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Managing Bone Disease in Adults with Eating Disorders

Young patients with eating disorders have an increase in bone disease and fragility. An American research team reviewed and summarized the causes and current treatment options for adults who have bone disease with an eating disorder.

Eating disorders are increasing and affect roughly 30 million people in the United States. Eating disorders are unique in that they not only affect the mental state but the physical state as well. Eating disorders lead to impaired physical health and potentially devastating physical consequences. Although most physical consequences of eating disorders can be reversed once weight is restored back to normal and eating behaviours also become normal, other long-term complications may arise.

Bone Disease as a Complication of Eating Disorders

One of these complications is an increase in bone disease which seems to be more of a permanent effect following an eating disorder. Anorexia-induced malnutrition can cause bone disease. Due to this, fractures easily occur because of the fragile state of bones. This has been shown to lead to permanent disability in young patients with eating disorders.  Although it is clear that there is a correlation between eating disorders and the prevalence bone disease, the causes and potential therapeutic options in adult patients with eating disorders remain unknown.

Anne Drabkin and her colleagues recently published a paper that compiled and reviewed the literature of already published data to get a better understanding of the causes and clinical options for adults with eating disorders that were affected by bone disease. Their interpretations were recently summarized in the Journal of Eating Disorders. The authors searched studies published between 1996 and 2016 for keywords such as ‘anorexia nervosa’ and ‘bone density’. Papers were chosen manually based on a number of different criteria.

The authors found that there was consistently an increase in bone disease in patients with eating disorders. After a thorough literature review, the causes of bone disease in patients with eating disorders seemed to be multifaceted and remained under investigation. It seems that some eating disorder patients already were predisposed to high risks for bone disease. It was also found that changes that lead to bone disease are linked to a decreased body mass index. Some other common causes of secondary bone disease were due to the following: premenopausal amenorrhea, Cushing’s syndrome, celiac disease, liver disease, low testosterone, hyperthyroidism, rheumatoid arthritis, lupus, different medications, diabetes, vitamin D deficiency, cigarette smoking, and alcohol consumption.

How is Bone Disease Treated in Patients with Eating Disorders?

To manage bone disease, the initial treatment is always weight restoration along with the resumption of normal menses in females. It was also found that the proper intake of both vitamin D and calcium should be restored.  The scientists recommended that exercises that are focused on weights should not be undertaken unless a professional team is monitoring the exercises with the goal of restoring weight. Health care providers should consider estrogen and progesterone for patients at risk for fracture or continued decline in bone density. Other drugs including denosumab and testosterone in men have still yet to be tested in patients that present with eating disorders. However, these agents can be used as trials if there is a basis for them and it seems that bone disease will persist or worsen.

There are currently no established guidelines for the treatment of patients with eating disorders that have bone disease. Current options for these patients are slim and not standardized. Restoring weight seems to be the main option for patients with eating disorders and bone disease. Authors recommend that patients be screened for other known causes of bone disease. Ultimately at the end, choosing pharmacological agents to target this population remains to be a question of cost, administration, and tailoring drugs to fit patient-specific needs. More research is needed for this group of patients who are at risk of continued and persistent bone disease in order to prevent permanent deformities that may affect them for life.

Written by Ingrid Qemo, BSc

Reference: Drabkin, A., Rothman, M.S., Wassenaar, E., Mascolo, M., Mehler, P.S. 2017. Assessment and clinical management of bone disease in adults with eating disorders: a review. J Eat Disord. doi: 10.1186/s40337-017-0172-0

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