Weight and skeletal maturation - a study of radiological and chronological age in an anorexia nervosa population

Prospective Longitudinal Assessment of Linear Growth and Adult Height in Female Adolescents With Anorexia Nervosa

CONTEXT

Growth retardation is an established complication of anorexia nervosa (AN); however, findings concerning the adult height of AN patients are inconsistent.

OBJECTIVE

The objective of this work was to assess linear growth and adult height in female adolescents with AN.

DESIGN AND SETTING

A prospective observational study was conducted in a tertiary university hospital.

PARTICIPANTS

Participants included all 255 female adolescent AN patients hospitalized in the pediatric psychosomatic department between January 1, 2000 and May 31, 2015.

INTERVENTIONS

Height and weight were assessed at admission and during hospitalization. Patients were subsequently invited for measurement of adult height. Additional data collected included premorbid height data, menstrual history, skeletal age, pertinent laboratory studies, and parental heights.

MAIN OUTCOME MEASURE

The main outcome measure of this study was adult height.

RESULTS

Mean age at admission was 15.4 ± 1.75 years, mean body mass index (BMI) was 15.7 ± 1.8 kg/m2 (BMI SDS = -2.3 ± 1.45 kg/m2). Premorbid height SD scores (SDS) were not significantly different from those expected in normal adolescents (0.005 ± 0.96). However, height SDS at admission (-0.36 ± 0.99), discharge (-0.34 ± 0.96), and at adult height (-0.29 ± 0.95), were significantly (P < .001) lower than expected. Furthermore, adult height was significantly (P = .006) shorter compared to the midparental target height. Stepwise forward linear regression analysis identified age (r = 0.32, P = .002) and bone age (r = -0.29, P = .006) on admission, linear growth during hospitalization (r = 0.47, P < .001), and change in luteinizing hormone during hospitalization (r = -0.265, P = .021) as independent predictors of improvement in height SDS from the time of admission to adult height.

CONCLUSIONS

Whereas the premorbid height of female adolescent AN patients is normal, linear growth retardation is a prominent feature of their illness. Weight restoration is associated with catch-up growth, but complete catch-up is often not achieved.

Preserved white matter microstructure in young patients with anorexia nervosa?

A massive but reversible reduction of cortical thickness and subcortical gray matter (GM) volumes in Anorexia Nervosa (AN) has been recently reported. However, the literature on alterations in white matter (WM) volume and microstructure changes in both acutely underweight AN (acAN) and after recovery (recAN) is sparse and results are inconclusive. Here, T1-weighted and diffusion-weighted MRI data in a sizable sample of young and medication-free acAN (n = 35), recAN (n = 32), and age-matched female healthy controls (HC, n = 62) were obtained. For analysis, a well-validated global probabilistic tractography reconstruction algorithm including rigorous motion correction implemented in FreeSurfer: TRACULA (TRActs Constrained by UnderLying Anatomy) were used. Additionally, a clustering algorithm and a multivariate pattern classification technique to WM metrics to predict group membership were applied. No group differences in either WM volume or WM microstructure were detected with standard analysis procedures either in acAN or recAN relative to HC after controlling for the number of performed statistical tests. These findings were not affected by age, IQ, or psychiatric symptoms. While cluster analysis was unsuccessful at discriminating between groups, multivariate pattern classification showed some ability to separate acAN from HC (but not recAN from HC). However, these results were not compatible with a straightforward hypothesis of impaired WM microstructure. The current findings suggest that WM integrity is largely preserved in non-chronic AN. This finding stands in contrast to findings in GM, but may help to explain the relatively intact cognitive performance of young patients with AN and provide the basis for the fast recovery of GM structures. Hum Brain Mapp 37:4069-4083, 2016. © 2016 Wiley Periodicals, Inc.

Relation of adrenal-derived steroids with bone maturation, mineral density and geometry in healthy prepubertal and early pubertal boys

BACKGROUND

Little is known about the effects of adrenal steroids on skeletal maturation and bone mass acquisition in healthy prepubertal boys.

OBJECTIVE

To study whether adrenal-derived steroids within the physiological range are associated with skeletal maturation, areal and volumetric bone mineral density (aBMD and vBMD) and bone geometry in healthy prepubertal and early pubertal boys.

METHODS

98 healthy prepubertal and early pubertal boys (aged 6-14 y) were studied cross-sectionally. Androstenedione (A) and estrone (E1) were determined by liquid chromatography tandem mass spectrometry and DHEAS was determined by immunoassay. Whole body and lumbar spine aBMD and bone area were determined by dual-energy X-ray absorptiometry. Trabecular (distal site) and cortical (proximal site) vBMD and bone geometry were assessed at the non-dominant forearm and leg using peripheral QCT. Skeletal age was determined by X-ray of the left hand.

RESULTS

Adrenal-derived steroids (DHEAS, A and E1) are positively associated with bone age in prepubertal and early pubertal children, independently of age. There are no associations between the adrenal-derived steroids and the studied parameters of bone size (lumbar spine and whole body bone area, trabecular or cortical area at the radius or tibia, periosteal circumference and cortical thickness at the radius or tibia) or BMD (aBMD or vBMD).

CONCLUSION

In healthy prepubertal and early pubertal boys, serum adrenal-derived steroid levels, are associated with skeletal maturation, independently of age, but not with bone size or (v)BMD. Our data suggest that adrenal derived steroids are not implicated in the accretion of bone mass before puberty in boys.

Poor catch-up growth in late adolescent boys with eating disorders, weight loss and stunting of growth

OBJECTIVE

The study aims to investigate the catch-up growth of boys presenting with an eating disorder (ED) and a stunting of growth.

METHOD

Weight gain and growth of 46 boys with ED were followed up for 1-3 years.

RESULTS

A total of 13 boys who had not started their pubertal growth spurt at presentation started catch-up growth immediately following nutritional rehabilitation and weight gain. After 3 years, they had returned to their premorbid growth curve. Thirty-three boys who had started their pubertal growth spurt prior to presentation never caught up in height but continued to catch down despite weight gain. After 3 years, they had lost 0.64 ± 0.55 height standard deviation scores corresponding to approximately 4.5 cm of potential height.

CONCLUSIONS

In prepubertal boys with EDs, catch-up growth is possible. Pubertal boys are at a disadvantage in that catch-up growth may not occur despite weight gain.

Near normalisation of lumbar spine bone density in young women with osteopenia recovered from adolescent onset anorexia nervosa: a longitudinal study

To investigate the effect of the progression of adolescent onset anorexia nervosa (AN) on bone parameters we followed two cohorts (Disease cohort and recovered cohort) of adolescents for a total of 5.2 years. In the 'Disease' cohort (n = 18), lumbar spine bone density (BMD) was reduced by 0.6 SD after 0.8 years of disease and was reduced a further 1.0 SD after a total 2.5 years of disease (p < 0.001). At the third lumbar vertebra there was bone loss (-3.7%, p < 0.05) resulting in reduced volumetric BMD (-5.1%, p < 0.08). In the 'recovered' cohort, lumbar spine BMD was reduced by 1.9 SD after 1.7 years of disease, and increased by 1.5 SD after 2.7 years of recovery (p < 0.001). At the third lumbar vertebra there was an increase in bone mass (20.5%, p < 0.001) and bone volume (14.1%, p < 0.001), resulting in increased volumetric BMD (6.3%, p < 0.08). Normalisation of lumbar spine BMD may be achieved in patients with adolescent onset AN when the successful recovery of body weight is combined with the return of regular menses.

Decreased final height of children with growth deceleration secondary to poor weight gain during late childhood

Eighteen healthy, short children with normal growth during most of their childhood were evaluated after a sustained fall in weight and reduced linear growth. Growth was followed after nutritional counseling until final height. This report demonstrates the need for an appropriate-for-age weight gain in growing children as a relatively minor but prolonged caloric restriction, leading to a sustained fall in weight centiles, will affect growth velocities long term and may lead to reduced final heights.

Stunting of growth as a major feature of anorexia nervosa in male adolescents

OBJECTIVE

To assess growth retardation in male adolescent patients who have a diagnosis of anorexia nervosa (AN) and the effect of weight restoration on catch-up growth.

METHODS

Medical charts of all male adolescent AN patients (n = 12) who were admitted to the Pediatric Psychosomatic Department at the Sheba Medical Center from January 1, 1994, to December 31, 1998, were reviewed. Height and weight measurements were obtained before the onset of AN, at admission, and thereafter routinely during hospitalization and follow-up.

RESULTS

Eleven patients exhibited growth retardation during the course of their illness, as evident in a decrease in their height standard deviation score (SDS). The mean height SDS at the time of admission (-0.81 +/- 0.93) was significantly lower than the premorbid SDS (-0.21 +/- 0.91). Weight restoration resulted in accelerated linear growth (up to 2 cm/mo) in all patients. Positive weight gain (weight gain rate >1 kg/y) was associated with a mean height gain of 6.97 +/- 6.48 cm/y, whereas weight loss or failure to gain weight (weight gain rate <or=1 kg/y) was associated with a mean of 2.7 +/- 3.9 cm/y. This between-group difference was highly significant. Complete catch-up growth was not achieved in 9 of 12 patients. There was a trend for the mean adult final height SDS (-0.52 +/- 0.84) to be higher than the admission height SDS but lower than both the premorbid height SDS and the midparental target height SDS (-0.21 +/- 0.79).

CONCLUSIONS

Linear growth retardation was a prominent feature of AN in our sample of male adolescent patients, preceding, in some cases, the reported detection of the eating disorder. Weight restoration, particularly when target weight is based on the premorbid height percentile, may be associated with significant catch-up growth, but complete catch-up growth may not be achieved.

Osteoporosis in young people. Research and treatment in eating disorders

We still have much to learn about BMD problems in eating disorders. Much progress has been made in the past 10 years; most clinicians and many patients and their families are now aware of the problem. More research is crucial, however, the authors suggest focusing on three areas: 1. Treatment and prevention: Such studies are difficult to conduct for similar reasons to the difficulties in conducting treatment trials of therapy for AN. First, the relative rarity of the condition makes it difficult to recruit subjects; second, drop-out rates are higher because of ambivalence; and third, the population is heterogeneous both in terms of symptoms and cause. 2. Better understanding of bone turnover in AN. More studies are needed to examine turnover of bone in patients with AN using biochemical markers. In particular, prospective studies are needed to examine the effects of refeeding, weight gain, and treatments such as calcium supplementation. 3. Long-term course of bone density. It would be particularly instructive to examine this in individuals with a short or long history of AN. It would also be useful to study women approaching menopause who had an episode of AN in their teens or early twenties compared with women who were of normal weight during this period.

Bone density of women who have recovered from anorexia nervosa

OBJECTIVE

To examine bone density in 19 women who had previously experienced classical anorexia nervosa from which they had been fully recovered for a mean of 21 years (current characteristics: median age 40.2 years; Eating Attitudes Test [EAT] score 2; body mass index [BMI] 21.1; average 1.8 offspring).

METHOD

Probands were compared, blindly, in respect of bone density, with 13 control subjects matched for age and sex and with no history of eating disorders. Dual energy X-ray absorptiometry (DXA) was used to evaluate the bone mineral density (BMD) of the lumbar spine and the head of the femur.

RESULTS

Femur BMD was still significantly less among ex-anorectic sufferers. Two subjects had experienced pathological fractures while anorectic, both having been strenuous exercisers. None appeared to have suffered post illness fractures. BMD at follow-up did not relate to the severity or chronicity of previous anorexia nervosa.

DISCUSSION

Full clinical recovery from anorexia nervosa does not quite confer full establishment of normal bone density. However, pathological fractures are not a feature thereafter, within middle life.

Effects of weight loss on bone mineral density in rats

OBJECTIVE

To evaluate the effects of weight loss on bone mineral density (BMD).

METHODS

Eight-week-old female rats were divided into 4 groups: Those in Group A received a restricted diet for 4 weeks; those in Group B received a restricted diet and were treated with estrogen; those in Group C were castrated; and those in Group D underwent sham operations. The rat's body weight (BW) and vaginal smears were checked, and their femoral BMD was measured.

RESULTS

The BW and BMD at 12 weeks were lower in Groups A and B than in Groups C and D; thereafter, however, these values increased for Groups A and B, but were still lower than those in Group D even at 20 weeks. In Group C, the BMD did not decrease, but it was significantly lower than that in Group D at 16 and 20 weeks. Group A showed continuous diestrus 2 weeks after dietary restriction began, but recovered to a 4-day cycle 2 weeks after the initiation of free food consumption.

CONCLUSION

Weight loss had a greater effect on BMD than hypoestrogenism.

Bone metabolism and osteopenia in eating disorders

Bone loss is a potentially debilitating condition in women with eating disorders. Complications may include failure to achieve peak bone mass, increased risk of premature fractures, and inability to reach the height potential. We therefore conducted a comprehensive evaluation of 58 women with anorexia nervosa (AN), bulimia (BUL) and anorexia/bulimia (AB), comparing bone mineral density (BMD) to physical parameters, biochemical indices, and markers for bone formation and resorption. BMDs were significantly lower in patients with AN than in those with AB and BUL, and overt osteopenia was uncommon in AB and BUL. Hypercortisolism was the best laboratory marker to assess the risk of osteopenia in patients with AN. However, there were no associated changes in bone formation or resorption parameters. No direct correlation was found between BMD and body mass index, estrogen deficiency, tubular reabsorption of phosphorus, serum vitamin D, PTH, BGP, or alkaline phosphatase levels. Although the prognosis for complete recovery to normal BMD is poor, treatment of the underlying depressive disorder, improvement in nutrition with increased weight, and spontaneous resumption of menses are associated with restoring bone health.

Anorexia nervosa: physical health and neurodevelopment at 16 and 21 years

Fifty-one cases of anorexia nervosa (AN) and 51 age-, sex- and school-matched controls, all drawn from a community sample of 15- to 16-year-olds, were compared at 16 and 21 years with regard to physical health and neurodevelopment. The AN group had significantly lower mean height than the comparison group at age 21 years. There were significantly more individuals that were overweight and underweight in the AN group at age 21 years. Fractures were slightly, but significantly, more common. Dysdiadochokinesis was very much more common in the AN group at both ages, and its occurrence was not correlated with low weight. It is suggested that diadochokinesis in AN might mirror some inherent underlying immaturity or other abnormality of the central nervous system in a subgroup of cases. The presence of dysdiadochokinesis was associated with a tendency towards poorer psychosocial outcome, even in cases that were no longer underweight.

Outcome of bone mineral density in anorexia nervosa patients 11.7 years after first admission

Osteopenia is a typical finding in patients suffering from anorexia nervosa. Unfortunately, available longitudinal studies are limited by a relatively short follow-up period. Therefore cross-sectional long-term followup studies may help to determine both the outcome of this bone lesion and variables that influence its subsequent development. Of an initial 66 consecutive patients with anorexia nervosa, 51 (77.3%) could be further evaluated. After an average of 11.7 years following first admission, cross-sectional measurements of lumbar and proximal radial bone mineral density (BMD) were performed. The ability to predict BMD using variables obtained from anamnestic and clinical data was then determined by multiple-regression analysis. The BMD of both radial and lumbar bone in anorexic patients with poor disease outcome (as defined by the Morgan-Russell general outcome categories) deviated by -2.18 and -1.73 SD (Z score), respectively. In patients with a good disease outcome lumbar BMD was significantly less reduced compared with radial BMD (-0.26 versus -0.68 SD). Variables reflecting estrogen deficiency and nutritional status in the course of the disease, that is, relative estrogen exposure (for lumbar BMD) and years of anorexia nervosa (for radial BMD), allowed the best prediction of BMD. A marked reduction in cortical and trabecular BMD in anorexic patients with poor disease outcome suggests a higher risk of fractures in these patients. Furthermore, the finding of a persistently reduced cortical and a slightly reduced trabecular BMD, even in patients with good disease outcome, suggests that a recovery of trabecular BMD might be possible, at least in part. Recovery of cortical bone, if possible at all, seems to proceed more slowly.

The medical complications of anorexia nervosa

The physical complications of anorexia nervosa are common and can be life threatening, but psychiatrists and the increasing number of non-medical therapists involved in treatment programmes often overlook these complications. Cardiovascular complications are the most common, and the most likely to result in fatalities, particularly in those patients who vomit, purge or abuse diuretics, because of the electrolyte abnormalities induced. Osteoporosis is an early and perhaps irreversible consequence of severe weight loss. Further, there are dangers in rapid intravenous hyperalimentation.

Osteoporosis in anorexia nervosa: the influence of peak bone density, bone loss, oral contraceptive use, and exercise

Anorexia nervosa occurs early in life and predisposes to osteoporosis. Exercise may be protective. We asked: (1) Does failure to attain peak bone density contribute to the deficit in bone density? (2) Does oral contraceptive use protect against osteoporosis? (3) Is any protective effect of exercise confined to weight-bearing sites? Areal bone density (g/cm2) and body composition were measured by dual x-ray absorptiometry in 65 patients with anorexia nervosa and 52 controls. Comparing the 12 patients with primary amenorrhea and the 37 patients with secondary amenorrhea, bone density (mean +/- SEM) at the lumbar spine was 0.88 +/- 0.04 versus 1.06 +/- 0.03 (P = 0.001), respectively. Bone density at the femoral neck was 0.80 +/- 0.04 versus 0.92 +/- 0.03 (P < 0.05), respectively. These values differed before, but not after, adjusting for the respective duration of illness (73.0 +/- 10.3 versus 34.1 +/- 4.8 months, P < 0.001) and fat-free mass (31.6 +/- 1.3 versus 35.4 +/- 0.5 kg, P < 0.01). Bone density at the lumbar spine in the 16 patients with 31.8 +/- 8.3 months of contraceptive exposure was higher than in the 49 patients with no contraceptive exposure (1.14 +/- 0.05 versus 1.02 +/- 0.02 P < 0.02) but was lower than in controls (1.14 +/- 0.05 versus 1.27 +/- 1.02, P < 0.01). No protective effect of contraceptive exposure was detectable at the femoral neck.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of anorexia nervosa on linear growth

To study the effect of severe undernutrition on linear growth during adolescence, a report was obtained on the ultimate adult height of 71 patients who had had anorexia nervosa at or before age 16 years. At time of diagnosis (ages 9-16 years) median height percentile was 49; at adult follow-up (ages 18-29 years) the median height percentile was 55. This change favoring growth was statistically significant (p less than 0.01). Height percentile was maintained or increased in 45 patients and decreased in 26 patients. In only four patients did it change by more than 20 percentile points downward; in 12 patients height percentile increased by more than 20 points. We conclude that, despite weight loss of up to 45 percent at or before age 16 years, most patients with anorexia nervosa continue to grow in stature according to expected norms.

Osteoporosis in women with anorexia nervosa

Because estrogen deficiency predisposes to osteoporosis, we assessed the skeletal mass of women with anorexia nervosa, using direct photon absorptiometry to measure radial bone density in 18 anorectic women and 28 normal controls. The patients with anorexia had significantly reduced mean bone density as compared with the controls (0.64 +/- 0.06 vs. 0.72 +/- 0.04 g per square centimeter, P less than 0.001). Vertebral compression fractures developed in two patients, and bone biopsy in one of them demonstrated osteoporosis. Bone density in the patients was not related to the estradiol level (r = 0.02). Levels of parathyroid hormone, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D were normal despite low calcium intakes. The patients with anorexia who reported a high physical activity level had a greater bone density than the patients who were less active (P less than 0.001); this difference could not be accounted for by differences in age, relative weight, duration of illness, or serum estradiol levels. The bone density of physically active patients did not differ from that of active or sedentary controls. We conclude that women with anorexia nervosa have a reduced bone mass due to osteoporosis, but that a high level of physical activity may protect their skeletons.

Osteopenia in hypoestrogenic young women with anorexia nervosa

Replacement estrogen therapy for premenopausal women with secondary hypogonadism (exercise/weight loss amenorrheas) remains controversial. In a group of 14 women with anorexia nervosa, amenorrhea, and no evidence of other endocrinopathy or protein-calorie malnutrition, significant osteopenia was demonstrated as assessed by cortical thickness of carpal bones. The degree of bone thinning was related to the duration and age at onset of amenorrhea as well as abnormalities of pubertal milestone progression. In the young women with "constitutionally delayed" menarche, or with secondary amenorrhea and hypogonadism, significant osteopenia may also be present. For those women with (1) hypoestrogenism and amenorrhea of over 36 months' duration, (2) pubertal delay, and (3) early onset of secondary amenorrhea, evaluation of osteopenia radiographically, and serious consideration for estrogen replacement, is important.

Anorexia nervosa presenting as growth retardation in adolescents

Two adolescent males and one adolescent female were referred for evaluation of short stature. Extensive laboratory studies, often performed over several years, were unremarkable. After several years of observation, the diagnosis of anorexia nervosa was established. We emphasize the necessity to consider anorexia nervosa in the differential diagnosis of growth retardation in young adolescents.