Common Questions
What treatment is effective in reversing bone loss in anorexia nervosa?
There is currently no effective treatment for reduced bone density in patients with anorexia nervosa. There have been only a few clinical trials to investigate various treatments for decreased bone density secondary to this medical problem. These include estrogen replacement (1-4), weight gain (5-8), recombinant human Insulin-Like Growth Factor (rh IGH-I) (3), DHEA (4), and bisphosphonates (9). Unfortunately, osteoporosis may be a permanent consequence of anorexia nervosa despite recovery (10).
Estrogen replacement or weight gain have not been consistently associated with improvement in bone density. Recombinant human IGF-I, a hormone that promotes bone formation, has been shown to increase bone density when combined with oral contraceptive pills. More research is needed to confirm these findings. There has been one small trial of alendronate in adolescents with anorexia nervosa. Alendronate was associated with small increases in bone density as compared to placebo after one year of treatment. However, bisphosphonates are a class C category in pregnancy and the long-term implications and safety for adolescents and young women are uncertain. They are not FDA approved for use in women of childbearing age.
Pending further research, recommendations are to optimize the nutritional status with appropriate weight gain in all patients with anorexia nervosa. Patients should get 1000 to 1500 mg/day of calcium and 400 IU vitamin D/day to correct potential vitamin D deficiency (11).
| Therapy | Study | Results |
|---|---|---|
| Estrogen replacement | 48 amenorrheic women with anorexia nervosa randomized to receive estrogen/progestin replacement or no replacement. (1) | The hormone treated group had no significant change in bone density compared with the control group; however, there was a 4 percent increase in mean bone density in patients with an initial body weight of less than 70 percent who were treated with hormones. Untreated patients in this group had a 20.1 percent decrease in bone density. |
| Prospective cohort study of 50 premenopausal women with anorexia on OCPs compared with women not on OCPs. (2) | OCPs did not prevent progressive bone loss. | |
| Weight gain | 27 women with anorexia nervosa followed for a median of 25 months. (5) | No significant change in bone density between women who attained 80 percent of ideal weight and those who did not. No change in bone density between groups who did or did not regain menses, take calcium or estrogen, or exercise vigorously. |
| 56 women with eating disorders followed between 9 and 51 months with initial and follow-up DXA scans. (6) | No significant change in bone density despite increases in body mass index. | |
| 419 women with a history of anorexia nervosa from which they had recovered compared with 13 age-matched controls. (7) | A full recovery from anorexia nervosa did not confer full establishment of normal bone density. Bone density did not correlate with the severity or the chronicity of previous anorexia nervosa. | |
| 15 adolescents with a history of anorexia nervosa followed prospectively for 12 to 16 months (8) | Increases in weight, height, and BMI were significant predictors of increase in bone density. | |
| Recombinant Human Insulin-Like Growth Factor (rh IGF-I) with or without OCPs | 65 osteopenic women with anorexia nervosa were randomized to one of four groups: rh IGF-I, OCPs, OCPs and rh IGF-I, or no treatment. Bone density measured initially and at 9 months. (3) | Bone density increased the most (1.8%) in the women taking both rh IGF-I and OCPs as compared to the untreated group. |
| DHEA vs OCPs | 61 females randomized to 50 mg DHEA or OCP (20ug ethinyl estradiol/0.1 mg levonorgestrel) for one year. (4) | No treatment effect on bone density with either DHEA or OCP after controlling for weight gain. |
| Bisphosphonates | Randomized placebo controlled trial of 32 adolescents treated with alendronate, calcium, and vitamin D for one year (9) | Body weight and amount of weight gain were associated with increases in bone density. There was a slight independent treatment effect on the femoral neck with alendronate. |
- Klibanski A, Biller BM, Schoenfeld DA, Herzog DB, Saxe VC. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. Journal of Clinical Endocrinology and Metabolism 1995; 80(3): 898-904.
- Golden NH, Lanzkowsky L, Schedenbach J, Palestro CJ, Jacobsen MS, Shenker IR. The effect of estrogen-progestin treatment on bone mineralization density in anorexia nervosa. J Ped Adol Gyn 2002; 15: 135-143.
- Grinspoon S, Thomas L, Miller KK, Herzog DB, Klibanski A. Effects of recombinant human IGF-1 and oral contraceptive administration on bone density in anorexia nervosa. J Clin Endocrinol Metab 2002; 87: 2883-91.
- Gordon CM, Grace E, Emans, SJ, Feldman HA, et al. Effects of Oral Dehydroepiandrosterone on Bone Density in Young Women with Anorexia Nervosa. J Clin Endocrinol and Metabol 2002; 87: 4935-4941.
- Rigotti NA, Neer RM, Skates SJ, Herzog DB, Nussbaum SR. The clinical course of osteoporosis in anorexia nervosa: A longitudinal study of cortical bone mass.. JAMA 1991; 265(9): 1133-1138.
- Baker D, Robert R, Towell T. Factors predictive of bone mineral density in eating-disordered women: A longitudinal study. International Journal of Eating Disorders 2000; 27: 29-35.
- Hartman D, Crisp A, Rooney B, Rackow C, Atkinson R, Patel S. Bone density of women who have recovered from anorexia nervosa. Int J Eat Disord 2000; 28(1): 107-12.
- Bachrach LK, Katzman DK, Litt IF, Guido D, Marcus R. Recovery from osteopenia in adolescent girls with anorexia nervosa. Journal of Clinical Endocrinology and Metabolism 1991; 72: 602-606.
- Golden NH, Igleseas EA, Jacobsen MS, Carey D, et al. Alendronate for the treatment of osteopenia in anorexia nervosa: A randomized, double-blind, placebo-controlled trial. J Endocrinol Metab 2002; 90: 3179-85.
- Herzog W, Minne H, deter C, et al. Outcome of bone mineral density in anorexia nervosa patients 11.7 years after first admission. J Bone Miner Res 1993; 8: 597-605.
- Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Eng J Med 1997; 340: 1092-98.