Skeletal Complications of Eating Disorders Abigail A. Donaldson, Catherine M. Gordon PII: DOI: Reference:
S0026-0495(15)00168-7 doi: 10.1016/j.metabol.2015.06.007 YMETA 53227
To appear in:
Metabolism
Received date: Revised date: Accepted date:
8 October 2014 4 June 2015 9 June 2015
Please cite this article as: Donaldson Abigail A., Gordon Catherine M., Skeletal Complications of Eating Disorders, Metabolism (2015), doi: 10.1016/j.metabol.2015.06.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
Skeletal Complications of Eating Disorders
Hasbro Children’s Hospital and Alpert Medical School of Brown University,
SC
Providence RI
RI P
a
T
Abigail A. Donaldson, MDa and Catherine M. Gordon, MD, MSca
NU
Address correspondence to: Abigail A. Donaldson, MD
MA
Assistant Professor of Pediatrics
593 Eddy Street, Potter 200
PT
Providence, RI 02903
ED
Medical Director, Hasbro Children’s Hospital Eating Disorders Program
Tel: 401-444-4712; Fax: 401-444-6220
CE
[email protected]
AC
Second Author e-mail address: [email protected]
Both authors materially contributed to the article preparation, and have approved the final article. The authors declare no conflicts of interest or financial disclosures.
Word Count: 4,242
1
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
Structured Abstract Anorexia Nervosa (AN) is a psychiatric illness with profound medical consequences.
T
Among the many adverse physical sequelae of AN, bone health is impacted by starvation and
RI P
can be permanently impaired over the course of the illness. In this review of skeletal complications associated with eating disorders, we discuss the epidemiology, neuroendocrine
SC
changes, adolescent vs. adult skeletal considerations, orthopedic concerns, assessment of bone
NU
health, and treatment options for individuals with AN. The focus of the review is the skeletal sequelae associated with anorexia nervosa, but we also briefly consider other eating disorders
MA
that may afflict adolescents and young adults. The review presents updates to the field of bone
ED
health in AN, and also suggests knowledge gaps and areas for future investigation.
CE
Abbreviations:
PT
Key Words: eating disorder, anorexia nervosa, bone health, bone mineral density
AC
Anorexia Nervosa (AN)
bone mineral density (BMD)
2
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
dual-energy X-ray absorptiometry (DXA) International Society for Clinical Densitometry (ISCD)
T
gonadotropin releasing hormone (GnRH)
RI P
follicular stimulating hormone (FSH) luteinizing hormone (LH)
SC
insulin-like growth factor I (IGF-I) body mass index (BMI)
NU
Growth hormone (GH)
serum 25-hydroxyvitamin D (25OHD)
MA
anterior cruciate ligament (ACL)
ED
quantitative computed tomography (QCT) dehydroepiandrosterone (DHEA)
PT
Food and Drug Administration (FDA)
International Olympic Committee (IOC)
AC
CE
Relative Energy Deficit in Sport (RED-S)
3
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
Introduction Anorexia Nervosa (AN) is a psychiatric illness with profound medical consequences.
T
Among the many adverse physical sequelae of AN, bone health is impacted by starvation and
RI P
can be permanently impaired over the course of the illness.1,2,3 In this review of skeletal complications associated with eating disorders, we discuss both screening and treatment
SC
considerations. The focus of the review is the skeletal sequelae associated with anorexia
NU
nervosa, but we also briefly consider other eating disorders that may afflict adolescents and
MA
young adults.
Epidemiology
ED
Under-nutrition is the primary cause of compromised bone health in AN. However, there
PT
are other factors that contribute to diminished bone mass and skeletal strength in this population. Lifestyle choices can be detrimental to bone health, including low physical activity, excess
CE
caffeine and/or carbonated beverages, a strict vegetarian diet, high salt diet, and regular cigarette
AC
or alcohol use.4,5 In addition, genetics explain approximately three quarters of skeletal phenotypic variance, an important point to consider in any patient who presents for care.4 The body draws on its nutrient-rich skeletal reserve to support physiologic function in the absence of adequate oral intake. Over time, this process leads to decreased bone mineral density (BMD), a common consequence of a restrictive eating disorder such as AN. Low BMD is most frequently detected using dual-energy X-ray absorptiometry (DXA). Among adolescent females with anorexia, decreased BMD at the lumbar spine is highly prevalent when compared with agematched controls.6,7,8,9 The prevalence of males who present to our practice continues to rise, and among males low BMD has been shown to be more common at the hip, femoral neck, and
4
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
trochanteric and intertrochanteric sites than among age-matched controls.10 Osteopenia (defined as -1.0 SD >/= T-score > -2.5 SD) is present in 92%, and osteoporosis (defined as T-score
S0026-0495(15)00168-7 doi: 10.1016/j.metabol.2015.06.007 YMETA 53227
To appear in:
Metabolism
Received date: Revised date: Accepted date:
8 October 2014 4 June 2015 9 June 2015
Please cite this article as: Donaldson Abigail A., Gordon Catherine M., Skeletal Complications of Eating Disorders, Metabolism (2015), doi: 10.1016/j.metabol.2015.06.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
Skeletal Complications of Eating Disorders
Hasbro Children’s Hospital and Alpert Medical School of Brown University,
SC
Providence RI
RI P
a
T
Abigail A. Donaldson, MDa and Catherine M. Gordon, MD, MSca
NU
Address correspondence to: Abigail A. Donaldson, MD
MA
Assistant Professor of Pediatrics
593 Eddy Street, Potter 200
PT
Providence, RI 02903
ED
Medical Director, Hasbro Children’s Hospital Eating Disorders Program
Tel: 401-444-4712; Fax: 401-444-6220
CE
[email protected]
AC
Second Author e-mail address: [email protected]
Both authors materially contributed to the article preparation, and have approved the final article. The authors declare no conflicts of interest or financial disclosures.
Word Count: 4,242
1
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
Structured Abstract Anorexia Nervosa (AN) is a psychiatric illness with profound medical consequences.
T
Among the many adverse physical sequelae of AN, bone health is impacted by starvation and
RI P
can be permanently impaired over the course of the illness. In this review of skeletal complications associated with eating disorders, we discuss the epidemiology, neuroendocrine
SC
changes, adolescent vs. adult skeletal considerations, orthopedic concerns, assessment of bone
NU
health, and treatment options for individuals with AN. The focus of the review is the skeletal sequelae associated with anorexia nervosa, but we also briefly consider other eating disorders
MA
that may afflict adolescents and young adults. The review presents updates to the field of bone
ED
health in AN, and also suggests knowledge gaps and areas for future investigation.
CE
Abbreviations:
PT
Key Words: eating disorder, anorexia nervosa, bone health, bone mineral density
AC
Anorexia Nervosa (AN)
bone mineral density (BMD)
2
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
dual-energy X-ray absorptiometry (DXA) International Society for Clinical Densitometry (ISCD)
T
gonadotropin releasing hormone (GnRH)
RI P
follicular stimulating hormone (FSH) luteinizing hormone (LH)
SC
insulin-like growth factor I (IGF-I) body mass index (BMI)
NU
Growth hormone (GH)
serum 25-hydroxyvitamin D (25OHD)
MA
anterior cruciate ligament (ACL)
ED
quantitative computed tomography (QCT) dehydroepiandrosterone (DHEA)
PT
Food and Drug Administration (FDA)
International Olympic Committee (IOC)
AC
CE
Relative Energy Deficit in Sport (RED-S)
3
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
Introduction Anorexia Nervosa (AN) is a psychiatric illness with profound medical consequences.
T
Among the many adverse physical sequelae of AN, bone health is impacted by starvation and
RI P
can be permanently impaired over the course of the illness.1,2,3 In this review of skeletal complications associated with eating disorders, we discuss both screening and treatment
SC
considerations. The focus of the review is the skeletal sequelae associated with anorexia
NU
nervosa, but we also briefly consider other eating disorders that may afflict adolescents and
MA
young adults.
Epidemiology
ED
Under-nutrition is the primary cause of compromised bone health in AN. However, there
PT
are other factors that contribute to diminished bone mass and skeletal strength in this population. Lifestyle choices can be detrimental to bone health, including low physical activity, excess
CE
caffeine and/or carbonated beverages, a strict vegetarian diet, high salt diet, and regular cigarette
AC
or alcohol use.4,5 In addition, genetics explain approximately three quarters of skeletal phenotypic variance, an important point to consider in any patient who presents for care.4 The body draws on its nutrient-rich skeletal reserve to support physiologic function in the absence of adequate oral intake. Over time, this process leads to decreased bone mineral density (BMD), a common consequence of a restrictive eating disorder such as AN. Low BMD is most frequently detected using dual-energy X-ray absorptiometry (DXA). Among adolescent females with anorexia, decreased BMD at the lumbar spine is highly prevalent when compared with agematched controls.6,7,8,9 The prevalence of males who present to our practice continues to rise, and among males low BMD has been shown to be more common at the hip, femoral neck, and
4
ACCEPTED MANUSCRIPT RUNNING HEADER: Bone Health in Eating Disorders
trochanteric and intertrochanteric sites than among age-matched controls.10 Osteopenia (defined as -1.0 SD >/= T-score > -2.5 SD) is present in 92%, and osteoporosis (defined as T-score
