Medical Complications of Eating Disorders – Osteoporosis and Osteopenia
One of the best known and most feared complications of eating disorders is osteoporosis. Osteoporosis is a disease in which there is a loss of bone mass, often throughout the body, and a significantly increased risk of fracture and pain. Osteoporosis is a diagnosis made through bone scans, particularly a DEXA scan. A score of -2.5 or greater on a DEXA scan is considered to be osteoporosis. A score of -1 to -2.5 is defined as osteopenia. Anyone with osteopenia is at great risk of developing osteoporosis. Statistically, 40% of people with anorexia will have osteoporosis and as high as 90% will have osteopenia.
Osteoporosis results most often from nutritional insufficiency, caused by a depletion of necessary nutritional elements. Changes to the body’s composition, as well as endocrine changes, also contribute to osteoporosis. In addition, the low energy state of the body and the energy imbalance created by restriction increases bone loss. There are many other hormonal changes implicated in osteoporosis. The most specific risk of osteoporosis is the chance of fracture, particularly bone fracture of the vertebra, hips, and long bones. When exercise is present, the stress of the exercise with osteoporosis also increases fracture risk. This is one of the many reasons that clients with anorexia should not engage in stressful exercise.
While hormone replacement therapy may be an effective treatment for osteoporosis that is not caused by an eating disorder, medications designed to treat osteoporosis for post-menopausal women are likely less effective in patients with anorexia. In addition, medications designed for post-menopausal women should not be used in women of childbearing age, as we do not know much about their long-term safety. Unfortunately, because osteoporosis that results from anorexia often occurs at a young age, often during bone formation, it may be more serious than bone loss at a later age.
The upshot of all of this it two-fold: 1. The best way to manage osteoporosis is not to get it in the first place. Osteopenia is often reversible while osteoporosis may not be. 2. The best treatment for existing osteoporosis is refeeding and weight restoration. In practical terms, early recognition, early diagnosis, and aggressive treatment of the underlying eating disorder at the earliest possible moment is by far the most effective way to manage osteoporosis. As we have stated many times before, therapy that focuses on anything but refeeding has a significant chance of leading to harm rather than improvement. If you have any concerns that you might have osteoporosis, have your physician refer you immediately for a bone scan.
ABOUT THE AUTHOR
Mark Warren, MD
Mark Warren is the chief medical officer of The Emily Program. He is also one of the original founders of the Cleveland Center for Eating Disorders, which became The Emily Program – Cleveland in 2014. A Cleveland native, he is a graduate of the Johns Hopkins University Medical School and completed his residency at Harvard Medical School. He served as Chairman of the Department of Psychiatry at Mt. Sinai Hospital and Medical Director of University Hospital Health System’s Laurelwood Hospital. A past vice-chair for clinical affairs at the Case School of Medicine Department of Psychiatry, he continues on the Clinical Faculty of the Medical School, teaching in both the Departments of Psychiatry and Pediatrics. He is currently a faculty member and former chair of the Board of Governors at the Gestalt Institute of Cleveland. Dr. Warren is a Distinguished Fellow of the American Psychiatric Association, a two-time recipient of the Exemplary Psychiatrist Award of the national Alliance for the Mentally Ill, and a winner of the Woodruff Award. He leads the Males and Eating Disorders special interest group for the Academy of Eating Disorders.