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Behan FP, Bull AMJ, Beck BR, Brooke-Wavell K, Müller R, Vico L, Isaksson H, Harvey NC, Buis A, Sherman K, Jefferson G, Cleather DJ, McGregor A, Bennett AN. Developing an exercise intervention to minimise hip bone mineral density loss following traumatic lower limb amputation: a Delphi study. Br J Sports Med 2024:bjsports-2024-108721. [PMID: 39227136 DOI: 10.1136/bjsports-2024-108721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVE To elicit expert opinion and gain consensus on specific exercise intervention parameters to minimise hip bone mineral density (BMD) loss following traumatic lower limb amputation. METHODS In three Delphi rounds, statements were presented to a panel of 13 experts from six countries. Experts were identified through publications or clinical expertise. Round 1 involved participants rating their agreement with 22 exercise prescription statements regarding BMD loss post amputation using a 5-point Likert scale. Agreement was deemed as 3-4 on the scale (agree/strongly agree). Statements of <50% agreement were excluded. Round 2 repeated remaining statements alongside round 1 feedback. Round 3 allowed reflection on round 2 responses considering group findings and the chance to change or maintain the resp onse. Round 3 statements reaching ≥70% agreement were defined as consensus. RESULTS All 13 experts completed rounds 1, 2 and 3 (100% completion). Round 1 excluded 12 statements and added 1 statement (11 statements for rounds 2-3). Round 3 reached consensus on nine statements to guide future exercise interventions. Experts agreed that exercise interventions should be performed at least 2 days per week for a minimum of 6 months, including at least three different resistance exercises at an intensity of 8-12 repetitions. Interventions should include weight-bearing and multiplanar exercises, involve high-impact activities and be supervised initially. CONCLUSION This expert Delphi process achieved consensus on nine items related to exercise prescription to minimise hip BMD loss following traumatic lower limb amputation. These recommendations should be tested in future interventional trials.
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Affiliation(s)
- Fearghal P Behan
- Imperial College London, London, UK
- Trinity College Dublin, Dublin, Ireland
| | - Anthony M J Bull
- Department of Bioengineering, Imperial College London, London, UK
| | | | | | - Ralph Müller
- Institute of Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Laurence Vico
- Inserm U1059 SAINBIOSE, Université Jean Monnet Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | | | | | | | - Daniel J Cleather
- School of Sport, Health and Applied Science, St. Mary's University, Twickenham, London, UK
| | - Alison McGregor
- Surgery and Cancer / Human Performance Group, Imperial College London, London, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Epsom, UK
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Behan FP, Bull AMJ, Bennett A. Developing an exercise intervention to improve bone mineral density in traumatic amputees: protocol for a Delphi study. BMJ Open 2023; 13:e073062. [PMID: 37844985 PMCID: PMC10582893 DOI: 10.1136/bmjopen-2023-073062] [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: 02/21/2023] [Accepted: 09/20/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Lower limb amputation results in reduced bone mineral density (BMD) on the amputated side. Exercise interventions have proven effective in improving BMD. However, such interventions have not been attempted in an amputee population. Exercises designed for people with intact limbs may not be suitable for amputees, due to joint loss and the mechanical interface between the exercise equipment and the femoral neck being mediated through a socket. Therefore, prior to intervention implementation, it would be prudent to leverage biomechanical knowledge and clinical expertise, alongside scientific evidence in related fields, to assist in intervention development. The objective of this study is to elicit expert opinion and gain consensus to define specific exercise prescription parameters to minimise/recover BMD loss in amputees. METHODS AND ANALYSIS The Delphi technique will be used to obtain consensus among international experts; this will be conducted remotely as an e-Delphi process. 10-15 experts from ≥2 continents and ≥5 countries will be identified through published research or clinical expertise. Round 1 will consist of participants being asked to rate their level of agreement with statements related to exercise prescription to improve amputee BMD using a 5-point Likert Scale. Agreement will be deemed as ≥3 on the Likert Scale. Open feedback will be allowed in round 1 and any statement which less than 50% of the experts agree with will be excluded. Round 2 will repeat the remaining statements with the addition of any input from round 1 feedback. Round 3 will allow participants to reflect on their round 2 responses considering statistical representation of group opinion and whether they wish to alter any of their responses accordingly. Statements reaching agreement rates of 70% or above among the experts will be deemed to reach a consensus and will be implemented in a future exercise interventional trial. ETHICS AND DISSEMINATION Ethical approval was received from Imperial College Research Ethics Committee (reference: 6463766). Delphi participants will be asked to provide digital informed consent. The findings will be disseminated through peer-reviewed publications.
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Affiliation(s)
- Fearghal P Behan
- Department of Bioengineering, Imperial College London, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Alexander Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
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3
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Cowgill L, Harrington L, MacKinnon M, Kurki HK. Gains in relative cortical area during growth and their relationship to nutrition, body size, and physical activity. AMERICAN JOURNAL OF BIOLOGICAL ANTHROPOLOGY 2023; 182:177-193. [PMID: 37377180 DOI: 10.1002/ajpa.24805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/17/2023] [Accepted: 05/27/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVES In studies of growth in the past, low percentage of cortical area (%CA) is commonly attributed to poor general health, due to factors including poor nutrition, low socioeconomic status, or other physiological stressors. What constitutes low relative cortical dimensions has not been established across a diverse range of human skeletal samples. This study examines %CA in a large immature skeletal sample to establish typical variation in humans with consideration of both body mass and subsistence strategy. MATERIALS AND METHODS Percentage of cortical area was calculated at the midshaft of the humerus, femur, and tibia in seven skeletal samples. Age at death was estimated from dental development, and body mass from bone dimensions. Patterns of %CA with age and log-transformed body mass were examined in the pooled sample and compared among samples using LOESS regression, Welch's ANOVA, and Kruskal-Wallis tests. RESULTS Across all samples, %CA displays a generally non-linear pattern, but variation in %CA with age was high, particularly in samples with lower levels of %CA. There was no relationship between %CA and age-adjusted body mass. DISCUSSION The lack of a relationship between %CA and body mass suggests that %CA should not be used as an indicator of mechanical loading. The variation present across samples implies that appositional bone growth is affected by physiological stress in varying ways. Without a deeper understanding of what is "typical" for long bone development, it is impossible to draw conclusions about individual or population level health.
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Affiliation(s)
- Libby Cowgill
- Department of Anthropology, University of Missouri, Columbia, Missouri, USA
| | - Lesley Harrington
- Department of Anthropology, University of Alberta, Edmonton, Alberta, Canada
| | - Marla MacKinnon
- Department of Anthropology, University of Victoria, Victoria, British Columbia, Canada
| | - Helen K Kurki
- Department of Anthropology, University of Victoria, Victoria, British Columbia, Canada
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4
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Dauty M, Menu P, Jolly B, Lambert S, Rocher B, Le Bras M, Jirka A, Guillot P, Pretagut S, Fouasson-Chailloux A. Inpatient Rehabilitation during Intensive Refeeding in Severe Anorexia Nervosa. Nutrients 2022; 14:nu14142951. [PMID: 35889908 PMCID: PMC9322979 DOI: 10.3390/nu14142951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Marc Dauty
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.D.); (P.M.); (B.J.)
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm UMR 1229, Regenerative Medicine and Skeleton, RMeS, Nantes Université, ONIRIS, 44042 Nantes, France
| | - Pierre Menu
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.D.); (P.M.); (B.J.)
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm UMR 1229, Regenerative Medicine and Skeleton, RMeS, Nantes Université, ONIRIS, 44042 Nantes, France
| | - Baptiste Jolly
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.D.); (P.M.); (B.J.)
| | - Sylvain Lambert
- Psychiatrie et Santé Mentale, UIC 18, CHU Nantes, Nantes Université, 44000 Nantes, France; (S.L.); (B.R.)
| | - Bruno Rocher
- Psychiatrie et Santé Mentale, UIC 18, CHU Nantes, Nantes Université, 44000 Nantes, France; (S.L.); (B.R.)
| | - Maëlle Le Bras
- Service d’Endocrinologie, Diabétologie et Nutrition, Institut du Thorax, CHU Nantes, Nantes Université, 44000 Nantes, France;
| | - Adam Jirka
- Equipe Transversale D’assistance Nutritionnelle, CHU Nantes, Nantes Université, 44000 Nantes, France;
| | - Pascale Guillot
- Service de Rhumatologie, CHU Nantes, Nantes Université, 44000 Nantes, France;
| | - Stéphane Pretagut
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
| | - Alban Fouasson-Chailloux
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.D.); (P.M.); (B.J.)
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm UMR 1229, Regenerative Medicine and Skeleton, RMeS, Nantes Université, ONIRIS, 44042 Nantes, France
- Correspondence:
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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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Herath M, Cohen A, Ebeling PR, Milat F. Dilemmas in the Management of Osteoporosis in Younger Adults. JBMR Plus 2022; 6:e10594. [PMID: 35079682 PMCID: PMC8771004 DOI: 10.1002/jbm4.10594] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/02/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
Osteoporosis in premenopausal women and men younger than 50 years is challenging to diagnose and treat. There are many barriers to optimal management of osteoporosis in younger adults, further enhanced by a limited research focus on this cohort. Herein we describe dilemmas commonly encountered in diagnosis, investigation, and management of osteoporosis in younger adults. We also provide a suggested framework, based on the limited available evidence and supported by clinical experience, for the diagnosis, assessment, and management of osteoporosis in this cohort. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Madhuni Herath
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Adi Cohen
- Department of Medicine Columbia University College of Physicians & Surgeons New York NY USA
| | - Peter R. Ebeling
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Frances Milat
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
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Indirli R, Lanzi V, Mantovani G, Arosio M, Ferrante E. Bone health in functional hypothalamic amenorrhea: What the endocrinologist needs to know. Front Endocrinol (Lausanne) 2022; 13:946695. [PMID: 36303862 PMCID: PMC9592968 DOI: 10.3389/fendo.2022.946695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
In the original definition by Klinefelter, Albright and Griswold, the expression "hypothalamic hypoestrogenism" was used to describe functional hypothalamic amenorrhoea (FHA). Given the well-known effects of estrogens on bone, the physiopathology of skeletal fragility in this condition may appear self-explanatory. Actually, a growing body of evidence has clarified that estrogens are only part of the story. FHA occurs in eating disorders, overtraining, and during psychological or physical stress. Despite some specific characteristics which differentiate these conditions, relative energy deficiency is a common trigger that initiates the metabolic and endocrine derangements contributing to bone loss. Conversely, data on the impact of amenorrhoea on bone density or microarchitecture are controversial, and reduced bone mass is observed even in patients with preserved menstrual cycle. Consistently, oral estrogen-progestin combinations have not proven beneficial on bone density of amenorrheic women. Low bone density is a highly prevalent finding in these patients and entails an increased risk of stress or fragility fractures, and failure to achieve peak bone mass and target height in young girls. Pharmacological treatments have been studied, including androgens, insulin-like growth factor-1, bisphosphonates, denosumab, teriparatide, leptin, but none of them is currently approved for use in FHA. A timely screening for bone complications and a multidisciplinary, customized approach aiming to restore energy balance, ensure adequate protein, calcium and vitamin D intake, and reverse the detrimental metabolic-endocrine changes typical of this condition, should be the preferred approach until further studies are available.
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Affiliation(s)
- Rita Indirli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: Rita Indirli,
| | - Valeria Lanzi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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8
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Romano E, Ma R, Perera G, Stewart R, Tsamakis K, Solmi M, Vancampfort D, Firth J, Stubbs B, Mueller C. Risk of hospitalised falls and hip fractures in working age adults receiving mental health care. Gen Hosp Psychiatry 2021; 72:81-87. [PMID: 34332346 DOI: 10.1016/j.genhosppsych.2021.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This retrospective cohort study investigates risks of hospitalised fall or hip fractures in working age adults receiving mental health care in South London. METHODS Patients aged 18 to 64, who received a first mental illness diagnosis between 2008 and 2016 were included. Primary outcome was hospitalised falls, secondary outcome was hip fractures. Age- and gender-standardised incidence rates and incidence rate ratios (IRRs) compared to local general population were calculated. Multivariate Cox proportionate hazard models were used to investigate which mental health diagnoses were most at risk. RESULTS In 50,885 patients incidence rates were 8.3 and 0.8 per 1,000 person-years for falls and hip fractures respectively. Comparing mental health patients to the general population, age-and-gender-adjusted IRR for falls was 3.6 (95% CI: 3.3-4.0) and for hip fractures 7.5 (95% CI: 5.2-10.4). The falls IRR was highest for borderline personality and bipolar disorder and lowest for schizophreniform and anxiety disorder. After adjusting for multiple confounders in the sample of mental health service users, borderline personality disorder yielded a higher and anxiety disorder a lower falls risk. CONCLUSION Working age adults using mental health services have almost four times the incidence of hospitalised falls compared to general population. Targeted interventions are warranted.
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Affiliation(s)
- Eugenia Romano
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom.
| | - Ruimin Ma
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Gayan Perera
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, Denmark Hill, London, United Kingdom
| | - Konstantinos Tsamakis
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; National and Kapodistrian University of Athens, School of Medicine, Second Department of Psychiatry, University General Hospital 'ATTIKON', Athens, Greece
| | - Marco Solmi
- Padua Neuroscience Center, University of Padova, Padova, Italy
| | - Davy Vancampfort
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium; University Psychiatric Centre, KU Leuven, Leuven Kortenberg, Belgium
| | - Joseph Firth
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Brendon Stubbs
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, Denmark Hill, London, United Kingdom
| | - Christoph Mueller
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, Denmark Hill, London, United Kingdom
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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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Abstract
Osteoporosis is a common and very serious complication of anorexia nervosa. It affects these patients, both males and females, at very young ages. This loss of bone mineral density begins quickly, soon after the onset of the eating disorder. It is one of the rare medical complications of anorexia nervosa which may result in irreparable harm, even if there is successful nutritional rehabilitation and weight restoration. Nevertheless, notwithstanding its high importance, there is a paucity of evidence-based medicine to guide the optimal approach to diagnosis, prevention, and treatment. This paper attempts to inform clinicians taking care of these patients about a reasonable and measured approach to this problem, while the field awaits more definitive medical literature.
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Affiliation(s)
- Philip S Mehler
- ACUTE at Denver Health , Denver , CO , USA.,Eating Recovery Center , Denver , CO , USA.,University of Colorado School of Medicine , Denver , CO , USA
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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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Park JS, Lee HS, Won SH, Lee DW, Jung KJ, Kim CH, Kim JH, Lee WS, Ryu A, Kim WJ. Intertrochanteric fracture with low-energy trauma in a young woman with anorexia nervosa: A case report. Medicine (Baltimore) 2019; 98:e16499. [PMID: 31335717 PMCID: PMC6708982 DOI: 10.1097/md.0000000000016499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Anorexia nervosa is a chronic psychiatric disease defined by severe weight loss, due to fear of obesity, and self-imposed semi-starvation. Of the many complications following anorexia nervosa, low bone mineral density (BMD) is a significant risk factor for fractures. Anorexia nervosa is associated with higher risk of incident fracture in females across all age groups, and in males >40 years old. Sites at highest risk of fracture include the hip/femur and pelvis in females, and vertebrae in males with anorexia nervosa. PATIENT CONCERNS A 29-year-old woman known to have suffered from anorexia nervosa 15 years ago visited the emergency department due to right hip pain after falling while getting out of a taxi. During the period of anorexia nervosa, she had a body mass index (BMI) of 14.06 kg/m (weight, 36 kg; height, 1.60 m) and suffered from amenorrhea. At the time of presentation, she had a BMI of 19.53 kg/m (weight, 50 kg; height, 1.60 m) and had regular menstrual periods, indicating clinical recovery from anorexia nervosa. DIAGNOSES Plain radiography, computed tomography, and bone scintigraphy revealed AO 31-A2.2 type right hip proximal femur intertrochanteric fracture. The BMD showed a T score of -3.9 in the hip and -3.6 at the lumbar level, indicating severe osteoporosis. INTERVENTIONS Osteosynthesis was performed with proximal femoral nail antirotation (PFNA) and wiring. OUTCOMES There were no specific symptoms, such as trauma or infection, during postoperative rehabilitation and postoperative management, and she was discharged after 2 weeks. After 1 year of follow-up at our outpatient clinic, she had no complications. LESSONS Here, we describe an unusual case of unilateral femoral intertrochanteric fracture that occurred after clinical recovery from anorexia nervosa. This case indicated that the risk of fracture remains even after recovery of BMI. We propose that women who have clinically recovered from anorexia nervosa should be advised to undergo annual osteodensitometric analyses after consulting with specialists in other areas (psychiatry, endocrinology, eating disorders).
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Affiliation(s)
- Jong Seok Park
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan
| | - Hong Seop Lee
- Department of Foot and Ankle Surgery, Nowon Eulji Medical Center, Eulji University, 68, Hangeulbiseok-ro, Nowon-gu
| | - Sung Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, 59, Daesagwan-ro, Yongsan-gu
| | - Dhong Won Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, 120-1, Neungdong-ro, Gwangjin-gu, Seoul
| | - Ki Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan
| | - Chang Hyun Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan
| | - Ja Hyung Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, 59, Daesagwan-ro, Yongsan-gu
| | - Won Seok Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, 59, Daesagwan-ro, Yongsan-gu
| | - Aeli Ryu
- Department of Obstetrics and Gynecology, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan, Korea
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan
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Schorr M, Drabkin A, Rothman MS, Meenaghan E, Lashen GT, Mascolo M, Watters A, Holmes TM, Santoso K, Yu EW, Misra M, Eddy KT, Klibanski A, Mehler P, Miller KK. Bone mineral density and estimated hip strength in men with anorexia nervosa, atypical anorexia nervosa and avoidant/restrictive food intake disorder. Clin Endocrinol (Oxf) 2019; 90:789-797. [PMID: 30817009 PMCID: PMC6615544 DOI: 10.1111/cen.13960] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Few bone mineral density (BMD) data are available in men with anorexia nervosa (AN), and none in those with atypical AN (ATYP) (AN psychological symptoms without low weight) or avoidant/restrictive food intake disorder (ARFID) (restrictive eating without AN psychological symptoms). We investigated the prevalence and determinants of low BMD and estimated hip strength in men with these disorders. DESIGN Cross-sectional: two centres. PATIENTS A total of 103 men, 18-63 years: AN (n = 26), ARFID (n = 11), ATYP (n = 18), healthy controls (HC) (n = 48). MEASUREMENTS Body composition, BMD and estimated hip strength (section modulus and buckling ratio) by DXA (Hologic). Serum 25OH vitamin D was quantified, as was daily calcium intake in a subset of subjects. RESULTS Mean BMI was lowest in AN and ARFID, higher in ATYP and highest in HC (AN 14.7 ± 1.8, ARFID 15.3 ± 1.5, ATYP 20.6 ± 2.0, HC 23.7 ± 3.3 kg/m2 ) (P < 0.0005). Mean BMD Z-scores at spine and hip were lower in AN and ARFID, but not ATYP, than HC (postero-anterior (PA) spine AN -2.05 ± 1.58, ARFID -1.33 ± 1.21, ATYP -0.59 ± 1.77, HC -0.12 ± 1.17) (P < 0.05). 65% AN, 18% ARFID, 33% ATYP and 6% HC had BMD Z-scores <-2 at ≥1 site (AN and ATYP vs HC, P < 0.01). Mean section modulus Z-scores were lower in AN than HC (P < 0.01). Lower BMI, muscle mass and vitamin D levels (R = 0.33-0.64), as well as longer disease duration (R = -0.51 to -0.58), were associated with lower BMD (P < 0.05). CONCLUSIONS Men with AN, ARFID and ATYP are at risk for low BMD. Men with these eating disorders who are low weight, or who have low muscle mass, long illness duration and/or vitamin D deficiency, may be at particularly high risk.
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Affiliation(s)
- Melanie Schorr
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Anne Drabkin
- ACUTE Center for Eating Disorders, Denver, Colorado
- Denver Health Medical Center, Denver, Colorado
| | - Micol S. Rothman
- Department of Medicine, Endocrinology, Diabetes, and Metabolism, University of Colorado School of Medicine, Denver, Colorado
| | - Erinne Meenaghan
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Gillian T. Lashen
- ACUTE Center for Eating Disorders, Denver, Colorado
- Denver Health Medical Center, Denver, Colorado
| | - Margherita Mascolo
- ACUTE Center for Eating Disorders, Denver, Colorado
- Denver Health Medical Center, Denver, Colorado
| | | | - Tara M. Holmes
- Translational and Clinical Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Kate Santoso
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Elaine W. Yu
- Harvard Medical School, Boston, Massachusetts
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kamryn T. Eddy
- Harvard Medical School, Boston, Massachusetts
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Philip Mehler
- ACUTE Center for Eating Disorders, Denver, Colorado
- Denver Health Medical Center, Denver, Colorado
| | - Karen K. Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Schorr M, Klibanski A. Anorexia Nervosa and Bone. CURRENT OPINION IN ENDOCRINE AND METABOLIC RESEARCH 2018; 3:74-82. [PMID: 31803857 PMCID: PMC6892594 DOI: 10.1016/j.coemr.2018.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Anorexia nervosa (AN), a psychiatric disorder characterized by altered body image, food restriction and low body weight, is associated with low bone mineral density and increased fracture risk. Despite broadening the definition of AN in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, the prevalence of low bone mass remains high, suggesting we continue to capture individuals at high risk for bone loss. Many of the endocrine disturbances adaptive to the state of chronic starvation are thought to be causal in impaired skeletal integrity in females and males with AN. Understanding mechanisms responsible for impaired bone quality is important given the disease's severity and chronicity. Further research is needed to formulate optimal treatment strategies to reduce fracture risk.
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Affiliation(s)
- Melanie Schorr
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Gibson D, Drabkin A, Krantz MJ, Mascolo M, Rosen E, Sachs K, Welles C, Mehler PS. Critical gaps in the medical knowledge base of eating disorders. Eat Weight Disord 2018; 23:419-430. [PMID: 29681012 DOI: 10.1007/s40519-018-0503-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
Eating disorders are unique in that they inherently have much medical comorbidity both as a part of restricting-type eating disorders and those characterized by purging behaviors. Over the last three decades, remarkable progress has been made in the understanding and treatment of the medical complications of eating disorders. Yet, unfortunately, there is much research that is sorely needed to bridge the gap between current medical knowledge and more effective and evidence-based medical treatment knowledge. These gaps exist in many different clinical areas including cardiology, electrolytes, gastrointestinal and bone disease. In this paper, we discuss some of the knowledge gap areas, which if bridged would help develop more effective medical intervention for this population of patients.
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Affiliation(s)
- Dennis Gibson
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Anne Drabkin
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Mori J Krantz
- Division of Cardiology, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | | | - Elissa Rosen
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Katherine Sachs
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Christine Welles
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Philip S Mehler
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA.
- Eating Recovery Center, Denver, 7351E Lowry Blvd, Denver, CO, 80230, USA.
- , Denver, USA.
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Drabkin A, Rothman MS, Wassenaar E, Mascolo M, Mehler PS. Assessment and clinical management of bone disease in adults with eating disorders: a review. J Eat Disord 2017; 5:42. [PMID: 29214023 PMCID: PMC5713040 DOI: 10.1186/s40337-017-0172-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/08/2017] [Indexed: 01/09/2023] Open
Abstract
AIM To review current medical literature regarding the causes and clinical management options for low bone mineral density (BMD) in adult patients with eating disorders. BACKGROUND Low bone mineral density is a common complication of eating disorders with potentially lifelong debilitating consequences. Definitive, rigorous guidelines for screening, prevention and management are lacking. This article intends to provide a review of the literature to date and current options for prevention and treatment. METHODS Current, peer-reviewed literature was reviewed, interpreted and summarized. CONCLUSION Any patient with lower than average BMD should weight restore and in premenopausal females, spontaneous menses should resume. Adequate vitamin D and calcium supplementation is important. Weight-bearing exercise should be avoided unless cautiously monitored by a treatment team in the setting of weight restoration. If a patient has a Z-score less than expected for age with a high fracture risk or likelihood of ongoing BMD loss, physiologic transdermal estrogen plus oral progesterone, bisphosphonates (alendronate or risedronate) or teriparatide could be considered. Other agents, such as denosumab and testosterone in men, have not been tested in eating-disordered populations and should only be trialed on an empiric basis if there is a high clinical concern for fractures or worsening bone mineral density. A rigorous peer-based approach to establish guidelines for evaluation and management of low bone mineral density is needed in this neglected subspecialty of eating disorders.
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Affiliation(s)
- Anne Drabkin
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
| | - Micol S. Rothman
- University of Colorado Hospital, Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO 80045 USA
| | | | - Margherita Mascolo
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
| | - Philip S. Mehler
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
- Eating Recovery Center, 7351 E. Lowry Blvd. Suite 200, Denver, CO 80230 USA
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17
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Exercise and physical therapy help restore body and self in clients with severe anorexia nervosa. J Bodyw Mov Ther 2016; 21:481-494. [PMID: 28750954 DOI: 10.1016/j.jbmt.2016.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/21/2016] [Accepted: 09/02/2016] [Indexed: 11/18/2022]
Abstract
Exercise in the context of anorexia nervosa is a multifaceted endeavour surrounded by controversy and uncertainty. A broader comprehension of this poorly understood phenomenon is required. Informed by the findings of a body examination of six individuals with anorexia nervosa, as well as exercise science, phenomenology and neurocognition, the purpose of this article is to elaborate on the potential role of exercise and physical therapy in the treatment of anorexia nervosa. The findings of the body assessment include constriction of posture, muscles and pattern of breathing. These bodily restraints are not necessarily merely associated with high levels of exercise, they may also reflect psychological strain accompanying the illness. The restricted breathing in particular is assumed to be associated with difficult thoughts and suppressed feelings. Based on the results of the body examination, as well as medical and psychological considerations accompanying the illness, it is suggested that interventions should focus on improving postural stability and restoring related muscular function. Integral to engaging in these activities, the potential to integrate proprioceptive information in this process may generate a more coherent experience of the body, as well as of the self, in these clients. Accordingly, constrictions of the body may have a vital role in constraining the experience of the self. As such, addressing bodily restraints in these clients may facilitate the experience of being the subject causing and controlling the movements. This is in marked contrast to clients' previous exercise experiences, which were associated with compulsion, rigidity and the absence of coherence and control.
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18
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Misra M, Golden NH, Katzman DK. State of the art systematic review of bone disease in anorexia nervosa. Int J Eat Disord 2016; 49:276-92. [PMID: 26311400 PMCID: PMC4769683 DOI: 10.1002/eat.22451] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Low bone mineral density (BMD) is a known consequence of anorexia nervosa (AN) and is particularly concerning during adolescence, a critical time for bone accrual. A comprehensive synthesis of available data regarding impaired bone health, its determinants, and associated management strategies in AN is currently lacking. This systematic review aims to synthesize information from key physiologic and prospective studies and trials, and provide a thorough understanding of impaired bone health in AN and its management. METHOD Search terms included "anorexia nervosa" AND "bone density" for the period 1995-2015, limited to articles in English. Papers were screened manually based on journal impact factor, sample size, age of participants, and inclusion of a control group. When necessary, we included seminal papers published before 1995. RESULTS AN leads to low BMD, impaired bone quality and increased fracture risk. Important determinants are low lean mass, hypogonadism, IGF-1 deficiency, and alterations in other hormones that impact bone health. Weight gain and menses restoration are critical for improving bone outcomes in AN. Physiologic estrogen replacement as the transdermal patch was shown to increase bone accrual in one study in adolescent females with AN; however, residual deficits persist. Bisphosphonates are potentially useful in adults with AN. DISCUSSION To date, evidence suggests that the safest and most effective strategy to improve bone health in AN is normalization of weight with restoration of menses. Pharmacotherapies that show promise include physiologic estradiol replacement (as the transdermal estradiol patch), and in adults, bisphosphonates. Further studies are necessary to determine the best strategies to normalize BMD in AN.
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Affiliation(s)
- Madhusmita Misra
- Division of Pediatric Endocrinology and the Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts,Correspondence to: Madhusmita Misra, MD, MPH, Division of Pediatric Endocrinology and the Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts.
| | - Neville H. Golden
- Division of Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Debra K. Katzman
- Division of Adolescent Medicine, Hospital for Sick Children and University of Toronto, Toronto, Canada
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19
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Abstract
Skeletal health is modulated by a variety of factors, including genetic makeup, hormonal axes, and environment. Across all ages, extremes of body weight may exert a deleterious effect on bone accretion and increase fracture risk. The incidence of both anorexia nervosa and obesity, each involving extreme alterations in body composition, is rising among youth, and secondary osteoporosis is increasingly being diagnosed among affected children and adolescents. Compared with the elderly, the definition of osteoporosis that stems from any underlying condition differs for the pediatric population and special precautions are required with regard to treatment of young patients. Early recognition and management of both underweight and overweight youth and the accompanying consequences on bone and mineral metabolism are essential for preservation of skeletal health, although prevention of bone loss and optimization of bone mineral accrual remain the most important protective measures.
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Affiliation(s)
- Shara R Bialo
- Division of Pediatric Endocrinology, Hasbro Children's Hospital/Alpert Medical School of Brown University, 593 Eddy Street, MPSII, Providence, RI, 02903, USA,
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20
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Emaus N, Wilsgaard T, Ahmed LA. Impacts of body mass index, physical activity, and smoking on femoral bone loss: the Tromsø study. J Bone Miner Res 2014; 29:2080-9. [PMID: 24676861 DOI: 10.1002/jbmr.2232] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 03/11/2014] [Accepted: 03/17/2014] [Indexed: 12/31/2022]
Abstract
Bone mineral density (BMD) is a reflection of bone strength and lifestyles that preserve bone mass and may reduce fracture risk in old age. This study examined the effect of combined profiles of smoking, physical activity, and body mass index (BMI) on lifetime bone loss. Data were collected from the population-based Tromsø Study. BMD was measured as g/cm(2) by dual-energy X-ray absorptiometry (DXA) at the total hip and femoral neck in 2580 women and 2084 men aged 30 to 80 years in the 2001-02 survey, and repeated in 1401 women and 1113 men in the 2007-08 survey. Height and weight were measured and lifestyle information was collected through questionnaires. Data were analyzed using linear mixed models with second-degree fractional polynomials. From the peak at the age around 40 years to 80 years of age, loss rates varied between 4% at the total hip and 14% at femoral neck in nonsmoking, physically active men with a BMI of 30 kg/m(2) to approximately 30% at both femoral sites in heavy smoking, physically inactive men with a BMI value of 18 kg/m(2) . In women also, loss rates of more than 30% were estimated in the lifestyle groups with a BMI value of 18 kg/m(2) . BMI had the strongest effect on BMD, especially in the oldest age groups, but a BMI above 30 kg/m(2) did not exert any additional effect compared with the population average BMI of 27 kg/m(2) . At the age of 80 years, a lifestyle of moderate BMI to light overweight, smoking avoidance, and physical activity of 4 hours of vigorous activity per week through adult life may result in 1 to 2 standard deviations higher BMD levels compared with a lifestyle marked by heavy smoking, inactivity, and low weight. In the prevention of osteoporosis and fracture risk, the effect of combined lifestyles through adult life should be highlighted. © 2014 American Society for Bone and Mineral Research.
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Affiliation(s)
- Nina Emaus
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
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21
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Zuckerman-Levin N, Hochberg Z, Latzer Y. Bone health in eating disorders. Obes Rev 2014; 15:215-23. [PMID: 24165231 DOI: 10.1111/obr.12117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 09/11/2013] [Accepted: 09/13/2013] [Indexed: 12/30/2022]
Abstract
Eating disorders (EDs) put adolescents and young adults at risk for impaired bone health. Low bone mineral density (BMD) with ED is caused by failure to accrue peak bone mass in adolescence and bone loss in young adulthood. Although ED patients diagnosed with bone loss may be asymptomatic, some suffer bone pains and have increased incidence of fractures. Adolescents with ED are prone to increased prevalence of stress fractures, kyphoscoliosis and height loss. The clinical picture of the various EDs involves endocrinopathies that contribute to impaired bone health. Anorexia nervosa (AN) is characterized by low bone turnover, with relatively higher osteoclastic (bone resorptive) than osteoblastic (bone formation) activity. Bone loss in AN occurs in both the trabecular and cortical bones, although the former is more vulnerable. Bone loss in AN has been shown to be influenced by malnutrition and low weight, reduced fat mass, oestrogen and androgen deficiency, glucocorticoid excess, impaired growth hormone-insulin-like growth factor 1 axis, and more. Bone loss in AN may not be completely reversible despite recovery from the illness. Treatment modalities involving hormonal therapies have limited effectiveness, whereas increased caloric intake, weight gain and resumption of menses are essential to improved BMD.
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Affiliation(s)
- N Zuckerman-Levin
- Eating Disorders Clinic, Psychiatric Division, Rambam Medical Center, Haifa, Israel
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22
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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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23
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Abstract
A key feature of anorexia nervosa, a disease primarily psychiatric in origin, is chronic starvation, which results in profound neuroendocrine dysregulation, including hypogonadism, relative growth hormone resistance, and hypercortisolemia. A recent area of investigation is appetite hormone dysregulation. Whether such dysregulation is compensatory or plays a role in the pathophysiology of anorexia nervosa is incompletely understood. The primary therapy for anorexia remains psychiatric, and endocrine abnormalities tend to improve with weight restoration, although residual endocrine dysfunction can occur. In addition, therapies directed at specific complications have been a particular focus of research.
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Affiliation(s)
- Karen Klahr Miller
- Harvard Medical School and Neuroendocrine Unit, BUL 457B, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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24
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de Moraes AM, Gonçalves EM, Barbeta VJDO, Guerra-Júnior G. Cross-sectional study of the association of body composition and physical fitness with bone status in children and adolescents from 11 to 16 years old. BMC Pediatr 2013; 13:117. [PMID: 23937889 PMCID: PMC3751508 DOI: 10.1186/1471-2431-13-117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 08/07/2013] [Indexed: 11/22/2022] Open
Abstract
Background The aim of the study was to verify the association between body composition and physical fitness with bone status in children and adolescents. Methods A cross-sectional study was conducted with 300 healthy students (148 boys, 152 girls). Weight, height, fat and fat-free mass, and percentage of body fat (%BF) were evaluated, as were physical fitness (abdominal exercise, flexibility, and horizontal jump tests) and maximum oxygen consumption. Bone parameters (amplitude-dependent speed of sound; AD-SoS) and the Ultrasound Bone Profile Index (UBPI) were evaluated using DBM Sonic BP ultrasonography. Results In the study group, girls had higher bone parameter values than boys. A univariate analysis assessed in a stepwise multiple regression model was conducted. It showed that for boys, the %BF and height were significant independent variables for AD-SoS and UBPI, but the horizontal jump test only for AD-SoS (adjusted r2 = 0.274; p < 0.001), and pubertal maturation only for UBPI (adjusted r2 = 0.295; p < 0.001). For girls, age and %BF were identified as significant independent variables for AD-SoS and UBPI (adjusted r2 = 0.093; p < 0.001) but height only for AD-SoS (adjusted r2 = 0.408; p < 0.001). Conclusions Variables related to growth (age, height, and pubertal maturation) are independent positive predictors for the bone parameters in both boys and girls. %BF is an independent negative predictor. For boys, the horizontal jump test was an independent positive predictor for AD-SoS, indicating that physical fitness related to the neuromotor system can influence the amount of bone present.
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Gicquel L. Anorexia nervosa during adolescence and young adulthood: towards a developmental and integrative approach sensitive to time course. ACTA ACUST UNITED AC 2013; 107:268-77. [PMID: 23542549 DOI: 10.1016/j.jphysparis.2013.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Anorexia nervosa is situated at the junction between two time scales, the time scale of adolescence, in which intense physiological and psychological upheavals are occurring over a relatively short period of time, and the time scale of the potentially chronic evolution of the disease over the course of the patient's lifespan. This second time scale links the critical period of adolescence with the pre-morbid period, during which a complex state of vulnerability, often unseen and unheard, combines with different risk factors, which may be isolated, associated, dissociated or concomitant, to produce the emergence of anorexia; it ushers also adolescence into the period of adulthood, flagged with the reorganization that occurs in the course of the healing process (in case of recovery), or pervaded by somatic and mental distress (in cases where the condition becomes chronic). Given the lifespan nature of the disease, it is difficult to differentiate premorbid pathogenic factors from changes resulting from the acute or chronic phases of the illness. It is also difficult to establish straightforward correlations between physiological disturbances and their clinical consequences, or conversely to assume that the restoration of physiological parameters means the disappearance of the underlying mental disorder. Taken together, these observations support an approach to anorexia nervosa that is both developmental and integrative, taking into account both the complexity of the pathways involved and the developmental timescales of these pathways. This type of approach can help to adjust therapeutic strategies and thus enhance prognosis, in particular by integrating the temporal parameter into the dynamics of care plans.
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Affiliation(s)
- Ludovic Gicquel
- INSERM U 894 Team 1, Centre de Psychiatrie et de Neurosciences, Paris, France.
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Howgate DJ, Graham SM, Leonidou A, Korres N, Tsiridis E, Tsapakis E. Bone metabolism in anorexia nervosa: molecular pathways and current treatment modalities. Osteoporos Int 2013; 24:407-21. [PMID: 22875459 DOI: 10.1007/s00198-012-2095-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 07/03/2012] [Indexed: 11/26/2022]
Abstract
Eating disorders are associated with a multitude of metabolic abnormalities which are known to adversely affect bone metabolism and structure. We aimed to comprehensively review the literature on the effects of eating disorders, particularly anorexia nervosa (AN), on bone metabolism, bone mineral density (BMD), and fracture incidence. Furthermore, we aimed to highlight the risk factors and potential management strategies for patients with eating disorders and low BMD. We searched the MEDLINE/OVID (1950-July 2011) and EMBASE (1980-July 2011) databases, focussing on in vitro and in vivo studies of the effects of eating disorders on bone metabolism, bone mineral density, and fracture incidence. Low levels of estrogen, testosterone, dehydroepiandrosterone, insulin-like growth factor-1 (IGF-1), and leptin, and high levels of cortisol, ghrelin, and peptide YY (PYY) are thought to contribute to the 'uncoupling' of bone turnover in patients with active AN, leading to increased bone resorption in comparison to bone formation. Over time, this results in a high prevalence and profound degree of site-specific BMD loss in women with AN, thereby increasing fracture risk. Weight recovery and increasing BMI positively correlate with levels of IGF-1 and leptin, normalisation in the levels of cortisol, as well as markers of bone formation and resorption in both adolescent and adult patients with AN. The only treatments which have shown promise in reversing the BMD loss associated with AN include: physiologic dose transdermal and oral estrogen, recombinant human IGF-1 alone or in combination with the oral contraceptive pill, and bisphosphonate therapy.
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Affiliation(s)
- D J Howgate
- Academic Department of Orthopaedics and Trauma, Salford Royal University Teaching Hospital, Salford Royal NHS Foundation Trust, Stott Lane, M6 8HD, Salford, UK
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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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Dehydroepiandrosterone treatment effects on weight, bone density, bone metabolism and mood in women suffering from anorexia nervosa-a pilot study. Psychiatry Res 2012; 200:544-9. [PMID: 22858403 DOI: 10.1016/j.psychres.2012.07.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 06/21/2012] [Accepted: 07/15/2012] [Indexed: 12/13/2022]
Abstract
We investigated the effects of the administration of dehydroepiandrosterone (DHEA) on weight, bone metabolism, bone density and clinical mood symptoms in outpatient Anorexia Nervosa (AN) patients. AN patients (n=26) were double-blindly randomized to receive DHEA (100mg) or placebo for 6 months. Outcome measures were bone mineral density (BMD) and bone mineral content (BMC) measured by dual energy X-ray absorptiometry (DXA) and metabolism indexes, steroid hormones, and mood and eating disorder symptoms measured at baseline and at the 3 and 6 months follow-up visits. Mood and eating disorder symptoms were assessed monthly by the Beck Depression Inventory, Eating Disorder Inventory and Clinical Global Improvement Scales. No treatment or treatment by time interaction was observed for any bone density measures. Deoxypiridinolyne (DPD) was positively correlated with weight (P=0.02). An increase in body mass index (BMI) in the DHEA group was significantly higher at 4 months compared to the control group (P=0.05). Improvement of mood was significantly correlated with weight only in the DHEA group. Despite a significant decrease in DPD, no improvement in bone mineral density was detected. However, patients treated with DHEA benefited from a significant increase in BMI, which was positively correlated with improvement in mood.
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Abstract
The relationship between body composition and skeletal metabolism has received growing recognition. Low body weight is an established risk factor for fracture. The effect of obesity on skeletal health is less well defined. Extensive studies in patients with anorexia nervosa and obesity have illuminated many of the underlying biologic mechanisms by which body composition modulates bone mass. This review examines the relationship between body composition and bone mass through data from recent research studies throughout the weight spectrum ranging from anorexia nervosa to obesity.
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Affiliation(s)
- Alexander Faje
- BUL 457, Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Abstract
PURPOSE OF REVIEW Anorexia nervosa is associated with low bone mineral density (BMD), concerning for an increased risk of fractures, and decreased bone accrual in adolescents, concerning for suboptimal peak bone mass. This review discusses causes of impaired bone health in anorexia nervosa and potential therapeutic strategies. RECENT FINDINGS Low BMD in anorexia nervosa is consequent to decreased lean mass, hypogonadism, low insulin-like growth factor-1 (IGF-1), relative hypercortisolemia and alterations in hormones impacted by energy availability. Weight gain causes some improvement in bone accrual, but not to the extent observed in controls, and vitamin D supplementation does not increase BMD. Oral estrogen is not effective in increasing BMD, likely from IGF-1 suppressive effects. In contrast, transdermal estrogen replacement is effective in increasing bone accrual in adolescents with anorexia nervosa, although not to the extent seen in controls. Recombinant human IGF-1 increases bone formation in adolescents, and with oral estrogen increases BMD in adults with anorexia nervosa. Bisphosphonates increase BMD in adults, but not in adolescents, and should be used cautiously given their long half-life. SUMMARY Further investigation is necessary to explore therapies for low BMD in anorexia nervosa. Weight gain is to be encouraged. Transdermal estrogen in adolescents, and bisphosphonates in adults, have a potential therapeutic role.
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Affiliation(s)
- Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Abstract
CONTEXT Anorexia nervosa is a primary psychiatric disorder with serious endocrine consequences, including dysregulation of the gonadal, adrenal, and GH axes, and severe bone loss. This Update reviews recent advances in the understanding of the endocrine dysregulation observed in this state of chronic starvation, as well as the mechanisms underlying the disease itself. EVIDENCE ACQUISITION Findings of this update are based on a PubMed search and the author's knowledge of this field. EVIDENCE SYNTHESIS Recent studies have provided insights into the mechanisms underlying endocrine dysregulation in states of chronic starvation as well as the etiology of anorexia nervosa itself. This includes a more complex understanding of the pathophysiologic bases of hypogonadism, hypercortisolemia, GH resistance, appetite regulation, and bone loss. Nevertheless, the etiology of the disease remains largely unknown, and effective therapies for the endocrine complications and for the disease itself are lacking. CONCLUSIONS Despite significant progress in the field, further research is needed to elucidate the mechanisms underlying the development of anorexia nervosa and its endocrine complications. Such investigations promise to yield important advances in the therapeutic approach to this disease as well as to the understanding of the regulation of endocrine function, skeletal biology, and appetite regulation.
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Affiliation(s)
- K K Miller
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.
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