OSTEOPOROSIS AND EATING DISORDERS
publications and education since 1980.
September/October 2000 • Volume 11, Number 5
Bone Loss in Anorexia Nervosa:
Mechanisms and Treatment Options Looking at Temperament
Steven K. Grinspoon, MD and Elizabeth R. Thomas, NP
in Anorexia Nervosa
• Massachusetts General Hospital
• Boston, Massachusetts
can be used as a potential predictor ofbinge eating and purging in persons with
ric Institute and Clinic evaluated tempera-
significantly higher on harm avoidance and
significantly lower on cooperativeness than
Estrogen therapy: Still a major
with restricting-type AN scored the highest
differences among groups, suggesting thatsubtle temperamental differences occur
Mechanisms of anorexia-related
ALSO IN THIS ISSUE
Nutrition Notes: Motivational Interviewing . 4
Long-term Prognosis in Anorexia Nervosa . 5
Book Reviews:Contending with Slimmist Propaganda . 6
Bulimia Nervosa: When Psychotherapy Fails, Fluoxetine is Worth a Try . 7
Hypophosphatemia in Severely Malnourished Anorectic Patients . 7
Predicting Outcome in Bulimia Nervosa . 7
Q&A: Topiramate: Can It Be Used for Binge Eating and Obesity? . 8
Patient Information Sheet: Osteoporosis.INSERT
Current Clinical Information for the Professional Treating Eating Disorders
The overall inadequacy of
Princeton Medical Center Eating Disorders Program, NJ
estrogen therapy in anorexia
nervosa stands in marked
contrast to its efficacy in
preventing bone loss in post-
George Washington School of Medicine, Washington, DC
Bone formation and resorption
Western Psychiatric Institute, Pittsburgh
University of North Dakota School of Medicine, Fargo
Bone is in a continuous state ofturnover, with new bone formed by
Columbia University College of Physicians and Surgeons,
Although patients with anorexianervosa demonstrate elevated
University of North Dakota School of Medicine, Fargo
University of Hawaii School of Medicine, Honolulu
Copyright 2000 by Gürze Books.
reserved. Reproduction, photocopying, storage or
transmission by electronic means without permission from
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right will result in legal action, including civil and/or crimi-
nal penalites, and suspension of service.
Eating Disorders Review®
(ISSN 1048-6984) is pub-
lished bimonthly by Gürze Books, PO Box 2238, Carlsbad CA
92018. 760/434-7533, fax 760/434-5476, [email protected]
Prior indexes and more information at
will be replaced without charge if the
publisher is notified within 60 days of publication. Otherwise,
replacement and back issues are available for $10.00 by
should be addressed to Joel Yager, MD
or Mary K. Stein c/o MD Communications, 302 S. Pinto Place,
Insulin-like growth factor deficiency
Tucson AZ 85748-6902, 520/296-6400, fax 520/296-6464;
—see page 8.
rhea. J Clin Endocrinol Metab
estrogen administration on trabecularbone loss in young women with
anorexia nervosa. J Clin Endocrinol
human insulin-like growth factoradministration on bone turnover in
1. Lucas AR, Beard, CM, O’Fallon, et al.
evaluation. J Nucl Med
populations. Int J Eat Disord
18. Grinspoon S, Baum H, Kim V, et al.
anorexia nervosa. J Clin Endocrinol
Clin Endocrinol Metab
with anorexia nervosa. N Engl J Med
19. Hock JM, Centrella M, Canalis E.
6. Bachrach L, Katzman D, Litt I, et al.
20. McCarthy TL, Centrella M, Canalis E.
of hyperprolactinemic amenorrhea. N
binding proteins. J Clin Endocrinol
bone loss. J Clin Endocrinol Metab
weight recovery. J Clin Endocrinol
action. J Clin Invest
creates and the possibility ofchanging some eating behaviors. At
Why Use MI as a Counseling
An Interview with Eileen
Stellefson, MPH, RD, FADA
: Why do you recommend
stage, the client has
: Motivational interviewing is
helps patients overcome
the conflict between getting
better and maintaining
their eating disorder.
The most appropriate
Determining Readiness to
of change are: 1) pre-contemplation
: How do you assess a client’s
change); 2) contemplation
and physical and nutritional status.
thinking about change); 3) prepara-
(inconsistently taking action); 4)
I use open-ended questions
counseling strategies in the Prepa-
stage. This stage is a good
In the Action
stage, the nutrition
How can the nutrition
—Linda M. Watts, MA, RD
When a client is medically
and eating disorders since 1981. Currently
counsels clients with eating disorders in a
small private practice. Ms. Stellefson’s
Linda Watts, MA, RD
, is our
new “Nutrition Notes” columnist.
I have noticed that a client’s
Long-term Prognosis in
Reverting to an Earlier Stage of
for patients with anorexia nervosa (AN).
: In your experience, have
You are absolutely correct.
A polarization of patients.
At the 21-
recovered, 10.4% still met full diagnostic
: Clients almost always revert
less when first referred. Other factors that
Osteoporosis, renal failure.
the client on what’s different now.
action plans for those who “don’t want to
take it any more.” In a very chatty style,
messages to which we’re subjected.
And, the advertising is targeted at us in
negative self-images and self-destructive
Deadly Persuasion: Why Women
designed to appeal to each of our private
and Girls Must Fight the Addic-
egos. Her chapter titles tell the story.
tive Power of Advertising
are the product”; “In Your Face All over
Body Wars: Making Peace with
corruption of relationship,” and so on. In
means of liberally sprinkled, well-placed
“Please, Please, You’re Driving Me Wild:
detailed lists of resources are presented
advertising’s attempts to foster sexual
chapter by chapter, offered as tools that
relations between men and their cars.
those interested in fighting back. We’re
daily battles. Dislike your body? See the
list of “25 Ways to Love Your Body” —
“Obesity Quiz: Fact or Fiction,” and a
down to size.” Subtle acts of “clique”
their ways into contemporary advertising.
part of a “systems approach” to reverse
successful coping over the long haul.
Many other themes are covered as well.
perfection. This is all in hopes of being
loved, admired, supported and accepted.
women and other major social problems.
Stone Center circle at Wellesley College,
change zeitgeists and social climates.
Teachers.” There’s even a chapter for
needed. Let’s face it: we’re fighting
Women.” All in all, this is an extremely
comes in, oriented toward the lay reader,
Both are available from Gürze Books:
hypnotic effects of advertising, so subtle
Fails, Fluoxetine Is
Characteristics of dropouts
Worth a Try
malnourished patients, either asinpatients or outpatients, to be alert
anorexia nervosa (Int J Eat Disord
patients and 1.7 mg/dl in the third.
(Am J Psychiatry
Sixth Annual Coordinators Training
Predicting Outcome in
2nd Annual Professional Symposium for
Watch for Hypophos-
phatemia in Severely
Healing In Eating Disorders: Biological,
Psychological, Humanistic and Spiritual
criteria for bulimia nervosa (Am J
Questions & Answers
In the Next Issue
effects (J Clin Psychiatry
Assessing Readiness and
Topiramate: Can It Be
According to the Physician’s Desk
Motivation for Change
Used for Binge Eating
By Josie Geller, PhD, St. Paul’s
Hospital • University of British
: One of my patients recently read
any information on this? (J.S., Seattle)
Your patient may be referring to
• Weight-related Behaviors
• Maternal Effect on Self-esteem
Among Hispanic and Anglo
•Should Significant Funds Be
Allocated for Prevention of
FDA Issues Warning on
mood problems, and some of thepatients lost weight. As a result, open
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Osteoporosis and Eating Disorders
If you have an eating disorder, you may be at increased risk of developing bone loss. Although it is very easy to
think of osteoporosis as a disease that only affects older persons, about half of young female patients with anorexianervosa have osteoporosis. Further, about 85% of partially recovered anorexia nervosa patients have bone mineraldeficiencies, even if they have regained their periods and are within 10% of ideal body weight.
Patients with bulimia nervosa or eating disorders not otherwise specified (EDNOS) are also at risk of osteoporo-
sis, especially if they have had anorexia nervosa in the past or have had episodes of amenorrhea or significantweight loss. Female athletes who restrict their eating or who have amenorrhea may also be at increased risk ofdeveloping bone loss. Also, not only women develop osteoporosis, men with anorexia nervosa are also at risk .
The damage caused by osteoporosis is often silent. Hip fractures are painful and easily detected, but fractures of
the lumbar spine may initially be painless. Osteoporosis is, for the most part, a silent, ongoing disorder, discoveredonly after fractures occur.
What is Osteoporosis?
In osteoporosis, the bones are weakened by loss of bone tissue (a condition called osteopenia, pronounced os-
te-o-peen-ia), making a person much more susceptible to fractures. Osteoporosis is defined by the World HealthOrganization as bone mineral deficiency that is 2.5 standard deviations (SD) below the mean peak value in youngadults (T score). Osteopenia is a T score between 1 and 2.5 SD below the mean peak value.
Although we think of bone as solid and stable, in reality our bones are constantly being remodeled as bone is
reabsorbed and new bone is laid down. In fact, about 10% of the bone in our bodies is replaced each year. Bonemineral mass increases during childhood and adolescence, and near peak bone mass is reached by about age 15.
A smaller amount is produced until about age 30; after this, we lose about 1% of our bone mass per year. Bone losscan accelerate at any age, and can do so with excessive weight loss (as in anorexia nervosa) and excessive exercise.
Throughout our lives, there is a dynamic balance between bone formation and bone resorption. This balance canbe upset by many factors, including lack of adequate nutrition and hormonal influences.
Exercise can also influence bone mineral density. Moderate weight-bearing aerobic exercises, such as walking,
can slow bone loss, but very strenuous exercise can speed bone loss.
Several diagnostic aids are now available to diagnose osteoporosis. Certain chemicals act as markers of bone
formation and bone resorption and can be measured with blood tests. Markers that indicate lower-than-normallevels of bone formation include calcitonin, a hormone secreted by the thyroid gland, and type-1 procollagencarboxy terminal propeptide. Markers of bone resorption that have been found to be increased in women withanorexia nervosa include serum type-1collagen carboxy terminal telopeptiode.
Another helpful blood test measures serumestradiol levels; estradiol is the strongest of
Calcium Content of Some Common Foods
clearly show bone loss. Dual energy x-ray
examine two areas at greatest risk, the hip
little more expensive than regular x-rays,
and less expensive than CAT scans, but is
much lower levels of radiation. The test is
quick, easy, and painless, and involves a
Tip: Read labels! Many foods are now fortified and it is easy to
composition (particularly fat content), and
find high-calcium foods in most supermarkets.
use of calcium and vitamin D supple-ments. Estrogen supplementation (without
Source: Adapted from
The Medical Letter, vol. 42, Issue 1075,
Eating Disorders Review • (800) 756-7533 • www.bulimia.com This handout may be reproduced. #EDRPH115A
loss or correct low bone mineral density.
. For young teens, body fat content should be at least 17%; adult women should aim for a
body fat composition between 22% and 25%. Gaining weight helps, but may not fully restore bone mass.
The average American consumes less than 800 mg of calcium per day. The National Academy
of Sciences recommends 1300 mg of calcium/day for children 9 to 18, 1000 mg per day for adults 19 to 50, includ-ing pregnant and lactating women, and 1200 mg/day for everyone over 50 years of age.
Although it hasn’t been proved that calcium can help restore bone in patients with anorexia nervosa, the current
recommendation is that patients eat 1,500 mg per day of calcium, preferably in calcium-rich foods such as milk (seeTable 1, “Calcium Content of Some Common Foods”). Also, many non-dairy foods are now fortified with calcium.
If it isn’t possible to get the full requirement from food alone, oral calcium supplements may be the answer.
Vitamin D, 400 international units (IU)/day, is also recommended because it helps the body absorb calcium. Cal-cium tablets are usually easy to take and cause few symptoms. Sometimes calcium carbonate tablets may causeconstipation, bloating, and excess gas. If this is the case, individuals should switch to a different brand and increaseyour fluid intake. People who have a tendency to form calcium stones in the urinary tract are usually advised notto take calcium supplements.
Calcium supplements come in a variety of forms. Some come from natural products such as oyster shell or bone.
Others are marketed mainly as antacids (like Tums, for example). Calcium carbonate and phosphate preparationshave the highest amount of elemental calcium, about 40%. Calcium citrate contains 21% elemental calcium; calciumlactate and calcium gluconate contain 13 and 9% elemental calcium, respectively. There is little evidence that onetype of calcium is more effective than another in preventing osteoporotic fractures; calcium citrate may be betterabsorbed, however.
Moderate exercise, such as walking or yoga may be helpful—once your weight is restored.
Strength training may also be useful. It is a real challenge: exercise may lessen appetite and slow continuingweight gain in a person recovering from anorexia. Also, some patients may become compulsive about exercise.
Is there any good news about osteoporosis? The good news is that increased awareness can lead to earlier
diagnosis and treatment. Media campaigns promoting getting adequate calcium in the diet and the importance ofmoderate exercise are helping raise awareness of this devastating disease.
(Note: Dr. Pauline Powers contributed to this patient information sheet.)
Bone Disease Websites
NIH Osteoporosis and Related Bone Diseases-National Resource Center
Try http://www.osteo.org/ ,
the official website of the NIH-ORBD-NRC. This website gives
information about many aspects of osteoporosis and offers links to other bone-disease-related
websites. It also provides a “Bibliographies” page, which offers a selection of references related
to subjects such as eating disorders and bone density, sodium fluoride and osteoporosis, and
men and osteoporosis.
The National Osteoporosis Foundation (NOF)
The official website of the NOF is http://www.nof.org.
This easy-to-use website is designed
more for patients than clinicians, and offers advice on a wide range of topics, including mainte-
nance of a healthy diet, patient support groups, and ways of preventing or slowing the progress
of osteoporosis. This site is specially geared to health-care professionals, and offers information
on many aspects of osteoporosis, including an online version of “Osteoporosis Clinical Practice
American Society for Bone and Mineral Research
This website, http://www.asbmr.org/, is the official website for the American Society for Bone
and Mineral Research, and is aimed at researchers. The website lists future conferences, grants
and awards, employment opportunities as well as online access to abstracts of the latest issues
and back issues of the Society’s journals. (Full access requires membership in the Society.)
Eating Disorders Review • (800) 756-7533 • www.bulimia.com This handout may be reproduced. #EDRPH115B
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