a protective effect. Anorexic women using CHC showed at least the same or a greater weight gain in comparison with controls. Eating disorder attitudes did not worsen.Conclusion: We conclude, that at present there is no evidence, that use of CHC by AN patients has a negative impact on bone density or the course of disease.
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Affiliation(s)
| | - Johannes Bitzer
- Department of Obstetrics and Gynaecology, Basel University Hospital, Basel, Switzerland
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7
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Lenherr-Taube N, Trajcevski K, Sochett E, Katzman DK. Low PTH Levels in Adolescents With Anorexia Nervosa. Front Pediatr 2020; 8:99. [PMID: 32219087 PMCID: PMC7078244 DOI: 10.3389/fped.2020.00099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Patients with anorexia nervosa (AN) experience medical complications including impaired bone metabolism, increased fracture rate, kidney stones and chronic renal failure. However, the mechanisms of such complications are not fully understood. Healthy adolescents have been shown to have higher PTH levels when compared with pre-pubertal children and adults. Given the importance of central measures of calcium and vitamin D metabolism in bone and kidney health, 25-hydroxyvitamin D (25OHD) and parathyroid hormone (PTH) have been extensively investigated in patients with AN, however none of the previous studies accounted for age-specific reference ranges for PTH. The aim of this study was to investigate central measures of calcium and vitamin D metabolism in adolescents with newly diagnosed AN using age-specific reference ranges and to determine whether any significant abnormalities required further study. Methods: This was a cross-sectional study of 61 adolescents (mean age = aged 15.2 ± 1.56 years) with newly diagnosed AN, referred to a tertiary center over a period of 2 years. Demographic, auxiological, and nutrient (vitamin D and calcium) intake data was obtained. Central measures of calcium and vitamin D metabolism in blood and urine were investigated. PTH results were compared with age-specific reference ranges from the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER). Descriptive statistics and correlation analysis were performed. Results: Low PTH levels were observed in 35% of the cohort. Overall, serum calcium, phosphate and 25OHD were within the reference range. Using loess curves, PTH had a significant negative and non-linear correlation with 25OHD with an inflection point at a 25OHD level of 100 nmol/l, above which the association was no longer present. Correlation analysis did not show a significant association between PTH and total or corrected serum calcium, urine calcium/creatinine (Ca/Cr) ratio, total dietary calcium intake, magnesium or Tanner staging. Conclusion: PTH levels were reduced in approximately a third of adolescents with AN. This observation has not been reported given the universal usage of reference ranges that covers all ages. This finding may unmask a potential role for reduced PTH levels in the pathogenesis of kidney stones and bone phenotype in patients with AN.
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Affiliation(s)
- Nina Lenherr-Taube
- Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Karin Trajcevski
- Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Etienne Sochett
- Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Debra K Katzman
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Division of Adolescent Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada
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8
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McGrath C, Sankaran JS, Misaghian‐Xanthos N, Sen B, Xie Z, Styner MA, Zong X, Rubin J, Styner M. Exercise Degrades Bone in Caloric Restriction, Despite Suppression of Marrow Adipose Tissue (MAT). J Bone Miner Res 2020; 35:106-115. [PMID: 31509274 PMCID: PMC6980282 DOI: 10.1002/jbmr.3872] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 08/13/2019] [Accepted: 08/30/2019] [Indexed: 01/06/2023]
Abstract
Marrow adipose tissue (MAT) and its relevance to skeletal health during caloric restriction (CR) is unknown: It remains unclear whether exercise, which is anabolic to bone in a calorie-replete state, alters bone or MAT in CR. We hypothesized that response of bone and MAT to exercise in CR differs from the calorie-replete state. Ten-week-old female B6 mice fed a regular diet (RD) or 30% CR diet were allocated to sedentary (RD, CR, n = 10/group) or running exercise (RD-E, CR-E, n = 7/group). After 6 weeks, CR mice weighed 20% less than RD, p < 0.001; exercise did not affect weight. Femoral bone volume (BV) via 3D MRI was 20% lower in CR versus RD (p < 0.0001). CR was associated with decreased bone by μCT: Tb.Th was 16% less in CR versus RD, p < 0.003, Ct.Th was 5% less, p < 0.07. In CR-E, Tb.Th was 40% less than RD-E, p < 0.0001. Exercise increased Tb.Th in RD (+23% RD-E versus RD, p < 0.003) but failed to do so in CR. Cortical porosity increased after exercise in CR (+28%, p = 0.04), suggesting exercise during CR is deleterious to bone. In terms of bone fat, metaphyseal MAT/ BV rose 159% in CR versus RD, p = 0.003 via 3D MRI. Exercise decreased MAT/BV by 52% in RD, p < 0.05, and also suppressed MAT in CR (-121%, p = 0.047). Histomorphometric analysis of adipocyte area correlated with MAT by MRI (R2 = 0.6233, p < 0.0001). With respect to bone, TRAP and Sost mRNA were reduced in CR. Intriguingly, the repressed Sost in CR rose with exercise and may underlie the failure of CR-bone quantity to increase in response to exercise. Notably, CD36, a marker of fatty acid uptake, rose 4088% in CR (p < 0.01 versus RD), suggesting that basal increases in MAT during calorie restriction serve to supply local energy needs and are depleted during exercise with a negative impact on bone. © 2019 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
- Cody McGrath
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNCUSA
| | - Jeyantt S Sankaran
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNCUSA
| | - Negin Misaghian‐Xanthos
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNCUSA
| | - Buer Sen
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNCUSA
| | - Zhihui Xie
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNCUSA
| | - Martin A Styner
- Department of Computer ScienceUniversity of North CarolinaChapel HillNCUSA
- Department of PsychiatryUniversity of North CarolinaChapel HillNCUSA
| | - Xiaopeng Zong
- Biomedical Research Imaging CenterUniversity of North CarolinaChapel HillNCUSA
| | - Janet Rubin
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNCUSA
| | - Maya Styner
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNCUSA
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9
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Resulaj M, Polineni S, Meenaghan E, Eddy K, Lee H, Fazeli PK. Transdermal Estrogen in Women With Anorexia Nervosa: An Exploratory Pilot Study. JBMR Plus 2019; 4:e10251. [PMID: 31956852 PMCID: PMC6957987 DOI: 10.1002/jbm4.10251] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/29/2019] [Accepted: 11/04/2019] [Indexed: 01/10/2023] Open
Abstract
Anorexia nervosa (AN) is a psychiatric disorder characterized by self‐induced starvation, low body weight, and elevated levels of bone marrow adipose tissue (BMAT). BMAT is negatively associated with BMD in AN and more than 85% of women with AN have low bone mass and an increased risk of fracture. Although a majority of women with AN are amenorrheic, which is associated with low BMD, oral contraceptive pills, containing supraphysiologic doses of estrogen, are not effective in increasing bone mass. We performed a 6‐month, open‐label study of transdermal estradiol (0.045 mg/day) + levonorgestrel (0.015 mg/day) in 11 women with AN (mean age ± SEM: 37.2 ± 2.3 years) to investigate the effects of transdermal, physiologic doses of estrogen on BMD and BMAT in women with AN. We measured change in BMD by DXA, change in BMAT at the spine/hip by 1H‐magnetic resonance spectroscopy, and change in C‐terminal collagen cross‐links (CTX), P1NP, osteocalcin, IGF‐1, and sclerostin after 3 and 6 months of transdermal estrogen. Lumbar spine (2.0% ± 0.8%; p = 0.033) and lateral spine (3.2% ± 1.1%; p = 0.015) BMD increased after 6 months of transdermal estrogen. Lumbar spine BMAT decreased significantly after 3 months (−13.9 ± 6.0%; p = 0.046). Increases in lateral spine BMD were associated with decreases in CTX (p = 0.047). In conclusion, short‐term treatment with transdermal, physiologic estrogen increases spine BMD in women with AN. Future studies are needed to assess the long‐term efficacy of this treatment. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Megi Resulaj
- Neuroendocrine Unit Massachusetts General Hospital Boston MA USA
| | - Sai Polineni
- Neuroendocrine Unit Massachusetts General Hospital Boston MA USA
| | - Erinne Meenaghan
- Neuroendocrine Unit Massachusetts General Hospital Boston MA USA
| | - Kamryn Eddy
- Department of Psychiatry Massachusetts General Hospital Boston MA USA.,Harvard Medical School Boston MA USA
| | - Hang Lee
- Biostatistics Center Massachusetts General Hospital Boston MA USA.,Harvard Medical School Boston MA USA
| | - Pouneh K Fazeli
- Neuroendocrine Unit Massachusetts General Hospital Boston MA USA.,Harvard Medical School Boston MA USA.,University of Pittsburgh School of Medicine Pittsburgh PA USA
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10
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Legroux I, Cortet B. Factors influencing bone loss in anorexia nervosa: assessment and therapeutic options. RMD Open 2019; 5:e001009. [PMID: 31798952 PMCID: PMC6861073 DOI: 10.1136/rmdopen-2019-001009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
Decreased mineral density is one of the major complications of anorexia nervosa. The phenomenon is even more pronounced when the disease occurs during adolescence and when the duration of amenorrhoea is long. The mechanisms underlying bone loss in anorexia are complex. Oestrogen deficiency has long been considered as the main factor, but cannot explain the phenomenon on its own. The essential role of nutrition-related factors—especially leptin and adiponectin—has been reported in recent studies. Therapeutic strategies to mitigate bone involvement in anorexia are still a matter for debate. Although resumption of menses and weight recovery appear to be essential, they are not always accompanied by a total reversal of bone loss. There are no studies in the literature demonstrating that oestrogen treatment is effective, and the best results seem to have been obtained with agents that induce bone formation—such as IGF-1—especially when associated with oestrogen. As such, bone management in anorexia remains difficult, hence, the importance of early detection and multidisciplinary follow-up.
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Affiliation(s)
- Isabelle Legroux
- Department of Rheumatology and EA 4490, Lille University Hospital and University of Lille, Lille, France
| | - Bernard Cortet
- Department of Rheumatology and EA 4490, Lille University Hospital and University of Lille, Lille, France
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11
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Steinman J, Shibli-Rahhal A. Anorexia Nervosa and Osteoporosis: Pathophysiology and Treatment. J Bone Metab 2019; 26:133-143. [PMID: 31555610 PMCID: PMC6746661 DOI: 10.11005/jbm.2019.26.3.133] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/06/2019] [Accepted: 07/21/2019] [Indexed: 01/18/2023] Open
Abstract
Anorexia nervosa (AN) affects 2.9 million people, many of whom experience bone loss and increased fracture risk. In this article, we review data on the underlying pathophysiology of AN-related osteoporosis and possible approaches to disease management. Available research suggests that low body weight and decreased gonadal function are the strongest predictors of bone loss and fractures in patients with AN. Additionally, other metabolic disturbances have been linked to bone loss, including growth hormone resistance, low leptin concentrations, and hypercortisolemia, but those correlations are less consistent and lack evidence of causality. In terms of treatment of AN-related bone disease, weight gain has the most robust impact on bone mineral density (BMD). Restoration of gonadal function seems to augment this effect and may independently improve BMD. Bisphosphonates, insulin-like growth factor 1 supplementation, and teriparatide may also be reasonable considerations, however need long-term efficacy and safety data.
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Affiliation(s)
- Jeremy Steinman
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Amal Shibli-Rahhal
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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12
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Abstract
Anorexia nervosa, a psychiatric disease predominantly affecting women, is characterized by self- induced starvation and a resultant low-weight state. During starvation, a number of hormonal adaptations - including hypothalamic amenorrhea and growth hormone resistance - allow for decreased energy expenditure during periods of decreased nutrient intake, but these very same adaptations also contribute to the medical complications associated with chronic starvation, including low bone mass. Almost 90% of women with anorexia nervosa have bone mineral density (BMD) values more than one-standard deviation below the mean of healthy women at peak bone mineral density and this disease is associated with a significantly increased risk of fracture. Although multiple therapies have been studied for the treatment of low bone mass in anorexia nervosa, there are currently no approved therapies and few promising long-term therapeutic options. This review will outline the mediators of low bone mass in anorexia nervosa, discuss therapies that have been studied for the treatment of low BMD in this disorder, and highlight the important challenges that remain, including the differences in bone modeling in adolescents with anorexia nervosa as compared to adults, necessitating that potential therapies be tested in these two populations separately, and the paucity of long-term therapeutic strategies for treating bone loss in this disorder.
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Affiliation(s)
- Pouneh K Fazeli
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Maïmoun L, Renard E, Lefebvre P, Bertet H, Philibert P, Seneque M, Picot MC, Dupuy AM, Gaspari L, Ben Bouallègue F, Courtet P, Mariano-Goulart D, Sultan C, Guillaume S. Oral contraceptives partially protect from bone loss in young women with anorexia nervosa. Fertil Steril 2019; 111:1020-1029.e2. [PMID: 30922647 DOI: 10.1016/j.fertnstert.2019.01.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the potentially protective effects of oral contraceptives (OC) on bone loss in a large population of young women with anorexia nervosa (AN). DESIGN Cross-sectional study. SETTING University hospital. PATIENT(S) Three hundred and five patients with AN (99 of them using OC) and 121 age-matched controls. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Areal bone mineral density (aBMD) evaluated by dual-energy X-ray absorptiometry and bone turnover markers, with leptin evaluated concomitantly. RESULT(S) Although the AN patients taking OC presented lower aBMD compared with the controls at all bone sites, the whole body excepted, their aBMD values were systematically higher than those of AN patients who were not taking OC for the whole body and the lumbar spine, femoral neck, hip, and radius. These differences persisted after multiple adjustments. Preservation of aBMD improved with longer durations of OC use and shorter delays between disease onset and the start of OC. Moreover, patients with the lowest body mass index showed the best bone tissue responses to OC. Bone formation markers were systematically lower in the two groups of patients with AN compared with the controls. The markers of bone resorption were normalized in AN patients using OC. CONCLUSION(S) Although OC use does not provide total protection of aBMD, our data suggest that OC might be prescribed for young women with AN to limit their bone loss.
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Affiliation(s)
- Laurent Maïmoun
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France; Départment of Nuclear Médicine, CHU Montpellier, Montpellier, France.
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, CHU Montpellier, Montpellier, France; CIC INSERM 1411, Montpellier, France; Institut of Functional Genomics, CNRS INSERM, University of Montpellier, Montpellier, France
| | - Patrick Lefebvre
- Department of Endocrinology, Diabetes, Nutrition, CHU Montpellier, Montpellier, France
| | - Helena Bertet
- Unit of Clinical Research and Epidemiology, CHU Montpellier, Montpellier, France
| | - Pascal Philibert
- Department of Biochemistry and Hormonology, CHU Montpellier, Montpellier, France
| | - Maude Seneque
- Department of Emergency and Post-Emergency of Psychiatric, CHU Montpellier, University of Montpellier, INSERM, Montpellier, France
| | - Marie-Christine Picot
- CIC INSERM 1411, Montpellier, France; Unit of Clinical Research and Epidemiology, CHU Montpellier, Montpellier, France
| | - Anne-Marie Dupuy
- Department of Biochemistry and Hormonology, CHU Montpellier, Montpellier, France
| | - Laura Gaspari
- Unit of Paediatric Endocrinology and Gynecology, CHU Montpellier and University of Montpellier, Montpellier, France
| | - Fayçal Ben Bouallègue
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France; Départment of Nuclear Médicine, CHU Montpellier, Montpellier, France
| | - Philippe Courtet
- Department of Emergency and Post-Emergency of Psychiatric, CHU Montpellier, University of Montpellier, INSERM, Montpellier, France
| | - Denis Mariano-Goulart
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France; Départment of Nuclear Médicine, CHU Montpellier, Montpellier, France
| | - Charles Sultan
- Unit of Paediatric Endocrinology and Gynecology, CHU Montpellier and University of Montpellier, Montpellier, France
| | - Sébastien Guillaume
- Department of Emergency and Post-Emergency of Psychiatric, CHU Montpellier, University of Montpellier, INSERM, Montpellier, France
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Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews. J Clin Med 2019; 8:jcm8020278. [PMID: 30823566 PMCID: PMC6406645 DOI: 10.3390/jcm8020278] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 12/12/2022] Open
Abstract
Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa.
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15
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Robinson L, Aldridge VK, Clark EM, Misra M, Micali N. Bone health in adult women with ED: A longitudinal community-based study. J Psychosom Res 2019; 116:115-122. [PMID: 30577982 PMCID: PMC7105899 DOI: 10.1016/j.jpsychores.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 11/26/2022]
Abstract
Although Eating Disorders (ED) are known to affect bone health and development, little is known about the longitudinal effect of ED and ED behaviours on bone health in community dwelling adult women. Women (n = 3507) enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC) participated in a two-phase prevalence study to assess lifetime ED and ED behaviours (fasting, restrictive eating, vomiting and misuse of medication). Crude and adjusted linear regression methods investigated the association between ED diagnoses and behaviours, and total body, hip, leg and arm bone mineral density (BMD) DXA scans at mean ages of 48 and 52 years. Lifetime occurrence of Anorexia Nervosa (AN) was associated with lower BMD Z-scores for the whole body (mean difference (MD) = -0.28; 95% CI: -0.49, -0.05), hip (MD = -0.45; 95% CI -0.74, -0.16), leg (MD = -0.28; 95% CI -0.52, -0.03) and arm (MD = -0.44; 95% CI -0.68, -0.19) compared to no ED. This effect was mostly accounted for by lowest ever BMI. In post-hoc analyses, Restrictive AN, but not Binge-Purge AN was associated with a lower total body BMD Z-scores (MD = -0.37; 95% CI -0.62, -0.12). Lifetime Fasting and Restrictive Eating were associated with low BMD of the total body, hip, arm and leg in adjusted analyses, all p < 0.05. Both lifetime ED diagnoses and ED behaviours in a large community sample were predictive of low BMD in mid-life. This study confirms that the effects of AN, fasting and restrictive eating, and low BMI on bone health seen in clinical samples also occur in community samples.
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Affiliation(s)
- Lauren Robinson
- Section of Eating Disorders, Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 103 Denmark Hill, SE5 8AZ, UK; Institute of Child Health, University College London, Gower Street, London WC1E 6BT, UK.
| | - Victoria K Aldridge
- Institute of Child Health, University College London, Gower Street, London WC1E 6BT, UK; Health and Life Sciences, De Montfort University, Leicester LE1 9BH3, UK
| | - Emma M Clark
- Division of Pediatric Endocrinolgy, Massachusetts General Hospital for Children, Boston, MA 02114, USA
| | - Madhusmita Misra
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nadia Micali
- Institute of Child Health, University College London, Gower Street, London WC1E 6BT, UK; Child and Adolescent Psychiatry Division, Department of Child and Adolescent health, Geneva University Hospital, Geneva, Switzerland; Dept. of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, US; Musculoskeletal Research Unit, University of Bristol, Bristol, UK
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16
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Fazeli PK, Klibanski A. Effects of Anorexia Nervosa on Bone Metabolism. Endocr Rev 2018; 39:895-910. [PMID: 30165608 PMCID: PMC6226604 DOI: 10.1210/er.2018-00063] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 08/21/2018] [Indexed: 01/14/2023]
Abstract
Anorexia nervosa is a psychiatric disease characterized by a low-weight state due to self-induced starvation. This disorder, which predominantly affects women, is associated with hormonal adaptations that minimize energy expenditure in the setting of low nutrient intake. These adaptations include GH resistance, functional hypothalamic amenorrhea, and nonthyroidal illness syndrome. Although these adaptations may be beneficial to short-term survival, they contribute to the significant and often persistent morbidity associated with this disorder, including bone loss, which affects >85% of women. We review the hormonal adaptions to undernutrition, review hormonal treatments that have been studied for both the underlying disorder as well as for the associated decreased bone mass, and discuss the important challenges that remain, including the lack of long-term treatments for bone loss in this chronic disorder and the fact that despite recovery, many individuals who experience bone loss as adolescents have chronic deficits and an increased risk of fracture in adulthood.
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Affiliation(s)
- Pouneh K Fazeli
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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17
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Maïmoun L, Guillaume S, Lefebvre P, Bertet H, Seneque M, Philibert P, Picot MC, Dupuy AM, Paris F, Gaspari L, Ben Bouallègue F, Courtet P, Mariano-Goulart D, Renard E, Sultan C. Effects of the two types of anorexia nervosa (binge eating/purging and restrictive) on bone metabolism in female patients. Clin Endocrinol (Oxf) 2018; 88:863-872. [PMID: 29633301 DOI: 10.1111/cen.13610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 03/26/2018] [Accepted: 04/01/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study compared the profiles of the two types of anorexia nervosa (AN; restrictive: AN-R, and binge eating/purging: AN-BP) in terms of body composition, gynaecological status, disease history and the potential effects on bone metabolism. DESIGN Two hundred and eighty-six women with AN (21.8 ± 6.5 years; 204 AN-R and 82 AN-BP) and 130 age-matched controls (CON; 22.6 ± 6.8 years) were enrolled. Areal bone mineral density (aBMD) was determined using DXA and resting energy expenditure (REE) was indirectly assessed using calorimetry. Markers of bone formation (osteocalcin [OC], procollagen type I N-terminal propeptide [PINP] and resorption (type I-C telopeptide breakdown products [CTX]) and leptin were concomitantly evaluated. RESULTS Anorexia nervosa patients presented an alteration in aBMD and bone turnover. When compared according to type, AN-BP were older than AN-R and showed less severe undernutrition, lower CTx levels, longer duration of AN, and higher REE levels and aBMD at radius and lumbar spine. After adjustment for age, weight and hormonal contraceptive use, the aBMD and CTx differences disappeared. In both AN groups, aBMD was positively correlated with anthropometric parameters and negatively correlated with durations of AN and amenorrhoea, the bone formation markers (OC and PINP) and the leptin/fat mass ratio. REE was positively correlated with aBMD in AN-R patients only. CONCLUSIONS This study shows the profiles of AN patients according to AN type. However, the impact of the profile characteristics on bone status, although significant, was minor and disappeared after multiple adjustments. The positive correlation between REE and aBMD reinforces the concept that energy disposal and bone metabolism are strongly interdependent.
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Affiliation(s)
- Laurent Maïmoun
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
- Département de Biophysique, Service de Médecine Nucléaire, Hôpital Lapeyronie, CHU de Montpellier, France
| | - Sébastien Guillaume
- Département d'Urgence et Post-Urgence Psychiatrique, Hôpital Lapeyronie, CHRU Montpellier, UMI, INSERM U1061, Montpellier, France
| | - Patrick Lefebvre
- Departement d'Endocrinologie, Diabète, Nutrition, Hôpital Lapeyronie, CHRU Montpellier, Montpellier, France
| | - Helena Bertet
- Unité de Recherche Clinique et Epidémiologie, Hôpital Lapeyronie, CHRU Montpellier, Montpellier, France
| | - Maude Seneque
- Département d'Urgence et Post-Urgence Psychiatrique, Hôpital Lapeyronie, CHRU Montpellier, UMI, INSERM U1061, Montpellier, France
| | - Pascal Philibert
- Departement de Biochimie et d'Hormonologie, Hôpital Lapeyronie, CHRU Montpellier, Montpellier, France
| | - Marie-Christine Picot
- Unité de Recherche Clinique et Epidémiologie, Hôpital Lapeyronie, CHRU Montpellier, Montpellier, France
- Departement de Biochimie et d'Hormonologie, Hôpital Lapeyronie, CHRU Montpellier, Montpellier, France
| | - Anne-Marie Dupuy
- Departement de Biochimie et d'Hormonologie, Hôpital Lapeyronie, CHRU Montpellier, Montpellier, France
| | - Françoise Paris
- Unité d'Endocrinologie et Gynécologie Pédiatrique, Département de Pédiatrie, Hôpital Arnaud de Villeneuve, CHRU Montpellier et UMI, Montpellier, France
| | - Laura Gaspari
- Unité d'Endocrinologie et Gynécologie Pédiatrique, Département de Pédiatrie, Hôpital Arnaud de Villeneuve, CHRU Montpellier et UMI, Montpellier, France
| | - Fayçal Ben Bouallègue
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
- Département de Biophysique, Service de Médecine Nucléaire, Hôpital Lapeyronie, CHU de Montpellier, France
| | - Philippe Courtet
- Département d'Urgence et Post-Urgence Psychiatrique, Hôpital Lapeyronie, CHRU Montpellier, UMI, INSERM U1061, Montpellier, France
| | - Denis Mariano-Goulart
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
- Département de Biophysique, Service de Médecine Nucléaire, Hôpital Lapeyronie, CHU de Montpellier, France
| | - Eric Renard
- Departement d'Endocrinologie, Diabète, Nutrition, Hôpital Lapeyronie, CHRU Montpellier, Montpellier, France
- CIC INSERM 1001, Hôpital Gui de Chauliac, CHRU Montpellier, Montpellier, France
- Institut de Génomique Fonctionnelle, CNRS UMR 5203/INSERM, U661/Université Montpellier, Montpellier, France
| | - Charles Sultan
- Unité d'Endocrinologie et Gynécologie Pédiatrique, Département de Pédiatrie, Hôpital Arnaud de Villeneuve, CHRU Montpellier et UMI, Montpellier, France
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Abstract
PURPOSE OF REVIEW Eating Disorders are psychiatric disorders associated with a high risk for low bone mineral density (BMD) and fractures. Low BMD is a consequence of undernutrition, changes in body composition, and hormonal alterations. This review summarizes recent findings regarding novel strategies for assessing bone outcomes in patients with eating disorders, factors contributing to altered bone metabolism, and possible therapeutic strategies. RECENT FINDINGS Emerging research in this field suggests that not only anorexia nervosa, but also bulimia nervosa results in lower BMD compared to controls. To date studies of bone structure, and all randomized controlled trials examining the impact of various therapies on bone outcomes in anorexia nervosa, have focused on adolescent girls and women. We discuss the impact of anorexia nervosa on bone structure, and associations of resting energy expenditure, marrow adipose tissue (including the ratio of saturated to unsaturated fat), and cold activated brown adipose tissue with BMD and bone structure. Promising strategies for treatment include physiological estrogen replacement (rather than oral contraceptives) in adolescent girls with anorexia nervosa, and bisphosphonates, as well as teriparatide, in adult women with anorexia nervosa. SUMMARY Recent data on (i) BMD and bone structure in adolescent girls and women with eating disorders, (ii) factors that contribute to altered bone metabolism, and (iii) randomized controlled trials reporting positive effects of physiologic estrogen replacement, bisphosphonates and teriparatide on bone health, provide us with a greater understanding of the impact of eating disorders on bone and novel management strategies.
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Affiliation(s)
- Lauren Robinson
- Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Nadia Micali
- Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Madhusmita Misra
- Pediatric Endocrine and Neuroendocrine Units, Massachusetts General Hospital, Boston, MA 02114, USA
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19
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Robinson L, Aldridge V, Clark EM, Misra M, Micali N. Pharmacological treatment options for low Bone Mineral Density and secondary osteoporosis in Anorexia Nervosa: A systematic review of the literature. J Psychosom Res 2017; 98:87-97. [PMID: 28554377 PMCID: PMC7050204 DOI: 10.1016/j.jpsychores.2017.05.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Although there are several evidence-based treatments available to increase Bone Mineral Density (BMD) and reduce fracture risk in aging men and women, there are still uncertainties regarding which treatments are efficacious in reducing lifetime fracture risk in women with Anorexia Nervosa (AN). METHODS Medline, PsychInfo, Embase and the Cochrane Database were searched for English Language Studies. Inclusion criteria were studies of females of any age with AN who received pharmacological treatment with the primary aim to increase BMD or reduce fracture risk. Data were extracted from each study regarding pharmacological treatment and dosage used, BMD and bone formation marker outcomes; and participant characteristics including age, Body Mass Index (BMI), duration of AN, and duration of amenorrhea. RESULTS 675 studies were reviewed, of which 19 fit the inclusion criteria and were included in the final review, investigating a total of 1119 participants; 10 of the 19 included studies were double-blind RCTs. The remaining studies consisted of prospective observational studies, a retrospective cohort study, a case-control study and five non-randomised control trials. Bisphosphonates were effective in increasing BMD in adult women with AN, while estrogen administered transdermally resulted in significant increases in BMD in mature adolescents with AN. Administration of oral contraceptives (OC) did not significantly increase BMD in randomised or controlled trials, however, lifetime OC use was associated with higher spinal BMD. CONCLUSION Future research should clarify the safety of long-term bisphosphonate use in adult women with AN, and verify that transdermal estrogen replacement increases BMD in women with AN.
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Affiliation(s)
- Lauren Robinson
- Institute of Child Health, University College London, Gower Street, London WC1E 6BT, UK; Dept. of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Victoria Aldridge
- Institute of Child Health, University College London, Gower Street, London WC1E 6BT, UK
| | - Emma M Clark
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nadia Micali
- Institute of Child Health, University College London, Gower Street, London WC1E 6BT, UK,Dept. of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
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20
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21
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Bone mineral density in anorexia nervosa: Only weight and menses recovery? ACTA ACUST UNITED AC 2016; 63:458-465. [DOI: 10.1016/j.endonu.2016.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/18/2016] [Accepted: 06/24/2016] [Indexed: 11/22/2022]
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22
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Robinson L, Aldridge V, Clark EM, Misra M, Micali N. A systematic review and meta-analysis of the association between eating disorders and bone density. Osteoporos Int 2016; 27:1953-66. [PMID: 26782684 PMCID: PMC7047470 DOI: 10.1007/s00198-015-3468-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 12/16/2015] [Indexed: 11/25/2022]
Abstract
This meta-analysis investigates the effect of an eating disorder on bone mineral density in two eating disorder subtypes. Following conflicting findings in previous literature, this study finds that not only anorexia nervosa, but also bulimia nervosa has a detrimental effect on BMD. Key predictors of this relationship are discussed. This systematic review and meta-analysis investigates bone mineral density (BMD) in individuals with anorexia nervosa (AN) and bulimia nervosa (BN) in comparison to healthy controls (HCs). AN has been associated with low BMD and a risk of fractures and mixed results have been obtained for the relationship between BN and BMD. Deciphering the effect these two ED subtypes on BMD will determine the effect of low body weight (a characteristic of AN) versus the effects of periods of restrictive eating and malnutrition which are common to both AN and BN. We conducted a systematic search through the electronic databases MedLine, EMBASE and PsychInfo and the Cochrane Library to investigate and quantify this relationship. We screened 544 articles and included 27 studies in a random-effect meta-analysis and calculated the standardised mean difference (SMD) in BMD between women with a current diagnosis of AN (n = 785) vs HCs (n = 979) and a current diagnosis of BN (n = 187) vs HCs (n = 350). The outcome measures investigated were spinal, hip, femoral neck and whole body BMD measured by DXA or DPA scanning. A meta-regression investigated the effect of factors including age, duration since diagnosis, duration of amenorrhea and BMI on BMD. The mean BMI of participants was 16.65 kg/m(2) (AN), 21.16 kg/m(2) (BN) and 22.06 kg/m(2) (HC). Spine BMD was lowest in AN subjects (SMD, -3.681; 95 % CI, -4.738, -2.625; p < 0.0001), but also lower in BN subjects compared with HCs (SMD, -0.472; 95 % CI, -0.688, -0.255; p < 0.0001). Hip, whole body and femoral neck BMD were reduced to a statistically significant level in AN but not BN groups. The meta-regression was limited by the number of included studies and did not find any significant predictors. This meta-analysis confirms the association between low BMD and AN and presents a strong argument for assessing BMD not only in patients with AN, but also in patients with BN.
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Affiliation(s)
- L Robinson
- Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK.
| | - V Aldridge
- Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - E M Clark
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - M Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - N Micali
- Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
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23
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Solmi M, Veronese N, Correll CU, Favaro A, Santonastaso P, Caregaro L, Vancampfort D, Luchini C, De Hert M, Stubbs B. Bone mineral density, osteoporosis, and fractures among people with eating disorders: a systematic review and meta-analysis. Acta Psychiatr Scand 2016; 133:341-51. [PMID: 26763350 DOI: 10.1111/acps.12556] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To provide meta-analytical evidence of bone mineral density (BMD), fractures, and osteoporosis rates in eating disorders (ED) vs. healthy controls (HCs). METHOD Three independent authors searched major electronic databases from inception till August 2015 for cross-sectional studies reporting BMD in people with ED (anorexia nervosa, (AN); bulimia nervosa, (BN); eating disorders not otherwise specified, (EDNOS)) vs. HCs. Standardized mean differences (SMDs) ±95% and confidence intervals (CIs) were calculated for BMD, and odds ratios (ORs) for osteopenia, osteoporosis, and fractures. RESULTS Overall, 57 studies were eligible, including 21 607 participants (ED = 6485, HCs = 15 122). Compared to HC, AN subjects had significantly lower BMD values at lumbar spine (SMD = -1.51, 95% CI = -1.75, -1.27, studies = 42), total hip (SMD = -1.56, 95%CI = -1.84, -1.28, studies = 23), intertrochanteric region (SMD = -1.80, 95%CI = -2.46, -1.14, studies = 7), trochanteric region (SMD = -1.05, 95%CI = -1.44, -0.66, studies = 7), and femoral neck (SMD = -0.98, 95%CI = -1.12, -0.77, studies = 20). Reduced BMD was moderated by ED illness duration and amenorrhea (P < 0.05). AN was associated with an increased likelihood of osteoporosis (OR = 12.59, 95%CI = 3.30-47.9, P < 0.001, studies = 4) and fractures (OR = 1.84, 95% CI = 1.17-2.89, I(2) = 56, studies = 6). No difference in BMD was found between BN and EDNOS vs. HC. CONCLUSION People with AN have reduced BMD, increased odds of osteoporosis and risk of fractures. Proactive monitoring and interventions are required to ameliorate bone loss in AN.
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Affiliation(s)
- M Solmi
- Department of Neurosciences, University of Padova, Padova, Italy
| | - N Veronese
- Department of Medicine, Geriatrics Section, University of Padova, Italy
| | - C U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, North Shore-Long Island Jewish Health System, Glen Oaks, NY, USA.,Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - A Favaro
- Department of Neurosciences, University of Padova, Padova, Italy
| | - P Santonastaso
- Department of Neurosciences, University of Padova, Padova, Italy
| | - L Caregaro
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - D Vancampfort
- Department of Rehabilitation Sciences, Leuven - University of Leuven, Leuven, Belgium.,Z.org Leuven, KU Leuven - University of Leuven, Kortenberg, Belgium
| | - C Luchini
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, Verona, Italy
| | - M De Hert
- Department of Rehabilitation Sciences, Leuven - University of Leuven, Leuven, Belgium
| | - B Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Health Service and Population Research Department, Institute of Psychiatry King's College London, London, UK
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Eleazer CD, Jankauskas R. Mechanical and metabolic interactions in cortical bone development. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2016; 160:317-33. [PMID: 26919438 DOI: 10.1002/ajpa.22967] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 01/05/2016] [Accepted: 02/02/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Anthropological studies of cortical bone often aim to reconstruct either habitual activities or health of past populations. During development, mechanical loading and metabolism simultaneously shape cortical bone structure; yet, few studies have investigated how these factors interact. Understanding their relative morphological effects is essential for assessing human behavior from skeletal samples, as previous studies have suggested that interaction effects may influence the interpretation from cortical structure of physical activity or metabolic status. MATERIAL AND METHODS This study assesses cross-sectional geometric and histomorphometric features in bones under different loading regimes (femur, humerus, rib) and compares these properties among individuals under different degrees of metabolic stress. The study sample consists of immature humans from a late medieval Lithuanian cemetery (Alytus, 14th-18th centuries AD). Analyses are based on the hypothesis that metabolic bone loss is distributed within the skeleton in a way that optimizes mechanical competency. RESULTS Results suggest mechanical compensation for metabolic bone loss in the cross-sectional properties of all three bones (especially ribs), suggesting a mechanism for conserving adequate bone strength for different loads across the skeleton. Microscopic bone loss is restricted to stronger bones under high loads, which may mitigate fracture risk in areas of the skeleton that are more resistive to loading, although alternative explanations are examined. DISCUSSION Distributions of metabolic bone loss and subsequent structural adjustments appear to preserve strength. Nevertheless, both mechanics and metabolism have a detectable influence on morphology, and potential implications for behavioral interpretations in bioculturally stressed samples due to this interaction are explored. Am J Phys Anthropol 160:317-333, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Courtney D Eleazer
- Department of Biological Sciences, Florida International University, 11200 SW 8th Street, Miami, FL, 33199
| | - Rimantas Jankauskas
- Faculty of Medicine, Vilnius University, 21/27 M. K. Čiurlionio, Vilnius, LT-03101, Lithuania
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25
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Rodda C. Nutritional Aspects of Disease Affecting the Skeleton. Clin Nutr 2015. [DOI: 10.1002/9781119211945.ch19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Dragoman MV. The combined oral contraceptive pill -- recent developments, risks and benefits. Best Pract Res Clin Obstet Gynaecol 2014; 28:825-34. [PMID: 25028259 DOI: 10.1016/j.bpobgyn.2014.06.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 06/18/2014] [Indexed: 11/15/2022]
Abstract
The introduction of the birth control pill as an effective, coitally-independent method of contraception was a public health milestone of the last century. Over time, combined oral contraception (COC) formulations and pill-taking regimens have evolved with improved safety and tolerability while maintaining contraceptive efficacy. In addition to protection against pregnancy, use of combined oral contraception confers a number of significant non-contraceptive benefits to users. COC use is also associated with well-studied risks. Common side effects are generally self-limiting and improve with increasing duration of use while serious adverse events, including venous thromboembolism, are rare among healthy COC users. Contraceptive decision-making should include consideration of both the risks and benefits of a given method versus the real consequences of unintended pregnancy.
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MESH Headings
- Bone Density/drug effects
- Colorectal Neoplasms/prevention & control
- Contraception/methods
- Contraception/trends
- Contraceptives, Oral/administration & dosage
- Contraceptives, Oral/adverse effects
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Hormonal/administration & dosage
- Contraceptives, Oral, Hormonal/adverse effects
- Dysmenorrhea/drug therapy
- Endometrial Neoplasms/prevention & control
- Evidence-Based Medicine
- Female
- Gynecology/trends
- Humans
- Menstrual Cycle/drug effects
- Ovarian Neoplasms/prevention & control
- Pregnancy
- Risk Assessment
- Risk Factors
- Venous Thromboembolism/chemically induced
- Venous Thromboembolism/prevention & control
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Affiliation(s)
- Monica V Dragoman
- Einstein College of Medicine, Montefiore Medical Center, Department of Obstetrics and Gynecology & Women's Health, 1695 Eastchester Road, Bronx, NY 10461, USA.
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27
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Mallinson RJ, De Souza MJ. Current perspectives on the etiology and manifestation of the "silent" component of the Female Athlete Triad. Int J Womens Health 2014; 6:451-67. [PMID: 24833922 PMCID: PMC4014372 DOI: 10.2147/ijwh.s38603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The Female Athlete Triad (Triad) represents a syndrome of three interrelated conditions that originate from chronically inadequate energy intake to compensate for energy expenditure; this environment results in insufficient stored energy to maintain physiological processes, a condition known as low energy availability. The physiological adaptations associated with low energy availability, in turn, contribute to menstrual cycle disturbances. The downstream effects of both low energy availability and suppressed estrogen concentrations synergistically impair bone health, leading to low bone mineral density, compromised bone structure and microarchitecture, and ultimately, a decrease in bone strength. Unlike the other components of the Triad, poor bone health often does not have overt symptoms, and therefore develops silently, unbeknownst to the athlete. Compromised bone health among female athletes increases the risk of fracture throughout the lifespan, highlighting the long-term health consequences of the Triad. The purpose of this review is to examine the current state of Triad research related to the third component of the Triad, ie, poor bone health, in an effort to summarize what we know, what we are learning, and what remains unknown.
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Affiliation(s)
- Rebecca J Mallinson
- Department of Kinesiology, Women's Health and Exercise Laboratory in Noll Laboratory, Pennsylvania State University, University Park, PA, USA
| | - Mary Jane De Souza
- Department of Kinesiology, Women's Health and Exercise Laboratory in Noll Laboratory, Pennsylvania State University, University Park, PA, USA
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28
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DiVasta AD, Feldman HA, Beck TJ, LeBoff MS, Gordon CM. Does hormone replacement normalize bone geometry in adolescents with anorexia nervosa? J Bone Miner Res 2014; 29:151-7. [PMID: 23744513 PMCID: PMC3812374 DOI: 10.1002/jbmr.2005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/15/2013] [Accepted: 05/21/2013] [Indexed: 11/11/2022]
Abstract
Young women with anorexia nervosa (AN) have reduced secretion of dehydroepiandrosterone (DHEA) and estrogen contributing to skeletal deficits. In this randomized, placebo-controlled trial, we investigated the effects of oral DHEA + combined oral contraceptive (COC) versus placebo on changes in bone geometry in young women with AN. Eighty women with AN, aged 13 to 27 years, received a random, double-blinded assignment to micronized DHEA (50 mg/day) + COC (20 µg ethinyl estradiol/0.1 mg levonorgestrel) or placebo for 18 months. Measurements of areal bone mineral density (aBMD) at the total hip were obtained by dual-energy X-ray absorptiometry at 0, 6, 12, and 18 months. We used the Hip Structural Analysis (HSA) program to determine BMD, cross-sectional area (CSA), and section modulus at the femoral neck and shaft. Each measurement was expressed as a percentage of the age-, height-, and lean mass-specific mean from an independent sample of healthy adolescent females. Over the 18 months, DHEA + COC led to stabilization in femoral shaft BMD (0.0 ± 0.5% of normal mean for age, height, and lean mass/year) compared with decreases in the placebo group (-1.1 ± 0.5% per year, p = 0.03). Similarly, CSA, section modulus, and cortical thickness improved with treatment. In young women with AN, adrenal and gonadal hormone replacement improved bone health and increased cross-sectional geometry. Our results indicate that this combination treatment has a beneficial impact on surrogate measures of bone strength, and not only bone density, in young women with AN.
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Affiliation(s)
- Amy D. DiVasta
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA 02115
- Division of Pediatric and Adolescent Gynecology, Boston Children’s Hospital, Boston, MA 02115
| | - Henry A. Feldman
- Clinical Research Program, Boston Children’s Hospital, Boston, MA 02115
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA 02115
| | - Thomas J. Beck
- Beck Radiological Innovations, Inc., Baltimore, MD 21227
| | - Meryl S. LeBoff
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, MA 02115
| | - Catherine M. Gordon
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA 02115
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA 02115
- Divison of Adolescent Medicine, Hasbro Children’s Hospital, Providence, RI 02903
- Divison of Endocrinology, Hasbro Children’s Hospital, Providence, RI 02903
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29
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Abstract
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.
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Affiliation(s)
- Anastasia D Dede
- Department of Endocrinology and Metabolism, Hippokrateion General Hospital, Athens, Greece
| | | | - Symeon Tournis
- Laboratory for Research of Musculoskeletal System "Theodoros Garofalidis", University of Athens, KAT Hospital; Athens, Greece
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30
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ED management of patients with eating disorders. Am J Emerg Med 2013; 31:859-65. [PMID: 23623238 DOI: 10.1016/j.ajem.2013.02.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 02/21/2013] [Accepted: 02/25/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Eating disorders are one of the "great masqueraders" of the twenty-first century. Seemingly healthy young men and women with underlying eating disorders present to emergency departments with a myriad of complaints that are not unique to patients with eating disorders. The challenge for the Emergency Medicine physician is in recognizing that these complaints result from an eating disorder and then understanding the unique pathophysiologic changes inherent to these disorders that should shape management in the emergency department. OBJECTIVE In this article, we will review, from the perspective of the Emergency Medicine physician, how to recognize patients with anorexia and bulimia nervosa, the medical complications and psychiatric comorbidities, and their appropriate management. CONCLUSIONS Anorexia and bulimia nervosa are complex psychiatric disorders with significant medical complications. Recognizing patients with eating disorders in the ED is difficult, but failure to recognize these disorders, or failure to manage their symptoms with an understanding of their unique underlying pathophysiology and psychopathology, can be detrimental to the patient. Screening tools, such as the SCOFF questionnaire, are available for use by the EM physician. Once identified, the medical complications described in this article can help the EM physician tailor management of the patient to their underlying pathophysiology and effectuate a successful therapeutic intervention.
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31
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Trombetti A, Richert L, Herrmann FR, Chevalley T, Graf JD, Rizzoli R. Selective determinants of low bone mineral mass in adult women with anorexia nervosa. Int J Endocrinol 2013; 2013:897193. [PMID: 23634145 PMCID: PMC3619547 DOI: 10.1155/2013/897193] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 02/02/2013] [Accepted: 02/14/2013] [Indexed: 11/23/2022] Open
Abstract
We investigated the relative effect of amenorrhea and insulin-like growth factor-I (sIGF-I) levels on cancellous and cortical bone density and size. We investigated 66 adult women with anorexia nervosa. Lumbar spine and proximal femur bone mineral density was measured by DXA. We calculated bone mineral apparent density. Structural geometry of the spine and the hip was determined from DXA images. Weight and BMI, but not height, as well as bone mineral content and density, but not area and geometry parameters, were lower in patients with anorexia nervosa as compared with the control group. Amenorrhea, disease duration, and sIGF-I were significantly associated with lumbar spine and proximal femur BMD. In a multiple regression model, we found that sIGF-I was the only significant independent predictor of proximal femur BMD, while duration of amenorrhea was the only factor associated with lumbar spine BMD. Finally, femoral neck bone mineral apparent density, but not hip geometry variables, was correlated with sIGF-I. In anorexia nervosa, spine BMD was related to hypogonadism, whereas sIGF-I predicted proximal femur BMD. The site-specific effect of sIGF-I could be related to reduced volumetric BMD rather than to modified hip geometry.
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Affiliation(s)
- Andrea Trombetti
- Bone Diseases Service, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
- *Andrea Trombetti:
| | - Laura Richert
- Bone Diseases Service, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - François R. Herrmann
- Bone Diseases Service, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Thierry Chevalley
- Bone Diseases Service, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Jean-Daniel Graf
- Central Laboratory of Clinical Chemistry, Geneva University Hospitals, 1221 Geneva, Switzerland
| | - René Rizzoli
- Bone Diseases Service, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
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32
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Wnt-signaling-mediated antiosteoporotic activity of porcine placenta hydrolysates in ovariectomized rats. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 2012:367698. [PMID: 23258987 PMCID: PMC3522380 DOI: 10.1155/2012/367698] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 11/18/2012] [Indexed: 11/17/2022]
Abstract
Anti-osteoporotic effects of two types of porcine placenta hydrolysates (PPH) were evaluated in ovariectomized (OVX) rats orally administered PPH without (WPPH) or with (NPPH) ovarian hormones (1 g/kg bw/day). PPH groups were compared with OVX rats with estrogen replacement (0.1 mg/kg bw conjugated estrogen; EST), or dextrose (placebo; OVX-control) All rats received high-fat/calcium-deficient diets for 12 weeks. NPPH contained less estrogen and progesterone, but more essential amino acids, whereas the opposite was true for WPPH. NPPH decreased body weight and peri-uterine fat pads, and maintained uterus weight. NPPH rats had higher femur and lumbar spine bone mass density compared to controls; but less than those of EST rats. Serum phosphorus and urinary calcium and phosphorus levels were reduced in NPPH rats compared to OVX-controls. Serum bone-specific alkaline phosphatase, osteocalcin, and bone turnover marker levels were reduced NPPH rats compared to OVX-controls. WPPH produced results similar to those of NPPH, but less significant. Both NPPH and estrogen upregulated low-density lipoprotein receptor-related protein 5 and β-catenin in OVX rats, while the expression of dickkopf-related protein 1 was suppressed. In conclusion, NPPH exerted anti-osteoporotic effects by activating osteogenesis and stimulating Wnt signaling, possibly mediated by the various amino acids and not ovarian hormones.
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33
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Bhukhai K, Suksen K, Bhummaphan N, Janjorn K, Thongon N, Tantikanlayaporn D, Piyachaturawat P, Suksamrarn A, Chairoungdua A. A phytoestrogen diarylheptanoid mediates estrogen receptor/Akt/glycogen synthase kinase 3β protein-dependent activation of the Wnt/β-catenin signaling pathway. J Biol Chem 2012; 287:36168-78. [PMID: 22936801 DOI: 10.1074/jbc.m112.344747] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Estrogen promotes growth in many tissues by activating Wnt/β-catenin signaling. Recently, ASPP 049, a diarylheptanoid isolated from Curcuma comosa Roxb., has been identified as a phytoestrogen. This investigation determined the involvement of Wnt/β-catenin signaling in the estrogenic activity of this diarylheptanoid in transfected HEK 293T and in mouse preosteoblastic (MC3T3-E1) cells using a TOPflash luciferase assay and immunofluorescence. ASPP 049 rapidly activated T-cell-specific transcription factor/lymphoid enhancer binding factor-mediated transcription activity and induced β-catenin accumulation in the nucleus. Interestingly, the effects of ASPP 049 on the transcriptional activity and induction and accumulation of β-catenin protein in the nucleus of MC3T3-E1 cells were greater compared with estradiol. Activation of β-catenin in MC3T3-E1 cells was inhibited by ICI 182,780, suggesting that an estrogen receptor is required. In addition, ASPP 049 induced phosphorylations at serine 473 of Akt and serine 9 of GSK-3β. Moreover, ASPP 049 also induced proliferation and expressions of Wnt target genes Axin2 and Runx2 in MC3T3-E1 cells. In addition, ASPP 049 increased alkaline phosphatase expression, and activity that was abolished by DKK-1, a blocker of the Wnt/β-catenin receptor. Taken together, these results suggest that ASPP 049 from C. comosa induced osteoblastic cell proliferation and differentiation through ERα-, Akt-, and GSK-3β-dependent activation of β-catenin signaling. Our findings provide a scientific rationale for using C. comosa as a dietary supplement to prevent bone loss in postmenopausal women.
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Affiliation(s)
- Kanit Bhukhai
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand
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34
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Divasta AD, Feldman HA, Giancaterino C, Rosen CJ, Leboff MS, Gordon CM. The effect of gonadal and adrenal steroid therapy on skeletal health in adolescents and young women with anorexia nervosa. Metabolism 2012; 61:1010-20. [PMID: 22257645 PMCID: PMC3465078 DOI: 10.1016/j.metabol.2011.11.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 11/29/2011] [Accepted: 11/30/2011] [Indexed: 12/20/2022]
Abstract
Anorexia nervosa (AN) is characterized by subnormal estrogen and dehydroepiandrosterone (DHEA) levels. We sought to determine whether the combination of DHEA + estrogen/progestin is superior to placebo in preserving skeletal health over 18 months in AN. Females with AN, aged 13 to 27 years, were recruited for participation in this double-blind, placebo-controlled, randomized trial. Ninety-four subjects were randomized, of whom 80 completed baseline assessments and received either study drug (oral micronized DHEA 50 mg + 20 µg ethinyl estradiol/0.1 mg levonorgestrel combined oral contraceptive pill [COC] daily; n = 43) or placebo (n = 37). Serial measurements of areal bone mineral density (aBMD), bone turnover markers, and serum hormone concentrations were obtained. Sixty subjects completed the 18-month trial. Spinal and whole-body aBMD z scores were preserved in the DHEA + COC group, but decreased in the placebo group (comparing trends, P = .008 and P = .001, respectively). Bone turnover markers initially declined in subjects receiving DHEA + COC and then returned to baseline. No differences in body composition, adverse effects of therapy, or alterations in biochemical safety parameters were observed. Combined therapy with DHEA + COC appears to be safe and effective for preventing bone loss in young women with AN, whereas placebo led to decreases in aBMD. Dehydroepiandrosterone + COC may be safely used to preserve bone mass as efforts to reverse the nutritional, psychological, and other hormonal components of AN are implemented.
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Affiliation(s)
- Amy D Divasta
- Division of Adolescent Medicine, Children's Hospital Boston, Boston, MA 02115, USA.
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35
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Ostrowska Z, Ziora K, Oświęcimska J, Swiętochowska E, Szapska B, Wołkowska-Pokrywa K, Dyduch A. RANKL/RANK/OPG system and bone status in females with anorexia nervosa. Bone 2012; 50:156-60. [PMID: 22001124 DOI: 10.1016/j.bone.2011.09.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 09/21/2011] [Accepted: 09/28/2011] [Indexed: 10/16/2022]
Abstract
Minimal data exist concerning the relationship between osteokines of the RANKL/RANK/OPG system, especially RANKL, and bone status in females with anorexia nervosa (AN). For this reason we investigated the relationship between bone metabolism (as assessed based on serum levels of OC and CTx), and OPG and sRANKL concentrations in females with AN. Ninety-one female patients with AN and 29 healthy female subjects aged 13 to 18 years of age participated in the study. Serum OC, CTx, OPG and sRANKL were measured by ELISA. The female patients with AN demonstrated an essential suppression of OC and CTx, increased OPG and sRANKL levels, and a reduced OPG/sRANKL ratio. OC, CTx and the OPG/sRANKL ratio correlated positively with body mass and BMI in these patients, whereas in the case of OPG and sRANKL the relationship was negative. A significant positive correlation was observed between OPG and sRANKL and also between bone markers and the OPG/sRANKL ratio, and negative between CTx and sRANKL. In female patients with AN, the OPG/RANKL ratio was a significant and independent predictor of osteocalcin, a bone formation marker - OC (R(2)=0.065, p=0.012) whereas the OPG/sRANKL ratio and BMI were significant and independent predictors of a bone resorption marker - CTx (R(2)=0.095; p=0.012). In conclusion, the body mass, BMI values, and bone markers suppression observed in female patients with AN might be associated with an increase in OPG and sRANKL levels and a significant decrease of the OPG/sRANKL ratio. Although higher OPG levels may compensate for excessive bone resorption in female patients with AN, the lower OPG/sRANKL ratio seems to indicate that some inadequacies exist regarding this compensation effect, which might contribute to low bone density in these patients. The OPG/sRANKL ratio might prove a more relevant marker to predict bone metabolism in female patients with AN than sRANKL and/or OPG alone.
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Affiliation(s)
- Zofia Ostrowska
- Department of Clinical Biochemistry, Zabrze, Medical University of Silesia in Katowice, Poland
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36
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Waugh EJ, Woodside DB, Beaton DE, Coté P, Hawker GA. Effects of exercise on bone mass in young women with anorexia nervosa. Med Sci Sports Exerc 2011; 43:755-63. [PMID: 20962688 DOI: 10.1249/mss.0b013e3181ff3961] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The response of bone to exercise in women with anorexia nervosa (AN) is unclear. We investigated the associations between bone mineral density (BMD) and exercise performed while ill and while recovered in women with a history of AN. METHODS A cross-sectional study was conducted with 141 women with AN (85 ill; 56 recovered), aged 17-40 yr. BMD at the lumbar spine (LS), femoral neck (FN), and total body (TB) was measured by dual-energy x-ray absorptiometry. Life History Calendar and Minnesota Leisure Time Physical Activity interviews were used to collect lifetime illness and exercise histories (amount and bone loading type). Average hours per week of each of moderate (MOD) and high (HI) bone loading exercise were determined for three illness phases: "before ill," "while ill," and "while recovered." Participants were categorized into four exercise groups for each phase: MOD-ONLY, HI-ONLY, BOTH, and NEITHER (reference group). Weight-adjusted BMD z-scores were compared in the exercise groups by multivariable linear regression, adjusting for illness duration and severity, and exercise during the other illness phases. RESULTS In ill participants, MOD-ONLY "while ill" had lower BMD at LS (β = -0.69, 95% confidence interval (CI) = -1.02 to -0.05) and TB (β = -0.73, 95% CI = -1.31 to -0.15) than the NEITHER group. In recovered participants, HI-ONLY "while recovered" had higher BMD at FN (β = 0.95, 95% CI = 0.15-1.75) and TB (β = 0.79, 95% CI = 0.07-1.51) than the NEITHER group. CONCLUSIONS The effect of exercise on bone in AN patients is dependent on both the type of mechanical loading and the phase of illness during which it was performed. Excessive moderate loading exercise while ill may put patients at higher risk of low bone mass, but high bone loading activities may provoke bone accrual during recovery.
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Affiliation(s)
- Esther J Waugh
- Osteoporosis Research Program, Women’s College Hospital, 76 Grenville St., 8th Floor E, Room 812B, Toronto, Ontario, Canada M5S 2B2.
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37
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Guo AJY, Choi RCY, Cheung AWH, Chen VP, Xu SL, Dong TTX, Chen JJ, Tsim KWK. Baicalin, a flavone, induces the differentiation of cultured osteoblasts: an action via the Wnt/beta-catenin signaling pathway. J Biol Chem 2011; 286:27882-93. [PMID: 21652696 PMCID: PMC3151034 DOI: 10.1074/jbc.m111.236281] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 06/01/2011] [Indexed: 12/13/2022] Open
Abstract
Flavonoids, a group of natural compounds found in a variety of vegetables and herbal medicines, have been intensively reported on regarding their estrogen-like activities and particularly their ability to affect bone metabolism. Here, different subclasses of flavonoids were screened for their osteogenic properties by measuring alkaline phosphatase activity in cultured rat osteoblasts. The flavone baicalin derived mainly from the roots of Scutellaria baicalensis showed the strongest induction of alkaline phosphatase activity. In cultured osteoblasts, application of baicalin increased significantly the osteoblastic mineralization and the levels of mRNAs encoding the bone differentiation markers, including osteonectin, osteocalcin, and collagen type 1α1. Interestingly, the osteogenic effect of baicalin was not mediated by its estrogenic activity. In contrast, baicalin promoted osteoblastic differentiation via the activation of the Wnt/β-catenin signaling pathway; the activation resulted in the phosphorylation of glycogen synthase kinase 3β and, subsequently, induced the nuclear accumulation of the β-catenin, leading to the transcription activation of Wnt-targeted genes for osteogenesis. The baicalin-induced osteogenic effects were fully abolished by DKK-1, a blocker of Wnt/β-catenin receptor. Moreover, baicalin also enhanced the mRNA expression of osteoprotegerin, which could regulate indirectly the activation of osteoclasts. Taken together, our results suggested that baicalin could act via Wnt/β-catenin signaling to promote osteoblastic differentiation. The osteogenic flavonoids could be very useful in finding potential drugs, or food supplements, for treating post-menopausal osteoporosis.
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MESH Headings
- Active Transport, Cell Nucleus/drug effects
- Active Transport, Cell Nucleus/physiology
- Animals
- Antigens, Differentiation/biosynthesis
- Calcification, Physiologic/drug effects
- Calcification, Physiologic/physiology
- Cell Differentiation/drug effects
- Cell Differentiation/physiology
- Cell Nucleus/metabolism
- Cells, Cultured
- Enzyme Inhibitors/pharmacology
- Female
- Flavonoids/pharmacology
- Glycogen Synthase Kinase 3/antagonists & inhibitors
- Glycogen Synthase Kinase 3/metabolism
- Glycogen Synthase Kinase 3 beta
- Humans
- Intercellular Signaling Peptides and Proteins/metabolism
- Osteoblasts/cytology
- Osteoblasts/metabolism
- Osteoporosis, Postmenopausal/metabolism
- Osteoporosis, Postmenopausal/prevention & control
- Phosphorylation/drug effects
- Phosphorylation/physiology
- RNA, Messenger/biosynthesis
- Rats
- Transcription, Genetic/drug effects
- Transcription, Genetic/physiology
- Wnt Proteins/metabolism
- Wnt Signaling Pathway/drug effects
- Wnt Signaling Pathway/physiology
- beta Catenin/metabolism
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Affiliation(s)
- Ava J. Y. Guo
- From the Division of Life Science and Center for Chinese Medicine, Hong Kong University of Science and Technology, Clear Water Bay Road, Hong Kong and
| | - Roy C. Y. Choi
- From the Division of Life Science and Center for Chinese Medicine, Hong Kong University of Science and Technology, Clear Water Bay Road, Hong Kong and
| | - Anna W. H. Cheung
- From the Division of Life Science and Center for Chinese Medicine, Hong Kong University of Science and Technology, Clear Water Bay Road, Hong Kong and
| | - Vicky P. Chen
- From the Division of Life Science and Center for Chinese Medicine, Hong Kong University of Science and Technology, Clear Water Bay Road, Hong Kong and
| | - Sherry L. Xu
- From the Division of Life Science and Center for Chinese Medicine, Hong Kong University of Science and Technology, Clear Water Bay Road, Hong Kong and
| | - Tina T. X. Dong
- From the Division of Life Science and Center for Chinese Medicine, Hong Kong University of Science and Technology, Clear Water Bay Road, Hong Kong and
| | - Ji J. Chen
- the State Key Laboratory of Phytochemistry and Plant Resources in West China, Kunming Institute of Botany, Chinese Academy of Sciences, Kunming, Yunnan 650204, China
| | - Karl W. K. Tsim
- From the Division of Life Science and Center for Chinese Medicine, Hong Kong University of Science and Technology, Clear Water Bay Road, Hong Kong and
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38
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Abstract
Combination hormonal contraception and progestin-only contraception (including depot medroxyprogesterone acetate [DMPA]) are effective and convenient forms of reversible contraception that millions of women use worldwide. In recent years, observations of reduced bone mineral density in current users of these methods have led to concerns that this hormone-induced bone loss might translate into long-term increased fracture risk. Special focus has been placed on adolescent users who have not yet attained their peak bone mass as well as perimenopausal users. In 2004, the FDA added a black box warning to DMPA package labeling warning of the risk of significant bone loss and cautioning against long-term use (> 2 years). This article reviews evidence on the use of hormonal contraception and its effect on bone density in adolescent, premenopausal, and perimenopausal populations. Recommendations from reproductive healthcare organizations are reviewed and clinical recommendations are provided.
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MESH Headings
- Adolescent
- Adult
- Bone Density/drug effects
- Contraceptive Agents, Female/administration & dosage
- Contraceptive Agents, Female/adverse effects
- Contraceptive Agents, Female/therapeutic use
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Combined/therapeutic use
- Contraceptives, Oral, Hormonal/adverse effects
- Contraceptives, Oral, Hormonal/therapeutic use
- Female
- Fractures, Bone/chemically induced
- Fractures, Bone/epidemiology
- Humans
- Lactation
- Perimenopause
- Practice Guidelines as Topic
- Risk Factors
- Young Adult
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Affiliation(s)
- Michelle M Isley
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, USA.
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39
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HASEGAWA A, USUI C, KAWANO H, SAKAMOTO S, HIGUCHI M. Characteristics of Body Composition and Resting Energy Expenditure in Lean Young Women. J Nutr Sci Vitaminol (Tokyo) 2011; 57:74-9. [DOI: 10.3177/jnsv.57.74] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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40
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Osteoporosis en individuos jóvenes. ACTA ACUST UNITED AC 2010; 6:217-23. [DOI: 10.1016/j.reuma.2009.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 02/02/2009] [Indexed: 01/04/2023]
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41
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Abstract
OBJECTIVE The removal of the amenorrhea criterion for anorexia nervosa (AN) is being considered for the fifth edition of The Diagnostic and Statistical Manual (DSM-V). This article presents and discusses the arguments for maintaining as well as those for removing the criterion. METHOD The psychological and biological literatures on the utility of amenorrhea as a distinguishing diagnostic criterion for AN and as an indicator of illness severity are reviewed. RESULTS The findings suggest that the majority of differences among patients with AN who do and do not meet the amenorrhea criterion appear largely to reflect nutritional status. Overall, the two groups have few psychological differences. There are mixed findings regarding biological differences between those with AN who do and do not menstruate and the relationship between amenorrhea and bone health among patients with AN. DISCUSSION Based on these findings, one option is to describe amenorrhea in DSM-V as a frequent occurrence among individuals with AN that may provide important information about clinical severity, but should not be maintained as a core diagnostic feature. The possibilities of retaining the criterion or eliminating it altogether are discussed.
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Affiliation(s)
- Evelyn Attia
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York, USA.
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42
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Abstract
Since the advent on non-invasive in vivo clinical bone densitometry, investigators have reported that regional bone mineral material loss accompanies the onset and continuance of anorexia nervosa (AN). Initial single-energy photon absorptiometric (SPA) studies were followed by a succession of dual-energy X-ray absorptiometric (DXA) investigations, and a few single-energy quantitative computer assisted tomographic (SEQCT) bone densitometry vertebral measurements. Although most all DXA studies found a relatively small diminution (approximately 3%) of bone mineral material at lumbar vertebral and proximal femoral bone-sites of AN-afflicted adolescent girls and young women, these findings have been consensually interpreted and near-universally accepted as losses of actual bone mineral material accompanying AN. It has also been claimed by some that about 50% of those beset by AN while still young adolescents were osteoporotic. Nonetheless, over the last intervening 2 decades of these studies, no specific underlying direct bone-biological causal link between AN and trabecular bone material loss has yet been uncovered. The present exposition shows that in vivo SPA, DXA, and SEQCT measurements of bone mineral material losses do not constitute evidence of actual loss of bone material, and that the attribution of osteopenia and osteoporosis to AN-afflicted younger adolescent girls is not sustainable. Rather, the full gamut of these reported bone material "losses" can be accounted for by the already well-documented AN-induced changes in the anthropometrics and compositional mixes of extra-osseous soft tissues (primarily in a very noticeable reduction of extra-skeletal fat) and intra-osseous bone marrow yellowing (marrow hypoplasia and marrow cell necrosis). These changes in soft tissue compositions and anthropometrics alone have been shown to be sufficient to cause in vivo SPA, DXA, and SEQCT to systematically mis-estimate true bone material density and erroneously register changes in bone mineral content, even when no actual changes in bone mineral material have occurred. As a result, it is seen that in vivo bone densitometry methodologies have not demonstrated that AN induces actual loss of bone mineral material. It is also demonstrated that DXA and SEQCT bone density measurements of predominantly trabecular bone-sites cannot be relied upon as gauges of heightened propensity for early (or late) osteoporotic development.
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Affiliation(s)
- H H Bolotin
- School of Medical Sciences, RMIT University, Bundoora, Victoria 3083, Australia.
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43
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DiVasta AD, Feldman HA, Quach AE, Balestrino M, Gordon CM. The effect of bed rest on bone turnover in young women hospitalized for anorexia nervosa: a pilot study. J Clin Endocrinol Metab 2009; 94:1650-5. [PMID: 19223524 PMCID: PMC2684474 DOI: 10.1210/jc.2008-1654] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Malnourished adolescents with anorexia nervosa (AN) requiring medical hospitalization are at high risk for skeletal insults. Even short-term bed rest may further disrupt normal patterns of bone turnover. OBJECTIVE The objective of the study was to determine the effect of relative immobilization on bone turnover in adolescents hospitalized for AN. DESIGN This was a short-term observational study. SETTING The study was conducted at a tertiary care pediatric hospital. STUDY PARTICIPANTS Twenty-eight adolescents with AN, aged 13-21 yr with a mean body mass index of 15.9 +/- 1.8 kg/m(2), were enrolled prospectively on admission. INTERVENTION As per standard care, all subjects were placed on bed rest and graded nutritional therapy. MAIN OUTCOME MEASURE Markers of bone formation (bone specific alkaline phosphatase), turnover (osteocalcin), and bone resorption (urinary N-telopeptides NTx) were measured. RESULTS During the 5 d of hospitalization, serum osteocalcin increased by 0.24 +/- 0.1 ng/ml . d (P = 0.02). Urine N-telopeptides reached a nadir on d 3, declining -6.9 +/- 2.8 nm bone collagen equivalent per millimole creatinine (P = 0.01) but returned to baseline by d 5 (P > 0.05). Bone-specific alkaline phosphatase exhibited a decline that was strongly age dependent, being highly significant for younger subjects only [age 14 yr: -0.42 +/- 0.11 (P = 0.0002); age 18 yr: -0.03 +/- 0.08 (P = 0.68)]. Age had no effect on other outcome measures. CONCLUSION Limitation of physical activity during hospitalization for patients with AN is associated with suppressed bone formation and resorption and an imbalance of bone turnover. Future interventional studies involving mechanical stimulation and/or weight-bearing activity are needed to determine whether medical protocols prescribing strict bed rest are appropriate.
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Affiliation(s)
- Amy D DiVasta
- Division of Adolescent Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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44
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Mehler PS, MacKenzie TD. Treatment of osteopenia and osteoporosis in anorexia nervosa: a systematic review of the literature. Int J Eat Disord 2009; 42:195-201. [PMID: 18951456 DOI: 10.1002/eat.20593] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To systematically review the evidence supporting treatment of osteopenia and osteoporosis in patients with anorexia nervosa (AN). DATA SOURCES We identified controlled clinical studies of interventions for low bone mass in AN via searches of MEDLINE; the Cochrane Library; EMBASE; PsycINFO; and cumulative index to nursing and allied health literature. Outcomes of interest were changes in bone mineral density and fracture incidence. RESULTS Six randomized controlled trials (RCTs) and two cohort trials examined five classes of medical therapy on bone mineral density outcomes. One RCT of bisphosphonates showed no benefit and a second flawed RCT showed some benefit; one RCT showed a benefit of insulin-like growth factor-I; none of the five trials evaluating estrogen therapy showed benefit. DISCUSSION Although patients with AN are often losing bone mass when they should be optimizing bone growth, there is no good evidence to guide medicinal interventions. Therefore, early detection and weight restoration are of utmost importance whereas ongoing trials define effective therapies.
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Affiliation(s)
- Philip S Mehler
- Department of Internal Medicine, Denver Health Medical Center, Denver, Colorado 80204, USA.
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45
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Legroux-Gerot I, Vignau J, Collier F, Cortet B. Factors influencing changes in bone mineral density in patients with anorexia nervosa-related osteoporosis: the effect of hormone replacement therapy. Calcif Tissue Int 2008; 83:315-23. [PMID: 18836675 DOI: 10.1007/s00223-008-9173-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Accepted: 08/05/2008] [Indexed: 11/25/2022]
Abstract
The purpose of this longitudinal study was to evaluate factors affecting changes in bone mineral density (BMD) in patients with anorexia nervosa (AN) and osteoporosis and, more particularly, to assess the benefits of hormone replacement therapy (HRT) on BMD in these patients. Our study involved 45 AN patients, 12 of whom had been treated by HRT for 2 years following a diagnosis of osteoporosis by densitometry (WHO criteria). Patients' mean age was 25.3 +/- 6.7 years. Mean duration of illness was 5.7 +/- 5.3 years. Serum calcium and phosphate were measured at baseline, as were bone remodeling markers. Osteodensitometry by dual-energy X-ray absorptiometry was performed at inclusion and after 2 years. After 2 years, no significant differences were observed between spine, femoral neck, and total hip BMDs either in the HRT group (P = 0.3, P = 0.59, P = 0.58) or in the nontreatment group (P = 0.17, P = 0.68, P = 0.98). Moreover, there were no significant differences between the two groups when changes in spine, femoral neck, and total hip BMDs at 2 years were compared (P = 0.72, P = 0.95, P = 0.58). In both groups, change in weight at 1 year correlated with change in spine BMD at 2 years (r = 0.35, P = 0.04) and change in total-hip BMD at 2 years (r = 0.35, P = 0.04) but not with change in femoral neck BMD at 2 years. Patients with a body mass index (BMI) > or = 17 kg/m(2) at 2 years showed a significant increase in total-hip BMD when compared with patients with a BMI < 17 kg/m(2) (+4.4% +/- 6.7 vs. -0.5% +/- 6.01, P = 0.03). No significant differences were observed for spine and femoral neck BMD. In patients who had recovered their menstrual cycle, significant increases were observed in spine BMD (+4% +/- 6.3 vs. -1.9% +/- 5.6, P = 0.008), femoral neck BMD (+3% +/- 6.2 vs. -2.4% +/- 8, P = 0.05), and total-hip BMD (+3% +/- 7.1 vs. -3.7% +/- 10, P = 0.04). Prevention of bone loss at 2 years in AN patients treated by HRT was not confirmed in this study. We did confirm that increase in weight at 1 year was the most predictive factor for the improvement of spine and hip BMD at 2 years.
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Affiliation(s)
- Isabelle Legroux-Gerot
- Department of Rheumatology, CHRU Lille, Hôpital Roger Salengro, 59037, Lille cédex, France.
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46
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47
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What is the optimal policy for osteoporosis management? Maturitas 2008; 60:3-9. [DOI: 10.1016/j.maturitas.2008.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 02/13/2008] [Accepted: 02/20/2008] [Indexed: 12/29/2022]
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48
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Vescovi JD, Jamal SA, De Souza MJ. Strategies to reverse bone loss in women with functional hypothalamic amenorrhea: a systematic review of the literature. Osteoporos Int 2008; 19:465-78. [PMID: 18180975 DOI: 10.1007/s00198-007-0518-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Accepted: 09/28/2007] [Indexed: 10/22/2022]
Abstract
UNLABELLED Functional hypothalamic amenorrhea (FHA) impairs the attainment of peak bone mass and as such can increase the risk of fractures later in life. To document available treatment strategies, we conducted a systematic review of the literature. We report that hormonal therapies have limited effectiveness in increasing bone mass, whereas increased caloric intake resulting in weight gain and/or resumption of menses is an essential strategy for restoring bone mass in women with FHA. INTRODUCTION Women with functional hypothalamic amenorrhea (FHA) may not achieve peak bone mass (PBM), which increases the risk of stress fractures, and may increase the risk of osteoporotic fractures in later life. METHODS To identify effective treatment strategies for women with FHA, we conducted a systematic review of the literature. We included randomized controlled trials (RCTs), cross-sectional studies, and case studies that reported on the effects of pharmacological and non-pharmacological interventions on bone mineral density (BMD) or bone turnover in women with FHA. RESULTS Most published studies (n=26) were designed to treat the hormonal abnormalities observed in women with FHA (such as low estrogen, leptin, insulin-like growth factor-1, and DHEA); however none of these treatments demonstrated consistent improvements in BMD. Therapies containing an estrogen given for 8-24 months resulted in variable improvements (1.0-19.0%) in BMD, but failed to restore bone mass to that of age-matched controls. Three studies reported on the use of bisphosphonates (3-12 months) in anorexic women, which appear to have limited effectiveness to improve BMD compared to nutritional treatments. Another three investigations showed no improvements in BMD after androgen therapy (DHEA and testosterone) in anorexic women. In contrast, reports (n=9) describing an increase in caloric intake that results in weight gain and/or the resumption of menses reported a 1.1-16.9% increase in BMD concomitant with an improvement in bone formation and reduction in bone resorption markers. CONCLUSIONS Our literature review indicates that the most successful, and indeed essential strategy for improving BMD in women with FHA is to increase caloric intake such that body mass is increased and there is a resumption of menses. Further long-term studies to determine the persistence of this effect and to determine the effects of this and other strategies on fracture risk are needed.
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Affiliation(s)
- J D Vescovi
- Women's Exercise and Bone Health Laboratory, Graduate Department of Exercise Science, University of Toronto, Toronto, ON, Canada M5S 2W6
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49
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Haagensen AL, Feldman HA, Ringelheim J, Gordon CM. Low prevalence of vitamin D deficiency among adolescents with anorexia nervosa. Osteoporos Int 2008; 19:289-94. [PMID: 17924053 PMCID: PMC3199303 DOI: 10.1007/s00198-007-0476-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 08/10/2007] [Indexed: 10/22/2022]
Abstract
UNLABELLED Fifty adolescents with AN and 200 healthy girls underwent vitamin D screening. Girls with AN reported exceptional compliance with vitamin D supplementation and PTH concentrations were lower. Vitamin D deficiency was less common in the group with AN, but when race was considered, the trend was no longer significant. INTRODUCTION The objective of this study was to determine whether patients with anorexia nervosa (AN) are more compliant with supplementation and have a lower prevalence of vitamin D deficiency than healthy controls. METHODS Fifty adolescents with AN and 200 controls were compared using anthropometric and lifestyle data, serum 25-hydroxyvitamin D (25OHD) and parathyroid hormone (PTH) concentrations, and prevalence of vitamin D deficiency. RESULTS The prevalence of deficiency (<20 ng/mL) was 2% in the AN group vs. 24% among controls (p = 0.003). 25OHD was similar among white participants with AN and white controls (39.5 vs. 36.0 ng/mL, p = 0.20), but higher than in non-white controls (20.6 ng/mL). Significantly more girls with AN reported vitamin D supplementation (86%) than the full control (14%) or white subgroup (27%) (p < 0.001). Participants with AN had lower PTH concentrations than controls, (27.8 vs. 47.4 pg/mL, p = 0.009), a trend that lost significance after age and race adjustment (41.7 pg/mL, p = 0.12). CONCLUSIONS Compared to healthy controls, adolescents with AN had a lower prevalence of vitamin D deficiency and PTH concentration. However, 25OHD and PTH concentrations were similar after adjustment for race and age. The trend of lower PTH levels in adolescents with AN, accompanied by exceptional compliance with supplementation, may have bone health implications for these patients.
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Affiliation(s)
- A L Haagensen
- Division of Endocrinology, Children's Hospital Boston, Boston, USA
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50
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Jayasinghe Y, Grover SR, Zacharin M. Current concepts in bone and reproductive health in adolescents with anorexia nervosa. BJOG 2008; 115:304-15. [PMID: 18190366 DOI: 10.1111/j.1471-0528.2007.01601.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Anorexia nervosa (AN) initiates an adaptive response at the level of the hypothalamus, which results in a complex interplay involving most elements of the neuroendocrine axis. Consequences of onset of disease in adolescence include amenorrhoea, pubertal arrest with potential loss of target height, and osteoporosis with reduced capacity for future attainment of peak bone mass. With recovery, delay in restoration of menses is common. Hormonal therapies for restoration of bone mineral density (BMD) in adolescents have shown limited efficacy. This review will discuss the reproductive endocrine effects of AN in adolescence, and discuss new investigative tools for monitoring restoration of reproductive function and BMD in this population.
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Affiliation(s)
- Y Jayasinghe
- Department of Gynaecology Royal Children's Hospital, Melbourne, Victoria, Australia.
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