Changes in bone turnover markers and menstrual function after short-term oral DHEA in young women with anorexia nervosa

Dehydroepiandrosterone sulfate levels predict weight gain in women with anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a serious condition characterized by undernutrition, complicated by endocrine dysregulation, and with few predictors of recovery. Urinary free cortisol (UFC) is a predictor of weight gain, but 24-h urine samples are challenging to collect. We hypothesized that serum dehydroepiandrosterone sulfate (DHEAS), which like cortisol is regulated by adrenocorticotropic hormone (ACTH), would predict weight gain and increases in fat mass in women with AN.

METHODS

We prospectively studied 34 women with AN and atypical AN, mean age 27.4 ± 7.7 years (mean ± SD), who received placebo in a 6-month randomized trial. Baseline DHEAS and 24-h UFC were measured by liquid chromatography with tandem mass spectrometry. Body composition was assessed at baseline and 6 months by DXA and cross-sectional abdominal CT at L4.

RESULTS

Mean baseline DHEAS level was 173 ± 70 μg/dl (0.7 ± 0.3 times the mean normal range for age) and mean baseline UFC (n = 15) was 20 ± 18 μg/24 h (normal: 0-50 μg/24 h). Higher DHEAS levels predicted weight gain over 6 months (r = 0.61, p < .001). DHEAS levels also predicted increases in fat mass (r = 0.40, p = .03), appendicular lean mass (r = 0.38, p = .04), and abdominal adipose tissue (r = 0.60, p < .001). All associations remained significant after controlling for age, baseline BMI, OCP use, duration of AN, and SSRI/SNRI use. DHEAS levels correlated with UFC (r = 0.61, p = .02).

DISCUSSION

In women with AN, higher serum DHEAS predicts weight gain and increases in fat and muscle mass. Additional studies are needed to confirm these findings and further elucidate the association between DHEAS and weight gain.

PUBLIC SIGNIFICANCE

Anorexia nervosa is a severe psychiatric condition, and predictors of weight recovery are needed to improve prognostication and guide therapeutic decision making. While urinary cortisol is a predictor of weight gain, 24-h urine collections are challenging to obtain. Like cortisol, dehydroepiandrosterone sulfate (DHEAS) is a hormone produced by the adrenal glands. As a readily available blood test, DHEAS holds promise as more practical biomarker of weight gain in anorexia nervosa.

Dehydroepiandrosterone status and efficacy of dehydroepiandrosterone supplementation for bone health in anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

This study was designed to determine the status of dehydroepiandrosterone (DHEA) in women with anorexia nervosa (AN) and to assess the efficacy of DHEA supplementation as a treatment for bone health in women with AN.

METHOD

Studies were retrieved from the PubMed, Embase, Cochrane Library, MEDLINE, and Scopus databases from inception to February 14, 2022. Observational studies that compared serum DHEA levels between women with AN and healthy controls were included for meta-analysis, and randomized controlled trials (RCTs) that evaluated the effects of DHEA supplementation on bone mass were reviewed.

RESULTS

Meta-analysis of 15 cross-sectional studies revealed that patients with AN had significantly elevated serum DHEA levels (mean difference (MD) = 311.63 ng/dl; 95% confidence interval (CI), 78.01-545.25) and reduced DHEAS levels (MD = -24.90 μg/dl; 95% CI, -41.72 to -8.07) compared with healthy controls. A systematic review of seven RCTs found that DHEA monotherapy does not improve bone mineral density (BMD) compared with placebo after adjusting for weight gain. While the combination of DHEA and conjugated oral contraceptives has led to increased bone strength and decreased bone loss, the beneficial effect appears to be limited to older adolescents and adults with closed physes. Potential detrimental effects on BMD were identified in younger adolescents with open physes in one study.

DISCUSSION

Due to the lack of apparent benefit of DHEA in women with AN and its potential detrimental effect on BMD in young patients with AN, current evidence does not support the use of DHEA.

PUBLIC SIGNIFICANCE

This study demonstrates that women with anorexia nervosa have abnormal levels of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS), which have been suggested by previous studies to play a role in the development of low bone density in this condition. However, current evidence does not support the use of DHEA as a treatment to preserve bone health in patients with anorexia nervosa given the lack of clear benefit following its use and also because of a potential detrimental effect on bone mineral density in young patients with anorexia nervosa.

Should Dehydroepiandrosterone Be Administered to Women?

CONTEXT

Androgen prohormones such as dehydroepiandrosterone (DHEA) increase in early puberty, peak in the second and third decade, and thereafter decline, independent of menopausal status. Investigators have examined their potential beneficial effects in normal women and those with DHEA-deficient states.

EVIDENCE ACQUISITION

A review of the literature from 1985 to 2021 on the potential benefits and risks of androgen prohormones in women.

EVIDENCE SYNTHESIS

Studies have examined the potential benefit of DHEA therapy for anti-aging, sexual dysfunction, infertility, metabolic bone health, cognition, and wellbeing in hormone-deficient states such as primary adrenal insufficiency, hypopituitarism, and anorexia as well as administration to normal women across the lifespan.

CONCLUSIONS

Data support small benefits in quality of life and mood but not for anxiety or sexual function in women with primary or secondary adrenal insufficiency or anorexia. No consistent beneficial effects of DHEA administration have been observed for menopausal symptoms, sexual function, cognition, or overall wellbeing in normal women. Local administration of DHEA shows benefit in vulvovaginal atrophy. Use of DHEA to improve induction of ovulation response in women with diminished ovarian reserve is not recommended. Risks of high physiologic or pharmacologic use of DHEA include androgenic and estrogenic side effects which are of concern for long-term administration.

CLINICAL CASE

A 49-year-old woman with Addison's disease who is on low dose estrogen with cyclic progesterone therapy for menopausal symptoms returns for follow-up. She is on a stable glucocorticoid replacement strategy of hydrocortisone 10 mg in the morning and 5 mg in the early afternoon and fludrocortisone 0.05 mg each morning. She has read on the internet that additional therapy with DHEA may help her overall quality of life and libido. She asks whether she should add this therapy to her regimen and at what dose.

Impact of Adrenal Hormone Supplementation on Bone Geometry in Growing Teens With Anorexia Nervosa

PURPOSE

Adolescents with anorexia nervosa (AN) have decreased dehydroepiandrosterone (DHEA) and estrogen concentrations that may contribute to skeletal deficits. We sought to determine whether DHEA + estrogen replacement (ERT) prevented bone loss in young adolescents with AN.

METHODS

We recruited females with AN (n = 70, ages 11-18 years) into a 12-month, randomized, double-blind placebo-controlled trial. Participants were randomized to oral micronized DHEA 50 mg + 20 mcg ethinyl estradiol/.1 mg levonorgestrel daily (n = 35) or placebo (n = 35). Outcomes included serial measures of bone mineral density (BMD) by dual-energy X-ray absorptiometry (total body, hip, spine) and peripheral quantitative computed tomography (pQCT; tibia). Magnetic resonance imaging of T1-weighted images of the left knee determined physeal status (open/closed).

RESULTS

Sixty-two subjects completed the trial. Physeal closure status was the strongest predictor of aBMD changes. Among girls with open physes, those who received DHEA + ERT showed a decline in BMD Z-scores compared with those receiving placebo, whereas there was no effect in those with at least one closed physis. Treatment did not affect any pQCT measures, regardless of physeal closure status.

CONCLUSIONS

Combined DHEA + ERT did not significantly improve dual-energy X-ray absorptiometry or pQCT BMD measurements in young adolescent girls with AN, in contrast to an earlier trial showing benefit in older adolescents and young women. In girls with open physes, the mean change in the placebo arm was greater than that of the DHEA + ERT group. We conclude that DHEA + ERT is ineffective for preserving bone health in growing young adolescents with AN at the dose and route of administration described in this report.

Pharmacological treatment options for low Bone Mineral Density and secondary osteoporosis in Anorexia Nervosa: A systematic review of the literature

OBJECTIVE

Although there are several evidence-based treatments available to increase Bone Mineral Density (BMD) and reduce fracture risk in aging men and women, there are still uncertainties regarding which treatments are efficacious in reducing lifetime fracture risk in women with Anorexia Nervosa (AN).

METHODS

Medline, PsychInfo, Embase and the Cochrane Database were searched for English Language Studies. Inclusion criteria were studies of females of any age with AN who received pharmacological treatment with the primary aim to increase BMD or reduce fracture risk. Data were extracted from each study regarding pharmacological treatment and dosage used, BMD and bone formation marker outcomes; and participant characteristics including age, Body Mass Index (BMI), duration of AN, and duration of amenorrhea.

RESULTS

675 studies were reviewed, of which 19 fit the inclusion criteria and were included in the final review, investigating a total of 1119 participants; 10 of the 19 included studies were double-blind RCTs. The remaining studies consisted of prospective observational studies, a retrospective cohort study, a case-control study and five non-randomised control trials. Bisphosphonates were effective in increasing BMD in adult women with AN, while estrogen administered transdermally resulted in significant increases in BMD in mature adolescents with AN. Administration of oral contraceptives (OC) did not significantly increase BMD in randomised or controlled trials, however, lifetime OC use was associated with higher spinal BMD.

CONCLUSION

Future research should clarify the safety of long-term bisphosphonate use in adult women with AN, and verify that transdermal estrogen replacement increases BMD in women with AN.

Cortisol and DHEA in development and psychopathology

Dehydroepiandrosterone (DHEA) and cortisol are the most abundant hormones of the human fetal and adult adrenals released as end products of a tightly coordinated endocrine response to stress. Together, they mediate short- and long-term stress responses and enable physiological and behavioral adjustments necessary for maintaining homeostasis. Detrimental effects of chronic or repeated elevations in cortisol on behavioral and emotional health are well documented. Evidence for actions of DHEA that offset or oppose those of cortisol has stimulated interest in examining their levels as a ratio, as an alternate index of adrenocortical activity and the net effects of cortisol. Such research necessitates a thorough understanding of the co-actions of these hormones on physiological functioning and in association with developmental outcomes. This review addresses the state of the science in understanding the role of DHEA, cortisol, and their ratio in typical development and developmental psychopathology. A rationale for studying DHEA and cortisol in concert is supported by physiological data on the coordinated synthesis and release of these hormones in the adrenal and by their opposing physiological actions. We then present evidence that researching cortisol and DHEA necessitates a developmental perspective. Age-related changes in DHEA and cortisol are described from the perinatal period through adolescence, along with observed associations of these hormones with developmental psychopathology. Along the way, we identify several major knowledge gaps in the role of DHEA in modulating cortisol in typical development and developmental psychopathology with implications for future research.

The endocrine manifestations of anorexia nervosa: mechanisms and management

Anorexia nervosa is a psychiatric disorder characterized by altered body image, persistent food restriction and low body weight, and is associated with global endocrine dysregulation in both adolescent girls and women. Dysfunction of the hypothalamic-pituitary axis includes hypogonadotropic hypogonadism with relative oestrogen and androgen deficiency, growth hormone resistance, hypercortisolaemia, non-thyroidal illness syndrome, hyponatraemia and hypooxytocinaemia. Serum levels of leptin, an anorexigenic adipokine, are suppressed and levels of ghrelin, an orexigenic gut peptide, are elevated in women with anorexia nervosa; however, levels of peptide YY, an anorexigenic gut peptide, are paradoxically elevated. Although most, but not all, of these endocrine disturbances are adaptive to the low energy state of chronic starvation and reverse with treatment of the eating disorder, many contribute to impaired skeletal integrity, as well as neuropsychiatric comorbidities, in individuals with anorexia nervosa. Although 5-15% of patients with anorexia nervosa are men, only limited data exist regarding the endocrine impact of the disease in adolescent boys and men. Further research is needed to understand the endocrine determinants of bone loss and neuropsychiatric comorbidities in anorexia nervosa in both women and men, as well as to formulate optimal treatment strategies.

State of the art systematic review of bone disease in anorexia nervosa

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.

Hormonal Add-Back Therapy for Females Treated With Gonadotropin-Releasing Hormone Agonist for Endometriosis: A Randomized Controlled Trial

OBJECTIVE

To assess whether add-back therapy with norethindrone acetate or norethindrone acetate plus conjugated equine estrogens is superior to maintain bone health in adolescents and young women using gonadotropin-releasing hormone agonists for endometriosis. Gonadotropin-releasing hormone agonists are associated with deleterious effects on bone. Hormonal add-back may mitigate these effects.

METHODS

Adolescents and young women (n=51) received a random, double-blind assignment to add-back with norethindrone acetate (5 mg/day) plus conjugated equine estrogens (0.625 mg/day) or norethindrone acetate plus placebo for 12 months. Body composition, bone mineral content, and bone mineral density (BMD) were obtained by dual-energy X-ray absorptiometry every 6 months. Quality-of-life measures were collected every 3 months. Intention-to-treat comparison of outcomes was conducted by repeated-measures analysis of variance.

RESULTS

Thirty-four adolescents and young women completed the trial; dropouts did not differ from those who completed the trial. Bone mineral density was normal at baseline. At 12 months, total body bone mineral content and BMD had increased in the norethindrone acetate plus conjugated equine estrogens group (bone mineral content +37 g, P<.001 and BMD +0.012 g/cm, P=.05), but not in those receiving norethindrone acetate plus placebo (bone mineral content P=.19 and BMD P=.95). Lean mass increased only in those receiving conjugated equine estrogens (+1.4 kg, P=.001). Improvements in physical functioning domains of quality-of-life assessments were greater with norethindrone acetate plus conjugated equine estrogens (P=.005). No differences were seen at the hip or lumbar spine by dual-energy X-ray absorptiometry. No significant adverse events occurred.

CONCLUSION

Hormonal add-back successfully preserved bone health and improved quality of life for adolescents and young women with endometriosis during 12 months of gonadotropin-releasing hormone agonist therapy. Combination norethindrone acetate plus conjugated equine estrogens add-back appears to be more effective for increasing total body bone mineral content, areal BMD, and lean mass than norethindrone acetate monotherapy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; www.clinicaltrials.gov, NCT00474851.

LEVEL OF EVIDENCE

I.

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting, and a number of differing psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008.

OBJECTIVES

To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies.

SELECTION CRITERIA

All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria.

DATA COLLECTION AND ANALYSIS

We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently.

MAIN RESULTS

We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias).The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU.Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMI MD -0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, no specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials.

AUTHORS' CONCLUSIONS

There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents. Larger RCTs of longer treatment duration and follow-up are needed.

20 years of leptin: role of leptin in human reproductive disorders

Leptin, as a key hormone in energy homeostasis, regulates neuroendocrine function, including reproduction. It has a permissive role in the initiation of puberty and maintenance of the hypothalamic-pituitary-gonadal axis. This is notable in patients with either congenital or acquired leptin deficiency from a state of chronic energy insufficiency. Hypothalamic amenorrhea is the best-studied, with clinical trials confirming a causative role of leptin in hypogonadotropic hypogonadism. Implications of leptin deficiency have also emerged in the pathophysiology of hypogonadism in type 1 diabetes. At the other end of the spectrum, hyperleptinemia may play a role in hypogonadism associated with obesity, polycystic ovarian syndrome, and type 2 diabetes. In these conditions of energy excess, mechanisms of reproductive dysfunction include central leptin resistance as well as direct effects at the gonadal level. Thus, reproductive dysfunction due to energy imbalance at both ends can be linked to leptin.

Anorexia nervosa and bone

Anorexia nervosa (AN) is a condition of severe low weight that is associated with low bone mass, impaired bone structure, and reduced bone strength, all of which contribute to increased fracture risk. Adolescents with AN have decreased rates of bone accrual compared with normal-weight controls, raising additional concerns of suboptimal peak bone mass and future bone health in this age group. Changes in lean mass and compartmental fat depots, and hormonal alterations secondary to nutritional factors contribute to impaired bone metabolism in AN. The best strategy to improve bone density is to regain weight and menstrual function. Oral estrogen-progesterone combinations are not effective in increasing bone density in adults or adolescents with AN, and transdermal testosterone replacement is not effective in increasing bone density in adult women with AN. However, physiological estrogen replacement as transdermal estradiol with cyclic progesterone does increase bone accrual rates in adolescents with AN to approximate that in normal-weight controls, leading to a maintenance of bone density Z-scores. A recent study has shown that risedronate increases bone density at the spine and hip in adult women with AN. However, bisphosphonates should be used with great caution in women of reproductive age, given their long half-life and potential for teratogenicity, and should be considered only in patients with low bone density and clinically significant fractures when non-pharmacological therapies for weight gain are ineffective. Further studies are necessary to determine the best therapeutic strategies for low bone density in AN.

Current perspectives on the etiology and manifestation of the "silent" component of the Female Athlete Triad

The Female Athlete Triad (Triad) represents a syndrome of three interrelated conditions that originate from chronically inadequate energy intake to compensate for energy expenditure; this environment results in insufficient stored energy to maintain physiological processes, a condition known as low energy availability. The physiological adaptations associated with low energy availability, in turn, contribute to menstrual cycle disturbances. The downstream effects of both low energy availability and suppressed estrogen concentrations synergistically impair bone health, leading to low bone mineral density, compromised bone structure and microarchitecture, and ultimately, a decrease in bone strength. Unlike the other components of the Triad, poor bone health often does not have overt symptoms, and therefore develops silently, unbeknownst to the athlete. Compromised bone health among female athletes increases the risk of fracture throughout the lifespan, highlighting the long-term health consequences of the Triad. The purpose of this review is to examine the current state of Triad research related to the third component of the Triad, ie, poor bone health, in an effort to summarize what we know, what we are learning, and what remains unknown.

Adrenal steroidogenesis following prenatal dexamethasone exposure in the spiny mouse

Antenatal stress disturbs the development of the fetal hypothalamic-pituitary-adrenal axis and adrenal steroidogenesis. We investigated the effect of brief maternal exposure to high glucocorticoids (dexamethasone (DEX)) at mid- and late-pregnancy on adrenal structure and production of steroids in spiny mouse. Pregnant spiny mice were treated for 60 h with 125 μg/kg DEX or saline s.c. by osmotic minipump at day 20 (0.5) or 30 (0.75) of gestation. Immunohistochemical expression of steroidogenic acute regulatory-protein (StAR), 3β-hydroxysteroid dehydrogenase (3βHSD), 17-hydroxylase,17-20lyase (P450C17), and cytochromeb5 (CYTB5) was determined in adrenals on postnatal (P) day 170±20. DHEA, testosterone, and cortisol were measured by RIA. Maternal DEX at 20 days significantly reduced the expression of STAR, P450C17 (CYP17A1), and CYTB5 in the adrenal zona reticularis (ZR) of adult offspring, with greater change in male vs female offspring (P<0.05). Plasma DHEA was decreased in male offspring from DEX-treated (6.84±1.24 ng/ml) vs saline-treated (13±0.06 ng/ml; P=0.01) dams, and the DHEA:cortisol ratio was lower in males (P<0.05). Testosterone levels increased in male offspring from DEX (266.03±50.75 pg/ml) vs saline (83.47±32.3 pg/ml, P<0.05)-treated dams. DEX treatment at 0.75 gestation had no significant effect on any parameters measured. This study shows that brief exposure to excess glucocorticoid has long-term impacts on the ZR and adrenal steroidogenesis, affecting the secretion of DHEA and testosterone in male offspring, an effect produced at 0.5 but not at 0.75 gestation. DHEA is important for brain development, and its suppression in adult life might contribute to the neurobehavioral pathologies that can arise after illness and stress during pregnancy.

Bone disease in anorexia nervosa

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.

Clinical Problems Encountered in the Treatment of Adolescents with Anorexia Nervosa 1Both authors contributed equally

The conceptualization of anorexia nervosa (AN) depends on the diagnostic criteria. Most patients with teenage onset AN seem to remit within 3–10 years depending on the definitions of recovery. The mortality of adolescent onset anorexia nervosa (AN) has fortunately decreased over the last two decades. Based on randomized controlled trials, we review different treatments including individual and group psychotherapy, family therapy, psychopharmacology, and hormone therapy. Treatment settings vary over time for any individual patient. Despite high rates of inpatient treatment, the respective evidence for effectiveness is meager. In underage patients with severe AN clinical, ethical and legal aspects need to be dealt with systematically if intermittent compulsory treatment is deemed necessary. The prolonged and frequently chronic course of AN often entails therapeutic discontinuity; the transition into adulthood requires a graded therapeutic concept that considers the severity of the disorder, developmental and chronological age, and parental involvement. Finally, we consider future clinical and research options to improve treatment and outcome of this eating disorder.

Bone metabolism in anorexia nervosa: molecular pathways and current treatment modalities

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.

Dehydroepiandrosterone treatment effects on weight, bone density, bone metabolism and mood in women suffering from anorexia nervosa-a pilot study

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.

The effect of gonadal and adrenal steroid therapy on skeletal health in adolescents and young women with anorexia nervosa

Anorexia nervosa (AN) is characterized by subnormal estrogen and dehydroepiandrosterone (DHEA) levels. We sought to determine whether the combination of DHEA + estrogen/progestin is superior to placebo in preserving skeletal health over 18 months in AN. Females with AN, aged 13 to 27 years, were recruited for participation in this double-blind, placebo-controlled, randomized trial. Ninety-four subjects were randomized, of whom 80 completed baseline assessments and received either study drug (oral micronized DHEA 50 mg + 20 µg ethinyl estradiol/0.1 mg levonorgestrel combined oral contraceptive pill [COC] daily; n = 43) or placebo (n = 37). Serial measurements of areal bone mineral density (aBMD), bone turnover markers, and serum hormone concentrations were obtained. Sixty subjects completed the 18-month trial. Spinal and whole-body aBMD z scores were preserved in the DHEA + COC group, but decreased in the placebo group (comparing trends, P = .008 and P = .001, respectively). Bone turnover markers initially declined in subjects receiving DHEA + COC and then returned to baseline. No differences in body composition, adverse effects of therapy, or alterations in biochemical safety parameters were observed. Combined therapy with DHEA + COC appears to be safe and effective for preventing bone loss in young women with AN, whereas placebo led to decreases in aBMD. Dehydroepiandrosterone + COC may be safely used to preserve bone mass as efforts to reverse the nutritional, psychological, and other hormonal components of AN are implemented.

Obstacles in the optimization of bone health outcomes in the female athlete triad

Maintaining low body weight for the sake of performance and aesthetic purposes is a common feature among young girls and women who exercise on a regular basis, including elite, college and high-school athletes, members of fitness centres, and recreational exercisers. High energy expenditure without adequate compensation in energy intake leads to an energy deficiency, which may ultimately affect reproductive function and bone health. The combination of low energy availability, menstrual disturbances and low bone mineral density is referred to as the 'female athlete triad'. Not all athletes seek medical assistance in response to the absence of menstruation for 3 or more months as some believe that long-term amenorrhoea is not harmful. Indeed, many women may not seek medical attention until they sustain a stress fracture. This review investigates current issues, controversies and strategies in the clinical management of bone health concerns related to the female athlete triad. Current recommendations focus on either increasing energy intake or decreasing energy expenditure, as this approach remains the most efficient strategy to prevent further bone health complications. However, convincing the athlete to increase energy availability can be extremely challenging. Oral contraceptive therapy seems to be a common strategy chosen by many physicians to address bone health issues in young women with amenorrhoea, although there is little evidence that this strategy improves bone mineral density in this population. Assessment of bone health itself is difficult due to the limitations of dual-energy X-ray absorptiometry (DXA) to estimate bone strength. Understanding how bone strength is affected by low energy availability, weight gain and resumption of menses requires further investigations using 3-dimensional bone imaging techniques in order to improve the clinical management of the female athlete triad.

Endocrine dysregulation in anorexia nervosa update

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.

Osteoporosis in anorexia nervosa

Anorexia nervosa is a condition associated with reduced bone mass and increased bone fragility, for which there is no known effective treatment. Anorexia nervosa usually has its onset during adolescence, the critical time when peak bone mass is accrued. Low bone mass is caused by reduced bone formation, as well as accelerated bone resorption. The etiology is multifactorial and includes poor nutrition, low bodyweight, sex hormone deficiency and hypercortisolism. Weight gain and resumption of menses is accompanied by some improvement in bone mass, but may not restore it to normal levels. Oral estrogen-replacement therapy is not effective in increasing bone mass in this disorder. The bisphosphonates, used in conjunction with nutritional rehabilitation and weight gain, have shown promise, but concerns about safety have limited their use. The aim of this article is to highlight recent recommendations regarding the assessment of fracture risk in children and adolescents, summarize the evidence for low bone mass and increased fracture risk in anorexia nervosa, and discuss approaches to the management of low bone mass in this disorder.

Stress fracture and military medical readiness: bridging basic and applied research

PURPOSE

Military recruits and distance runners share a special risk of stress fracture injury. Recent efforts by US and Israeli military-sponsored researchers have uncovered important mechanisms and practical low-cost interventions. This article summarizes key findings relevant to prevention of stress fracture, including simple strategies to identify and to mitigate risk.

METHODS

Published research supported through the Bone Health and Military Medical Readiness research program and related military bone research was analyzed for contributions to preventing stress fracture in military recruits and optimizing bone health.

RESULTS

Thousands of military recruits helped test hypotheses about predictors of risk, safer exercise regimens, and rest, nutrition, gait training, and technology interventions to reduce stress fracture risk. Concurrent cellular, animal, and human laboratory studies were used to systematically investigate mechanisms of mechanical forces acting on bone and interactions through muscle, hormonal and genetic influences, and metabolism. The iterative and sometimes simultaneous process of basic discovery and field testing produced new knowledge that will provide safer science-based physical training.

DISCUSSION

Human training studies evaluating effects on bone require special commitment from investigators and funders due to volunteer compliance and attrition challenges. The findings from multiple studies indicate that measures of bone elasticity, fragility, and geometry are as important as bone mineral density in predicting fracture risk, with applications for new measurement technologies. Risk may be reduced by high intakes of calcium, vitamin D, and possibly protein (e.g., milk products). Prostaglandin E2, insulin-like growth factor 1, and estrogens are important mediators of osteogenesis, indicating reasons to limit the use of certain drugs (e.g., ibuprofen), to avoid excessive food restriction, and to treat hypogonadism. Abnormal gait may be a correctable risk factor. Brief daily vibration may stimulate bone mineral accretion similar to weight-bearing exercise. Genetic factors contribute importantly to bone quality, affecting fracture susceptibility and providing new insights into fracture healing and tissue reengineering.

Strategies to reverse bone loss in women with functional hypothalamic amenorrhea: a systematic review of the literature

Functional hypothalamic amenorrhea (FHA) impairs the attainment of peak bone mass and as such can increase the risk of fractures later in life. To document available treatment strategies, we conducted a systematic review of the literature. We report that hormonal therapies have limited effectiveness in increasing bone mass, whereas increased caloric intake resulting in weight gain and/or resumption of menses is an essential strategy for restoring bone mass in women with FHA.

INTRODUCTION

Women with functional hypothalamic amenorrhea (FHA) may not achieve peak bone mass (PBM), which increases the risk of stress fractures, and may increase the risk of osteoporotic fractures in later life.

METHODS

To identify effective treatment strategies for women with FHA, we conducted a systematic review of the literature. We included randomized controlled trials (RCTs), cross-sectional studies, and case studies that reported on the effects of pharmacological and non-pharmacological interventions on bone mineral density (BMD) or bone turnover in women with FHA.

RESULTS

Most published studies (n=26) were designed to treat the hormonal abnormalities observed in women with FHA (such as low estrogen, leptin, insulin-like growth factor-1, and DHEA); however none of these treatments demonstrated consistent improvements in BMD. Therapies containing an estrogen given for 8-24 months resulted in variable improvements (1.0-19.0%) in BMD, but failed to restore bone mass to that of age-matched controls. Three studies reported on the use of bisphosphonates (3-12 months) in anorexic women, which appear to have limited effectiveness to improve BMD compared to nutritional treatments. Another three investigations showed no improvements in BMD after androgen therapy (DHEA and testosterone) in anorexic women. In contrast, reports (n=9) describing an increase in caloric intake that results in weight gain and/or the resumption of menses reported a 1.1-16.9% increase in BMD concomitant with an improvement in bone formation and reduction in bone resorption markers.

CONCLUSIONS

Our literature review indicates that the most successful, and indeed essential strategy for improving BMD in women with FHA is to increase caloric intake such that body mass is increased and there is a resumption of menses. Further long-term studies to determine the persistence of this effect and to determine the effects of this and other strategies on fracture risk are needed.

Current concepts in bone and reproductive health in adolescents with anorexia nervosa

Anorexia nervosa (AN) initiates an adaptive response at the level of the hypothalamus, which results in a complex interplay involving most elements of the neuroendocrine axis. Consequences of onset of disease in adolescence include amenorrhoea, pubertal arrest with potential loss of target height, and osteoporosis with reduced capacity for future attainment of peak bone mass. With recovery, delay in restoration of menses is common. Hormonal therapies for restoration of bone mineral density (BMD) in adolescents have shown limited efficacy. This review will discuss the reproductive endocrine effects of AN in adolescence, and discuss new investigative tools for monitoring restoration of reproductive function and BMD in this population.

Medical complications in children and adolescents with anorexia nervosa

A gyermek- és serdülőkorban kezdődő anorexia nervosa súlyos, potenciálisan életveszélyes betegség, mely korai halálozáshoz, valamint élethosszig tartó szomatikus és pszichoszociális megbetegedésekhez vezethet. Az állapot jelentős testi szövődményeket okoz a növekvő és fejlődő szervezet csaknem minden szervrendszerében. Bár ezek az eltérések a betegség gyógyulásával, a táplálkozási/táplálási rehabilitációval túlnyomó részben javulnak, némely elváltozás irreverzíbilis marad.A közlemény az elmúlt két évtized idevágó közleményeinek áttekintése alapján összefoglalja a gyermek- és serdülőkorban kezdődő anorexia nervosa szomatikus szövődményeinek evidenciákon alapuló szakirodalmát. Tárgyalja az akut tüneteket, kiemelten foglalkozik a só–víz háztartás zavaraival és az újratáplálási szindrómával, valamint részletezi a kardiovaszkuláris komplikációkat. Összefoglalja a gyermek- és serdülőkori anorexiára speciálisan jellemző elváltozásokat: a csont ásványianyag-tartalom csökkenését és az osteopenia lehetséges terápiás lehetőségeit, valamint a hossznövekedésbeni elmaradást.A szakirodalom áttekintése alapján megállapítható, hogy a gyermek- és serdülőkori anorexia nervosa szomatikus szövődményei különböznek a felnőttek megbetegedéseitől. A sajátságos klinikai megjelenés, a korai kezdet és a hosszú távú következmények ismeretének hiánya miatt szükséges külön tárgyalni a gyermek- és serdülőkori anorexia nervosát a felnőttekétől és felhívni a figyelmet a betegség minél korábbi felismerésének és hatékony terápiájának szükségességére. Egyre nő azon evidenciák száma, melyek az anorexia nervosa felismerésében és kezelésében hangsúlyozzák és elengedhetetlenné teszik a multidiszciplináris szakembercsoportok szerepét.

Open Issues in Anorexia Nervosa: Prevention and Therapy of Bone Loss

Anorexia nervosa and diet-induced amenorrhea have an important impact not only on gynecological health but also on bone mass, especially if the disease is not promptly recognized and treated. This is particularly important because these conditions usually arise in adolescence, when peak bone mass is normally achieved. In this article we discuss the therapeutic issues related to bone loss associated with eating disorders.

Adrenocorticotropic hormone and dehydroepiandrosterone sulfate levels of rheumatoid arthritis patients treated with glucocorticoids

To assess adrenal function with respect to the presence or absence of steroid therapy, we investigated differences in the blood levels of adrenocorticotropic hormone (ACTH) and dehydroepiandrosterone sulfate (DHEAS) in relation to steroid (prednisolone) administration in 123 patients with rheumatoid arthritis (RA). Levels of ACTH and DHEAS were significantly lower in the steroid-treated group than in the non-treated group (ACTH: 11.79 pg/ml vs 27.92 pg/ml) (DHEAS: 418.12 ng/ml vs 883.91 ng/ml) (P<0.0001). We observed no steroid dose-related differences in ACTH levels. However, DHEAS levels showed a slight decrease at a prednisolone dose of 2.5 mg/day, with a significant decrease being observed at a dose of 5 mg/day when statistical adjustments were made for age and sex (P<0.0001). At doses of 7.5 mg/day or greater, DHEAS levels were significantly lower than those for 5 mg/day (P<0.0006). These results suggest that low-dose prednisolone reduces adrenal function in patients with RA. We recommend that doses of prednisolone should be limited to 5 mg/day or less in consideration of adrenal function when treating RA patients. The measurement of ACTH and DHEAS may be useful for evaluating adrenal function in patients with RA.

Anorexia nervosa and osteoporosis

Anorexia nervosa (AN), a condition of severe undernutrition, is associated with low bone mineral density (BMD) in adults and adolescents. Whereas adult women with AN have an uncoupling of bone turnover markers with increased bone resorption and decreased bone formation markers, adolescents with AN have decreased bone turnover overall. Possible contributors to low BMD in AN include hypoestrogenism and hypoandrogenism, undernutrition with decreased lean body mass, and hypercortisolemia. IGF-I, a known bone trophic factor, is reduced despite elevated growth hormone (GH) levels, leading to an acquired GH resistant state. Elevated ghrelin and peptide YY levels may also contribute to impaired bone metabolism. Weight recovery is associated with recovery of BMD but this is often partial, and long-term and sustained weight recovery may be necessary before significant improvements are observed. Anti-resorptive therapies have been studied in AN with conflicting results. Oral estrogen does not increase BMD or prevent bone loss in AN. The combination of bone anabolic and anti-resorptive therapy (rhIGF-I with oral estrogen), however, did result in a significant increase in BMD in a study of adult women with AN. A better understanding of the pathophysiology of low BMD in AN, and development of effective therapeutic strategies is critical. This is particularly so for adolescents, who are in the process of accruing peak bone mass, and in whom a failure to attain peak bone mass may occur in AN in addition to loss of established bone.

Impaired reduction of enhanced levels of dehydroepiandrosterone by oral dexamethasone in anorexia nervosa

Allopregnanolone and dehydroepiendrosterone (DHEA) have been supposed to be involved in some psychiatric disorders including anorexia nervosa (AN). The secretion of DHEA and allopregnanolone occurs in both the brain and the adrenal gland, where it is under the control of the corticotrophin-releasing factor (CRF)/adrenocorticotrophin hormone (ACTH) system, and, according to the increased CRF/ACTH drive found in AN, we previously reported enhanced morning levels of both DHEA and allopregnanolone in underweight anorexic patients. To further characterize the physiology of these neurosteroids in AN, we measured plasma levels of cortisol, DHEA and allopregnanolone after the oral administration of 1 mg dexamethasone at 800h in six underweight AN women and ten age-matched healthy females. We found that, before dexamethasone administration, both cortisol and DHEA plasma concentrations were significantly increased in anorexic patients as compared to controls, whereas plasma allopregnanolone levels although increased in the former did not reach a statistical significance. Moreover, while cortisol levels after dexamethasone administration were suppressed in AN to values similar to normal controls, DHEA concentrations, although significantly decreased, remained higher than in normal controls. These data support the view that in AN, the increased production of DHEA may be linked to mechanisms other than the enhanced CRF/ACTH drive.

Changes in bone mineral density, body composition and biochemical markers of bone turnover during weight gain in adolescents with severe anorexia nervosa: a 1-year prospective study

Osteoporosis is a serious complication of anorexia nervosa and in affected adolescents may result in a permanent deficit in bone mass. The pathophysiology of this bone disease has not been clearly defined. In this prospective study of 26 young women with anorexia nervosa aged 13-20 years (mean 16.5) we have measured changes in bone mineral density, total body composition and biochemical indices of bone turnover over 1 year. Over this period there was a mean weight gain of 10 kg and significant height gain with baseline and final values for body mass index of 14.2+/-1.7 and 17.6+/-2.3 kg/m2 (P<0.001). However, no significant changes were seen in bone mineral density in the spine or proximal femur during the study; total body bone mineral content was significantly higher than baseline at 3 months and 12 months (P=0.001 and P<0.0001), but total body bone mineral density at 3 months was significantly lower than baseline (P=0.003). Serum osteocalcin and bone-specific alkaline phosphatase values increased significantly and remained higher than baseline at all time points whereas urinary NTX/creatinine excretion showed a non-significant increase over the first 6 months of the study, but at 12 months, the mean value was significantly lower than baseline. Mean serum 25-hydroxyvitamin D levels showed a significant decrease at 6 months (P<0.05), but returned towards baseline thereafter. There was a significant increase in serum parathyroid hormone levels at all time points compared to baseline, these occurring within the normal range. These results indicate that although weight gain in young anorexics is associated with linear growth, bone mineral density does not increase. Whether this deficit can be corrected subsequently requires longer-term prospective studies.

Relationship between insulin-like growth factor I, dehydroepiandrosterone sulfate and proresorptive cytokines and bone density in cystic fibrosis

INTRODUCTION

Patients with cystic fibrosis (CF) are known to be at risk for early osteoporosis, and the mechanisms that mediate bone loss are still being delineated. The aim of the present investigation was to investigate if a correlation exists in these patients between skeletal measurements by dual-energy x-ray absorptiometry (DXA) and two anabolic factors, dehydroepiandrosterone (DHEA) and insulin-like growth factor I (IGF-I), and proresorptive factors such as the cytokines interleukin-1beta, tumor necrosis factor alpha, and interleukin-6.

METHODS

We studied 32 outpatients (18 females; mean age: 26.2+/-7.9 years) at a tertiary care medical center. The subjects had venous samples obtained, underwent anthropometric and bone mineral density (BMD) measurements, and completed a health survey. Serum IGF-I concentrations were below the age-adjusted mean in 78% of the participants, and DHEA sulfate (DHEAS) concentrations were low in 72%. Serum concentrations of all cytokines were on the low side of normal; nonetheless, there was a modest inverse correlation between IL-1beta and BMD at all sites.

RESULTS

In univariate analyses, IGF-I and DHEAS were significant correlates of BMD or bone mineral content. In final multivariate models controlling for anthropometric and other variables of relevance to bone density, only IGF-I was identified as a significant independent skeletal predictor. While alterations in DHEAS, IGF-I, and specific cytokines may contribute to skeletal deficits in patients with CF, of these factors a low IGF-I concentration appears to be most strongly correlated with BMD.

CONCLUSIONS

These findings may have therapeutic implications for enhancing bone density in these patients.

A prospective study of changes in bone turnover and bone density associated with regaining weight in women with anorexia nervosa

Anorexia nervosa (AN) is a condition of self-induced weight loss, associated with an intense fear of gaining weight. Previous studies have shown that bone density may increase with regaining and maintaining normal weight; however, relatively little is known about the changes in bone metabolism that occur during weight restoration. We describe the effect of weight restoration and maintenance of weight over 1 year on bone mineral density (BMD) and bone turnover. We recruited women from the eating disorders services at the South West London and St George's Mental Health NHS Trust, and the Priory and Charter Nightingale Hospitals in London, UK. Details of their AN, fracture history, menstrual history and exercise were obtained by interview and case note review. Morning samples of blood and second void urine were taken for biochemical analysis. BMD was measured by DXA at the lumbar spine (LS), femoral neck (FN), distal radius (RD) and total body bone mineral content (BMC). Patients then entered the treatment program, which includes re-feeding, dietary education and psychotherapy. Over a period of 42 months, we recruited 55 women who agreed to participate in this study and underwent baseline investigations. Of these, 15 (27%) subjects achieved and then maintained their target weight for the duration of the study. At baseline for all subjects (n=55) estradiol levels were lower than the normal reference ranges (both follicular and luteal phases) in 91% of the women. Bone specific alkaline phosphatase (BSAP) concentrations were lower than the premenopausal reference range in 55% of women, and urinary deoxypyridinoline (DPD) was above the premenopausal reference range in 78% of women. Baseline lumbar spine BMD was positively related to BMI (Pearson's r=0.29, P=0.04) and inversely related to bone turnover markers: urinary DPD (Pearson's r=-0.39, P=0.01 and serum BSAP (Pearson's r=-0.3, P=0.06). The 15 patients who regained and maintained weight were followed-up for a mean duration of 69 weeks (SD 7.3, range 54 to 84 weeks). Mean BMI increased from 14.2 (1.7) to 20.2 (0.77) kg/m2 and remained stable throughout follow-up. Menstruation resumed in 8 of the 15 women. Total body BMC and LS BMD increased significantly over the duration of follow-up (by 4.3% each), but FN BMD and distal radius remained stable. Lumbar spine bone area also increased significantly, whereas FN and distal radius did not. These changes were associated with a significant increase in BSAP (P=0.01), and a non-significant trend for a decrease in DPD (P=0.10). Our findings suggest that when women are at low body weight they are in a hypo-estrogenic state, which is associated with imbalance of bone turnover (high bone resorption and low bone formation). This is reversed with weight gain and persists as target weight is maintained and is associated with increases in BMC and BMD.

Medical complications in adolescents with anorexia nervosa: a review of the literature

The purpose of the current article is to summarize the evidence-based medical complications and treatments that are both common and unique to adolescents with anorexia nervosa (AN). Recent literature relating to the cardiovascular complications, refeeding syndrome, alterations in linear growth, impaired bone mineral accretion, and structural and functional brain changes was reviewed. The literature suggests that the medical complications in adolescents with AN are different from those reported in adults. The unique clinical presentation, the early onset, and the unknown impact of these complications underscore the need for early identification and treatment of AN in adolescents. AN is a serious disorder with significant and often life-threatening medical complications. The increasing growth of evidence highlights the importance of early identification and treatment by an interdisciplinary team of health care providers who have expertise in managing adolescents with AN and their medical sequelae.

Independent effect of endogenous dehydroepiandrosterone-sulphate levels and birth weight on bone turnover parameters in young adults

Data indicate that bone turnover is higher in young adults born with a low birth weight (LBW). Moreover, several data support the presence of altered adrenal hormone production in this population. The aim of our study was to investigate whether there is any connection between altered bone homeostasis and adrenal hormone levels. Bone mineral density (BMD), serum osteocalcin (OC), and urinary deoxypyridinoline (DPD) excretion were related to dehydroepiandrosterone-sulphate (DHEAS), cortisol, estradiol, testosterone, and sex-hormone binding globulin (SHBG) levels in 47 healthy young women (of those, 33 were LBW) and 65 healthy young men (of those, 49 were LBW). The age of the subjects was 19-21 years. BMD values were normal and did not correlate with any of the factors investigated. Cortisol did not have any independent effect on bone turnover parameters in either men or women. In women, birth weight, DHEAS levels, and free estradiol index were responsible for almost 50% (corrected r2= 0.45) of serum OC variability. Independent positive associations were observed between DHEAS and OC, and between DHEAS and DPD excretion. In men, birth weight and DHEAS levels together were responsible for more than one-third (corrected r(2) = 0.36) of the variability of serum OC. In contrast with women, DHEAS and OC were inversely correlated in men. Our results suggest that bone turnover depends on the subjects' birth weight. Moreover, DHEAS is also an independent determinant. The effect of DHEAS on bone turnover is different in women and men. DHEAS increases bone turnover in fertile women, while it decreases this in men.

Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health. This CPG covers anorexia nervosa (AN).

METHOD

The CGP team consulted with scientists, clinicians, carers and consumer groups in meetings of over 200 participants and conducted a systematic review of meta-analyses, randomized controlled trials and other studies.

TREATMENT RECOMMENDATIONS

It is extremely difficult to draw general conclusions about the efficacy of specific treatment options for AN. There are few controlled clinical trials and their quality is generally poor. These guidelines necessarily rely largely upon expert opinion and uncontrolled trials. A multidimensional approach is recommended. Medical manifestations of the illness need to be addressed and any physical harm halted and reversed. Weight restoration is essential in treatment, but insufficient evidence is available for any single approach. A lenient approach is likely to be more acceptable to patients than a punitive one and less likely to impair self-esteem. Dealing with the psychiatric problems is not simple and much controversy remains. For patients with less severe AN who do not require in-patient treatment, out-patient or day-patient treatment may be suitable, but this decision will depend on availability of such services. Family therapy is a valuable part of treatment, particularly for children and adolescents, but no particular approach emerges as superior to any other. Dietary advice should be included in all treatment programs. Cognitive behaviour therapy or other psychotherapies are likely to be helpful. Antidepressants have a role in patients with depressive symptoms and olanzapine may be useful in attenuating hyperactivity.

Amenorrhea and bone health in adolescents and young women

PURPOSE OF REVIEW

We present an update on amenorrhea in adolescent girls and young women. Amenorrhea may herald the onset of estrogen deficiency, which can adversely affect peak bone mass and ultimate risk of osteoporosis.

RECENT FINDINGS

Adolescence is a critical period for bone accretion. Important modifiable factors that optimize bone accretion during this time are calcium intake, vitamin D, nutrition, and exercise. Another modifiable factor in the hands of the clinician is the prompt recognition and therapy of amenorrhea associated with estrogen deficient states, caused by conditions such as hyperprolactinemia and ovarian failure. An important recent observation is that adolescents with amenorrhea who diet, but who do not meet diagnostic criteria for anorexia nervosa, are nonetheless at significant risk for low bone density. Also, multiple factors contribute to the bone loss experienced by patients with anorexia nervosa, and the associated estrogen deficiency may not be the major contributor. Recent evidence also suggests that the contraceptive depot medroxyprogesterone acetate may contribute to impaired bone accretion. While estrogen/progestin replacement therapy has a clear role in the management of girls and young women with primary ovarian insufficiency, the exact role of this therapy in the amenorrhea associated with anorexia nervosa or exercise remains controversial.

SUMMARY

Increasingly, osteoporosis prevention is recognized as an important role for health care providers of adolescent girls and young women. Viewed from this perspective, there is a need for more aggressive evaluation and management of amenorrhea, and research is needed to define sound and cost effective strategies.

Patients With Eating Disorders

PURPOSE

To analyze fracture risk and bone mineral density in patients with eating disorders (anorexia nervosa, bulimia nervosa, and other eating disorders).

DESIGN

Clinical overview.

FINDINGS

Bone mineral density is decreased and fracture risk increased in patients with anorexia nervosa. In patients with bulimia nervosa, bone mineral is only marginally decreased and fracture risk marginally increased. In patients with other eating disorders (eating disorders not otherwise specified), bone mineral density is decreased and fracture risk increased.

CONCLUSIONS

Fracture risk is increased in patients with eating disorders. An eating disorder should be suspected in severely underweight young individuals (primarily girls) presenting with fractures, especially low-energy fractures.

Adrenarche and bone modeling and remodeling at the proximal radius: weak androgens make stronger cortical bone in healthy children

Adrenarche, the physiological increase in adrenal androgen secretion, may contribute to better bone status. Proximal radial bone and 24-h urinary steroid hormones were analyzed cross-sectionally in 205 healthy children and adolescents. Positive adrenarchal effects on radial diaphyseal bone were observed. Obviously, adrenarche is one determinant of bone mineral status in children.

INTRODUCTION

Increased bone mass has been reported in several conditions with supraphysiological adrenal androgen secretion during growth. However, no data are available for normal children. Therefore, our aim was to examine whether adrenal androgens within their physiological ranges may be involved in the strengthening of diaphyseal bone during growth.

METHODS

Periosteal circumference (PC), cortical density, cortical area, bone mineral content, bone strength strain index (SSI), and forearm cross-sectional muscle area were determined with peripheral quantitative computed tomography (pQCT) at the proximal radial diaphysis in healthy children and adolescents. All subjects, aged 6-18 years, who collected a 24-h urine sample around the time of their pQCT analysis (100 boys, 105 girls), were included in the present study, and major urinary glucocorticoid (C21) and androgen (C19) metabolites were quantified using gas chromatography-mass spectrometry.

RESULTS AND CONCLUSIONS

We found a significant influence of muscularity, but not of hormones, on periosteal modeling (PC) before the appearance of pubic hair (prepubarche). Similarly, no influence of total cortisol secretion (C21) was seen on the other bone variables. However, positive effects of C19 on cortical density (p < 0.01), cortical area (p < 0.001), bone mineral content (p < 0.001), and SSI (p < 0.001)--reflecting, at least in part, reduction in intracortical remodeling-were observed in prepubarchal children after muscularity or age had been adjusted for. This early adrenarchal contribution to proximal radial diaphyseal bone strength was further confirmed for all cortical variables (except PC) when, instead of C19 and C21, specific dehydroepiandrosterone metabolites were included as independent variables in the multiple regression model. During development of pubic hair (pubarche), muscularity and pubertal stage rather than adrenarchal hormones seemed to influence bone variables. Our study shows that especially the prepubarchal increase in adrenal androgen secretion plays an independent role in the accretion of proximal radial diaphyseal bone strength in healthy children.

Eating disorders

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified remain a significant cause of morbidity and mortality in girls and young women. Management of eating disorders typically requires a multidisciplinary team approach, often spear-headed by the clinician initially detecting the illness. This article addresses the definitions and prevalence of eating disorders, tips on recognition and management of medical complications, and reproductive health concerns for these young women. Issues surrounding care of the patient with the female athlete triad, or amenorrhea, osteopenia, and eating disorders, are also discussed.

Regional body composition in adolescents with anorexia nervosa and changes with weight recovery

BACKGROUND

Studies of regional fat distribution in adults with anorexia nervosa (AN) have shown decreased extremity fat at baseline and increased trunk fat with weight recovery, resulting in truncal adiposity. Little is known about fat distribution in adolescents with AN, especially with weight recovery.

OBJECTIVE

We sought to determine whether regional fat distribution in adolescents with AN is comparable with that in healthy adolescents and whether weight recovery results in increased trunk fat and truncal adiposity.

DESIGN

In 21 adolescent girls with AN and 21 control subjects matched for age and pubertal stage, we measured body-composition variables with dual-energy X-ray absorptiometry at baseline, 6 mo, and 12 mo. Weight recovery was defined as a > or = 10% increase in body mass index.

RESULTS

At baseline, the girls with AN had a lower percentage of trunk fat than did the control subjects, whereas the percentage of extremity fat was not significantly different between the groups. Weight recovery in 13 subjects with AN resulted in an increased percentage of trunk fat and an increased ratio of trunk fat to extremity fat; however, this ratio did not exceed that of control subjects.

CONCLUSIONS

In adolescents with AN, trunk fat rather than extremity fat is reduced. Weight recovery is associated with increased trunk fat and an increased ratio of trunk fat to extremity fat. In contrast with previous findings in adults, this most likely represents normalization of fat distribution rather than development of truncal adiposity.

Osteoporosis in anorexia nervosa: prevention and treatment

BACKGROUND

Osteoporosis is a very prevalent complication of anorexia nervosa. In contrast to the many other medical complications of anorexia, osteoporosis and its sequelae of fractures, kyphosis, and pain may persist regardless of the overall treatment outcome.

DISCUSSION

Traditional well-proven therapies for postmenopausal osteoporosis are not as effective against osteoporosis in anorexia nervosa. Therefore, clinicians who treat these patients must become increasingly vigilant about osteoporosis in regards to preventive, diagnostic, and treatment strategies.

Normal bone accretion and effects of nutritional disorders in childhood

Although osteoporosis is usually considered to be a health concern of the elderly, increased attention is being paid to children and adolescents who are at risk for developing this devastating disease. As osteoporosis is a preventable condition with no identified cure, focus has been placed on modifiable areas in a young person's life that may prevent the development of the disease. A child or adolescent's nutrition is an example of such an area. This review examines factors influencing normal bone development and emphasizes the importance of the adolescent years as a time for peak bone accretion. Current methods to evaluate skeletal status are examined, including the challenges that arise in interpreting bone densities in children who have growing bones. Children and adolescents who are at high risk for osteoporosis are discussed, with an emphasis on groups in whom poor nutrition likely mediates bone loss. Two models of malnutrition, anorexia nervosa and the female athlete triad, are discussed, with emphasis on the way in which each has deleterious effects on the adolescent skeleton. The promotion of skeletal health is ultimately the encouragement of good general health principles for all young people. Approaches for working with children and adolescents are reviewed, including literature supporting each strategy.

Eating disorders in adolescence and their sequelae

Eating disorders are prevalent in adolescents and are associated with significant medical and psychiatric morbidity. Amenorrhoea, one of the cardinal features of anorexia nervosa, is the most likely reason for consulting the gynaecologist. Amenorrhoea in a young woman should alert the gynaecologist to the possibility of an underlying eating disorder. Osteopenia is a potentially irreversible complication of prolonged amenorrhoea and a low oestrogen state. Eating disorders are best managed by a team approach, with the team comprising a physician, nutritionist and therapist. Oestrogen replacement therapy has not been shown to be an effective treatment for osteopenia in anorexia nervosa and the gynaecologist should avoid simply prescribing oestrogen replacement therapy without referring the patient for comprehensive treatment of the eating disorder. Nutritional rehabilitation, weight restoration and resumption of spontaneous menses are the mainstay of medical management. Calcium and vitamin D supplementation and moderate weight-bearing exercise should be prescribed where indicated. Newer therapeutic options for the treatment of osteopenia include DHEA, IGF-1 and alendronate.