Anorexia Nervosa and Osteoporosis

Exploring the Role of Hormones and Cytokines in Osteoporosis Development

The disease of osteoporosis is characterized by impaired bone structure and an increased risk of fractures. There is a significant impact of cytokines and hormones on bone homeostasis and the diagnosis of osteoporosis. As defined by the World Health Organization (WHO), osteoporosis is defined as having a bone mineral density (BMD) that is 2.5 standard deviations (SD) or more below the average for young and healthy women (T score < -2.5 SD). Cytokines and hormones, particularly in the remodeling of bone between osteoclasts and osteoblasts, control the differentiation and activation of bone cells through cytokine networks and signaling pathways like the nuclear factor kappa-B ligand (RANKL)/the receptor of RANKL (RANK)/osteoprotegerin (OPG) axis, while estrogen, parathyroid hormones, testosterone, and calcitonin influence bone density and play significant roles in the treatment of osteoporosis. This review aims to examine the roles of cytokines and hormones in the pathophysiology of osteoporosis, evaluating current diagnostic methods, and highlighting new technologies that could help for early detection and treatment of osteoporosis.

Multiple thoracolumbar compression fractures induced by glucocorticoid-induced osteoporosis and cachexia in a young adult female patient with systemic lupus erythematosus: a case report with a 5-year follow-up

BACKGROUND

High doses of glucocorticoids and severe weight loss can cause osteoporosis. We present a case of glucocorticoid-induced osteoporosis and cachexia in an 18-year-old woman who experienced severe appetite loss leading to weight loss, amenorrhea, and multiple thoracolumbar compression fractures.

CASE PRESENTATION

The patient had been receiving high-dose glucocorticoid treatment for systemic lupus erythematosus since the age of 13 and developed unexplained appetite loss since the age of 16. She subsequently developed thoracolumbar compression fractures, which necessitated repeated hospitalization. Gradual glucocorticoid tapering using belimumab and weight regain were achieved through high-calorie nutrition administration via the central vein, which helped the patient overcome her cachexic state. Romosozumab administration increased bone mineral density.

CONCLUSION

Long-term administration of glucocorticoids may lead to osteoporosis and cachexia, resulting in amenorrhea, especially in young adults. Approaches that taper glucocorticoids and promote weight regain may be helpful in the management of such patients.

Evaluation of Trabecular Bone Microarchitecture and Bone Mineral Density in Young Women, Including Selected Hormonal Parameters

The absence of non-invasive methods for assessing bone material and structural changes is a significant diagnostic challenge. Dual-energy X-ray absorptiometry (DXA) bone mineral density (BMD) testing is the gold standard for osteoporosis diagnosis. BMD and the trabecular bone score (TBS) have facilitated targeted osteoporosis prevention and treatment in clinical settings. The findings from this study indicate that BMD modulation in young women is influenced by various hormones, potentially compromising the diagnostic precision of BMD for subclinical bone demineralization. A total of 205 women aged 19 to 37 underwent anthropometric measurements and hormonal tests. BMD was determined using DXA, and TBS values were computed from the lumbar spine L1-L4 segment. The multivariate analysis findings suggest that BMD might not be determined by hormones. The relationship between TBS and TSH was statistically significant in the univariate analysis, which indicates the efficacy of further studies to determine the link between TBS and specific hormones. Analyzing the strength of the correlation between TBS and hormones in the univariate analysis shows which factors are worth considering in further analyses. This makes it possible to create better techniques that will help identify young women who are at a higher risk of developing osteoporosis.

Anorexia Nervosa and Osteoporosis: A Possible Complication to Remember

Anorexia nervosa (AN) belongs to the spectrum of food disorders and affects approximately 2.9 million people worldwide. It is responsible for numerous and serious medical complications. Osteoporosis is a common complication, and the decrease in bone mineral density (BMD) is one of the few potentially irreversible consequences of AN. When associated with AN, it can manifest at a very young age, possibly leading to irreparable damage. We describe the case of a 30-year-old woman with a one-year evolution diagnosis of AN, complaining of back pain. Physical examination revealed a slight elevation of the right shoulder and pain at compression of paravertebral right dorsal musculature with a palpable strained muscle. Full-length X-ray imaging of the dorsal spine revealed a slight dextroconvex dorsolumbar scoliosis. A dorsal spine computerized tomography (CT) was performed, confirming a fracture of the upper platform of the sixth dorsal vertebrae. Osteodensitometry showed lumbar spine osteoporosis and femoral osteopenia. The decrease in BMD and, later on, the development of osteoporosis can occur in both types of AN. It is a severe complication that affects up to 50% of these patients. It can be irreversible and increase the lifetime risk of bone fractures and, therefore, morbimortality. Low body weight and body mass index (BMI) strongly correlate with the decrease in BMD. Treatment of osteoporosis associated with AN is not standardized and clearly labeled. Weight gain is described as the strategy with the most impact in reversing the loss of bone mass and increasing the BMD. The regularization of gonadal function also seems to independently potentiate the increase of BMD. The occurrence of long bone and vertebrae fractures frequently results in a decrease in height and chronic back pain, culminating in greater morbimortality and healthcare costs. This clinical case aims to show theclose relationship between restrictive food disorders and the decrease of BMD and the subsequent development of osteoporosis and its complications. Although rare in young and healthy people, when associated with restrictive food disorders, it should raise a red flag in its clinical evaluation. Preventing osteoporosis development and reduction of fracture risk in this population is essential. The current absence of consistent evidence regarding screening of osteoporosis in this particular group should raise awareness and promote further larger-scale studies to establish standardized recommendations concerning not only screening but also pharmacological treatment of osteoporosis in patients with AN.

Fracture Risk in Patients with Anorexia Nervosa Over a 40-Year Period

Researchers have reported increased fracture risk in patients with anorexia nervosa (AN), but more knowledge on the long-term risk and the effects of age, male sex, and time-related changes is still needed. We examined the long-term (up to 40 years) fracture risk among patients with AN compared to a matched comparison cohort from the general population. We utilized data from the Danish Health Care Registers to identify 14,414 patients with AN (13,474 females and 940 males) diagnosed between 1977 and 2018, with a median age of 18.6 years and median follow-up time of 9.65 years. We calculated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) using Cox regression analysis for overall and site-specific fracture risks. The overall aHR of any fracture was 1.46 [95% CI: 1.36 to 1.48], with an aHR of 1.50 [95% CI: 1.43 to 1.57] for females and 0.95 [95% CI: 0.82 to 1.1] for males. For specific fractures we found an association with femur fractures both in females 4.06 [95% CI: 3.39 to 4.46] and in males 2.79 [95% CI: 1.45 to 2.37] and for fractures of the spine (females 2.38 [95% CI: 2.00 to 2.84], males 2.31 [95% CI: 1.20 to 4.42]). The aHR of any fracture decreased from 1.66 [95% CI: 1.52 to 1.81] in the period from 1977 to 1997 to 1.40 [95% CI: 1.33 to 1.40] from 1998 to 2018. In conclusion, we found that AN was associated with a 46% increased risk of any fracture up to 40 years after diagnosis. We found no overall increased risk in males, but in both sexes we found a particularly high site-specific fracture risk in the spine and femur. Fracture risk decreased in recent decades, indicating that more patients with AN have been diagnosed with presumably less severe disease and that the earlier detection and intervention of AN in recent years may translate into a lower facture risk. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Gaining consensus on clinical quality outcomes for eating disorders: Framework for the development of an Australian national minimum dataset

OBJECTIVES

Eating disorders (EDs) are complex psychiatric illnesses requiring multidisciplinary care across both mental and medical healthcare settings. Currently, no nationally comprehensive, consistent, agreed on or mandated data set or data collection strategy exists for EDs in Australia: thus, little is known about the outcomes of care nor treatment pathways taken by individuals with EDs. InsideOut Institute was contracted by the Australian Government Department of Health to develop a minimum dataset (MDS) for the illness group with consideration given to data capture mechanisms and the scoping of a national registry.

DESIGN

A four-step modified Delphi methodology was used, including national consultations followed by three rounds of quantitative feedback by an expert panel.

SETTING

Due to social distancing protocols throughout the global SARS-CoV-2 pandemic, the study was conducted online using video conferencing (Zoom and Microsoft Teams) (Step 1), email communication and the REDCap secure web-based survey platform (Steps 2-4).

PARTICIPANTS

14 data management organisations, 5 state and territory government departments of health, 2 Aboriginal and Torres Strait Islander advising organisations and 28 stakeholders representing public and private health sectors across Australia participated in consultations. 123 ED experts (including lived experience) participated in the first quantitative round of the Delphi survey. Retention was high, with 80% of experts continuing to the second round and 73% to the third.

MAIN OUTCOME MEASURES

Items and categories endorsed by the expert panel (defined a priori as >85% rating an item or category 'very important' or 'imperative').

RESULTS

High consensus across dataset items and categories led to the stratification of an identified MDS. Medical status and quality of life were rated the most important outcomes to collect in an MDS. Other items meeting high levels of consensus included anxiety disorders, depression and suicidality; type of treatment being received; body mass index and recent weight change.

CONCLUSIONS

Understanding presentation to and outcomes from ED treatment is vital to drive improvements in healthcare delivery. A nationally agreed MDS has been defined to facilitate this understanding and support improvements.

Radiofrequency echographic multispectrometry (REMS): an innovative technique for the assessment of bone status in young women with anorexia nervosa

PURPOSE

Reduced bone mineral density (BMD) and increase risk of fragility fracture are common complication of anorexia nervosa (AN). BMD by dual-energy X-ray absorptiometry (DXA) present several limits in subjects with AN. This study aimed to evaluate the usefulness of the new Radiofrequency echographic multispectrometry (REMS) technique in the assessment of bone status in young women with AN.

METHODS

In a cohort of 50 subjects with restrictive AN and in 30 healthy controls, we measured BMD at the lumbar spine (LS-BMD), at femoral neck (FN-BMD) and total hip (TH-BMD) using both DXA and REMS technique.

RESULTS

BMD evaluated by DXA and REMS technique at all measurement sites were all significantly (p < 0.01) lower in subjects suffering from AN subjects than in controls. Good correlations were detected between BMD by DXA and BMD by REMS measurements at LS (r = 0.64, p < 0.01) at FN (r = 0.86, p < 0.01) and at TH (r = 0.84, p < 0.01) in subjects suffering from AN. Moreover, Bland-Altman analysis confirmed the good agreement between the two techniques. The subjects suffering from AN with previous vertebral fragility fractures presented lower values of both BMD-LS and BMD-TH by DXA and by REMS with respect to those without fractures; however, the difference was significant only for BMD-TH by REMS (p < 0.05).

CONCLUSIONS

Our data suggest that REMS technique due to its characteristic of precision and reproducibility may represent an important tool for the evaluation of the changes in bone status in AN young women, especially during the fertile age and in case of pregnancy and breastfeeding.

LEVEL OF EVIDENCE

Level of evidence: level III cohort study.

Bone mass and biomarkers in young women with anorexia nervosa: a prospective 3-year follow-up study

INTRODUCTION

Anorexia nervosa (AN) increases the risk of impaired bone health, low areal bone mineral density (aBMD), and subsequent fractures. This prospective study investigated the long-term effects of bone and mineral metabolism on bone and biomarkers in 22 women with AN.

MATERIALS AND METHODS

Body composition and aBMD were measured by dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography. Total and free 25-hydroxyvitamin D (25OHD), C-terminal collagen cross-links (CTX), osteocalcin, bone-specific alkaline phosphatase (BALP), leptin, sclerostin, and oxidized/non-oxidized parathyroid hormone (PTH) were analyzed before and after 12 weeks of intensive nutrition therapy and again 3 years later. An age-matched comparison group of 17 healthy women was recruited for the 3-year follow-up.

RESULTS

Body mass index (BMI) and fat mass increased from baseline to 3 years in women with AN. Sclerostin decreased during nutrition therapy and further over 3 years, indicating reduced bone loss. CTX was elevated at baseline and after 12 weeks but decreased over 3 years. BALP increased during nutrition therapy and stabilized over 3 years. Free 25OHD was stable during treatment but decreased over 3 years. Non-oxidized PTH was stable during treatment but increased over 3 years. Trabecular volumetric BMD in AN patients decreased during the first 12 weeks and over 3 years despite stable BMI and bone biomarkers implying increased BMD.

CONCLUSION

Our findings highlight the importance of early detection and organized long-term follow-up of bone health in young women with a history of AN.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

The female athlete triad: review of current literature

PURPOSE OF REVIEW

Adolescence and young adulthood are a critical period in the life of women for optimizing long-term bone health. Young athletes lead a demanding lifestyle with increased dietary requirements to meet the robust demands of energy expenditure to maintain a state of energy balance. During a time of fast paced changes and unpredictable societal demands on young athletes, it is important to review the severe consequences of energy deficiency and options for adequate management.

RECENT FINDINGS

This review focuses on hormonal adaptations that occur in energy deficient female athletes that lead to menstrual irregularities and impaired bone health, increasing the risk for stress and other fractures. We also describe management strategies to mitigate the consequences of limited energy availability on bone and other outcomes.

SUMMARY

These strategies should help guide the management of young female athletes to prevent irreversible changes to their bone health. Identifying current knowledge should help increase awareness among medical providers, which can then be communicated to the sports community, parents, and athletes.

Oxytocin and Bone: Review and Perspectives

Recent data demonstrate the anabolic effect of oxytocin on bone. Bone cells express oxytocin receptors. Oxytocin promotes osteoblasts differentiation and function, leading to an increased bone formation with no effect on bone resorption and an improvement of bone microarchitecture. Oxytocin is synthetized by osteoblasts, and this synthesis is stimulated by estrogen. Animal studies demonstrate a direct action of oxytocin on bone, as the systemic administration of oxytocin prevents and reverses the bone loss induced by estrogen deficiency. Although oxytocin is involved in bone formation in both sexes during development, oxytocin treatment has no effect on male osteoporosis, underlining the importance of estrogen that amplifies its local autocrine and paracrine secretion. There are few human data showing a decrease in the oxytocin serum level in anorexia nervosa independently of estrogen and in amenorrheic women associated with impaired bone microarchitecture; in post-menopausal women a higher oxytocin serum level is associated with higher bone density, but not in osteoporotic men. Oxytocin displays many effects that may be beneficial in the management of osteoporosis, cardiovascular diseases, cognitive disorders, breast cancer, diabetes and body fat gain, all age-related diseases affecting elderly women, opening exciting therapeutic perspectives, although the issue is to find a single route, dosage and schedule able to reach all these targets.