Effect of Exercise and Antidepressants on Skeletal Outcomes in Adolescent Girls With Anorexia Nervosa

Inpatient Rehabilitation during Intensive Refeeding in Severe Anorexia Nervosa

Severe forms of anorexia nervosa are responsible for weight loss and life-threatening consequences. Refeeding represents a real psychiatric and somatic challenge. Physical activities are usually not recommended during intensive refeeding in order to avoid energy expenditure. This study assessed the interest in an early return to controlled physical activities, during a hospitalization in a Physical Medicine and Rehabilitation (PMR) department, including continuous nasogastric refeeding and psychiatric care. A total of 37 subjects aged 32 ± 11 years old performed inpatient physical activities during nasogastric refeeding initiated after intensive care. The physical activity program was adapted according to the hyperactivity of the patients. Evaluation parameters were weight, body mass index (BMI), body composition (fat, lean, and bone masses), and function (strength, balance, walking, ventilation). Patient satisfaction, re-hospitalizations, and physical activities continuation were assessed at 12 months of follow-up. Weight, BMI, and body fat increased significantly (+2.7 ± 1.7 kg; +1.0 ± 0.6 kg/m²; +1.7 ± 2.5 kg, respectively). Muscle strength increased even if the lean mass did not. Walking distance, balance, and respiratory function were significantly improved. Weight and fat mass gains did not differ according to the presence or absence of hyperactivity. At 12 months, 46% of the patients continued to be physically active, but 21% of the patients had been re-hospitalized. The early return to controlled physical activities in PMR hospitalization does not compromise the efficiency of intensive refeeding in severe anorexia nervosa patients.

Changes in trabecular bone score and bone density in female adolescents with anorexia nervosa: a longitudinal study

Impaired bone health is a common complication of anorexia nervosa (AN). We aimed to assess longitudinal changes in bone mineral density (BMD) and trabecular bone score (TBS), a measure of bone quality, in female adolescents with anorexia nervosa (AN). We conducted a retrospective longitudinal study of 41 female adolescents with AN who underwent two dual-energy X-ray absorptiometry (DXA) scans. Clinical data, including age, weight, height, body mass index (BMI), and DXA measurements were retrieved from the medical charts. Lumbar bone mineral apparent density (BMAD) was calculated to correct for size. Changes (Δ) in BMD, BMAD, and TBS were examined for correlations with clinical characteristics. Mean ages at the time of DXA scans were 14.8±1.9 and 16.8±2.0 years. There was a significant improvement in anthropometric parameters and DXA measurements at the second DXA scan. However, these values were still significantly lower than expected in the general population. The Δlumbar BMD Z-score was 0.3±0.7, the Δlumbar BMAD Z-score was 0.2±0.7 and the ΔTBS Z-score was 0.5±0.7. ΔTBS Z-score was positively correlated with Δheight Z-score, Δweight Z-score and ΔBMI Z-scores, and negatively correlated height Z-score, weight Z-score and TBS Z-scores at the first DXA scan (p<0.05). Δheight Z-score, ΔBMI Z-score and the progression from early to late puberty were identified as significant independent predictors of Δlumbar BMAD Z-score (p<0.05). During two years of treatment, both BMD and TBS increased significantly. Improvement in height and in weight status, and progression in puberty are predictors of improvement in BMD and TBS.

Subjective Experience of Antidepressant Prescription Among Adolescents With Anorexia Nervosa

INTRODUCTION

Major depressive disorder is considered the most common comorbidity of anorexianervosa in adolescence. Some evidence argues against antidepressant use in this population. Moreover, the fear of being threatened with autonomy and of becoming dependent specific to this adolescent population and at the very core of the anorexic disease, make the proposal of such a treatment difficult to accept. This qualitative research aimed to explore the perspectives of view of adolescents with anorexia nervosa about antidepressants.

METHODS

We conducted interviews with adolescents suffering from anorexia nervosa who had been treated with an antidepressant agent during their inpatient or outpatient care at Cochin Hospital. Adolescents were chosen by convenience sampling. Both verbal and written questions were asked to elicit their lived experiences. Interpretative Phenomenological Analysis was used to examine the data.

RESULTS

Fifteen adolescents (13 girls and two boys) were interviewed. We have reached total data saturation. The analysis found two meta-themes, each with two separate themes. (I) Reactions to the proposal of antidepressant with (i) an opposition phase (about the existence of depressive symptoms and about negative preconceptions) and (ii) need to share with family and other teenagers. (II) Reactions to antidepressant use with (iii) ambivalence and an initial perception of coercion, and (iv) effects of antidepressants (psychological effects, effects on the body and on anorexia nervosa and effects perceived through the eyes of others).

DISCUSSION

Despite positive effects, ambivalence toward the treatment remained present throughout the interviews: these adolescents still worry greatly about loss of control and weight gain. Depression as comorbidity seems to be entangled in the denial of disease, cognitive distortion and acquired fearlessness specific to AN. Its existence in adolescence can uncover transgenerational issues, sometimes previously hidden. An orodispersible/drinkable form of antidepressants would facilitate adherence to treatment in this specific population. The intervention of a "patient-expert" could reduce adolescents' anxiety about loss of control. A latency period seems necessary to allow them to understand the prescription at their own level and in the complexity of their anorexic illness.

Effect of Transdermal Estradiol and Insulin-like Growth Factor-1 on Bone Endpoints of Young Women With Anorexia Nervosa

CONTEXT

Anorexia nervosa (AN) is prevalent in adolescent girls and is associated with bone impairment driven by hormonal alterations in nutritional deficiency.

OBJECTIVE

To assess the impact of estrogen replacement with and without recombinant human insulin-like growth factor-1 (rhIGF-1) administration on bone outcomes.

DESIGN

Double-blind, randomized, placebo-controlled 12-month longitudinal study.

PARTICIPANTS

Seventy-five adolescent and young adult women with AN age 14 to 22 years. Thirty-three participants completed the study.

INTERVENTION

Transdermal 17-beta estradiol 0.1 mg/day with (i) 30 mcg/kg/dose of rhIGF-1 administered subcutaneously twice daily (AN-IGF-1+) or (ii) placebo (AN-IGF-1-). The dose of rhIGF-1 was adjusted to maintain levels in the upper half of the normal pubertal range.

MAIN OUTCOME MEASURES

Bone turnover markers and bone density, geometry, microarchitecture, and strength estimates.

RESULTS

Over 12 months, lumbar areal bone mineral density increased in AN-IGF-1- compared to AN-IGF-1+ (P = 0.004). AN-IGF-1+ demonstrated no improvement in areal BMD in the setting of variable compliance to estrogen treatment. Groups did not differ for 12-month changes in bone geometry, microarchitecture, volumetric bone mineral density (vBMD), or strength (and results did not change after controlling for weight changes over 12 months). Both groups had increases in radial cortical area and vBMD, and tibia cortical vBMD over 12 months. Levels of a bone resorption marker decreased in AN-IGF-1- (P = 0.042), while parathyroid hormone increased in AN-IGF-1+ (P = 0.019). AN-IGF-1- experienced irregular menses more frequently than did AN-IGF-1+, but incidence of all other adverse events did not differ between groups.

CONCLUSIONS

We found no additive benefit of rhIGF-1 administration for 12 months over transdermal estrogen replacement alone in this cohort of young women with AN.

Studying bone mineral density in young people: The complexity of choosing a pQCT reference database

BACKGROUND

Many chronic illnesses affect bone health, and commonly lead to mineralization abnormalities in young people. As cortical and trabecular bone may be differentially affected in certain diseases, an imaging technique that allows for detailed study of the bone structure is required. Peripheral quantitative computed tomography (pQCT) overcomes the limitations of dual energy X-ray absorptiometry (DXA) and is perhaps more widely available for use in research than bone biopsy. However, in contrast to DXA, where there are large reference datasets, this is not the case for pQCT.

METHODS

Fifty-five children and young adults aged 7 to 30 years had the non-dominant tibia scanned at the 3% & 4% sites for trabecular bone mineral density and the 38% site for cortical bone mineral density and bone mineral content. Image acquisition and analysis was undertaken according to the protocols of two of the largest reference datasets for tibial pQCT. The Z-scores generated were compared to examine the differences between protocols and the differences from the expected median of zero in a healthy population.

RESULTS

The trabecular bone mineral density Z-scores generated by the two protocols were similar. The same was true for cortical mineral content Z-scores at the 38% site. Cortical bone mineral density was significantly different between protocols and likely affected by differences in the ethnicity of our cohort compared to the reference datasets. Only one reference dataset extended from childhood to young adulthood. Only trabecular bone mineral density, periosteal and endosteal circumference Z-scores from one methodology were not significantly biased when tested for deviation of the median from zero.

CONCLUSIONS

pQCT is a useful tool for studying trabecular and cortical compartments separately but, there are variations in pQCT scanning protocols, analysis methodology, and a paucity of reference data. Reference datasets may not be generalizable to local study populations, even when analysed using identical analysis protocols.

Associations between exercise, bone mineral density, and body composition in adolescents with anorexia nervosa

OBJECTIVE

To identify the effect of duration of weight-bearing exercise and team sports participation on bone mineral density (BMD) and body composition among adolescents with anorexia nervosa (AN).

METHOD

We retrospectively reviewed electronic medical records of all patients 9-20 years old with a DSM-5 diagnosis of AN evaluated by the Stanford Eating Disorders Program (1997-2011) who underwent dual-energy X-ray absorptiometry.

RESULTS

A total of 188 adolescents with AN were included (178 females and 10 males). Using multivariate linear regression, duration of weight-bearing exercise (B = 0.15, p = 0.005) and participation in team sports (B = 0.53, p = 0.001) were associated with higher BMD at the hip and team sports (B = 0.39, p = 0.006) were associated with higher whole body BMC, controlling for covariates. Participation in team sports (B = - 1.06, p = 0.007) was associated with greater deficits in FMI Z-score. LBMI Z-score was positively associated with duration of weight-bearing exercise (B = 0.10, p = 0.018) and may explain the relationship between exercise and bone outcomes.

CONCLUSION

Duration of weight-bearing exercise and team sports participation may be protective of BMD at the hip and whole body BMC, while participation in team sports was associated with greater FMI deficits among adolescents with AN.

LEVEL OF EVIDENCE

Level V, descriptive retrospective study.

Low bone mineral density in anorexia nervosa: Treatments and challenges

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.

Effects of Anorexia Nervosa on Bone Metabolism

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.

The Impact of Psychotropic Medications on Bone Health in Youth

PURPOSE OF REVIEW

Psychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use.

RECENT FINDINGS

Through a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health. Awareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.

Role of antidepressants in the treatment of adults with anorexia nervosa

Introduction:

Anorexia nervosa (AN) is a severe psychiatric disorder that is difficult to treat and is associated with frequent relapses and high mortality rates. Psychiatric symptomatology (eg, depression, anxiety, obsessive-compulsive disorder/behaviors) are common comorbidities. This review provides current information about safety and efficacy of antidepressant therapy for management of AN in adults.

Methods:

A literature review of randomized controlled trials, open-label studies, and case reports with adults or adults/adolescents was conducted. PubMed and Medline were searched using anorexia management and treatment, antidepressants, selective serotonin reuptake inhibitors (SSRIs), fluoxetine, sertraline, citalopram, and mirtazapine in AN, relapse prevention in AN, and psychotropic medications in AN.

Results:

The role and utility of antidepressants in AN were published in double-blind, placebo-controlled studies; open-label trials; and a retrospective study. Antidepressants should not be used as sole therapy for AN although their use for confounding symptomatology makes discerning efficacy difficult as they are given together with other therapies. Neurobiological changes due to starvation and AN itself complicate results interpretation. For safety, tricyclic antidepressants and monoamine oxidase inhibitors are not recommended, and bupropion is contraindicated. Use of SSRIs during acute treatment lacks efficacy. Use of SSRIs—primarily fluoxetine and to some extent citalopram, sertraline, or mirtazapine—may aid in relapse prevention and improvement of psychiatric symptomatology in weight-restored anorexic patients.

Discussion:

Health care professionals should use clinical judgment regarding fluoxetine or possibly citalopram, sertraline or mirtazapine as adjunctive treatment to psychotherapy for relapse prevention, improvement of depressive and anxiety symptoms, and/or obsessive-compulsive behaviors unresolved with nutritional rehabilitation and psychotherapy.