Linking Osteoporosis and Eating Disorders: Strategies for Bone Health

By Rebecca Jaspan and the LCWNS Team

Among the many factors involved in eating disorder treatment, one that cannot be overlooked is bone health.  Osteoporosis, also known as “porous bones”, is defined by the National Osteoporosis Foundation as a “bone disease that occurs when the body loses too much bone, makes too little bone, or both.” This consequently leads to weakened bones that can break from something as minor as a sneeze. Osteoporosis is associated with low bone mass and enhanced skeletal fragility resulting in an increased risk of fractures.  Currently, osteoporosis and low bone mass affects almost 54 million people in the United States with increased risk as one ages.

Osteoporosis is a common complication of eating disorders. About 75% of women diagnosed with anorexia nervosa show evidence of bone mineral deficiency.  While our bones are constantly rebuilding themselves, undernutrition and low body mass index can cause bone development to slow. The cells known as osteoclasts break down old bone and the cells called osteocytes build new bone. Peak bone mass is reached at about 15 – 18 years old and starts to very slowly decline at age 30. The critical years in which bone mass is developed coincides with peak age of onset for anorexia nervosa.  Factors that influence the rate at which bone mass decreases include family history, smoking, over-exercising, certain medications, malnutrition, and hormonal imbalances.  The body responds to under nutrition first, by decreasing estrogen production and subsequently causing amenorrhea.  Since estrogen is necessary to lay bone mass, low estrogen, particularly in children and adolescents, leads to a decrease in bone production and increase in bone absorption.  As a result, these clients are at higher risk for developing osteoporosis if not treated.

Osteoporosis is diagnosed using a test known as the DEXA Scan which provides a “T score”, allowing your health professional to determine your level of bone health. This is a reliable and painless diagnostic tool which estimates the density of our bones and our chance of breaking a bone.  An adolescent with a 9-12 month history of anorexia should have a DEXA scan with follow up every 2 years while the eating disorder is active.  A DEXA scan is also recommended at age 18 and at younger ages in patients with low body weight, chronic glucocorticoid therapy, delayed puberty, gonadal failure, or history of a fracture.  A normal T-score is -1.0 or above.  A T-score between -1 and -2.5 indicates osteopenia or low bone density and a T-score of -2.5 or below indicates osteoporosis.

A 2016 meta-analysis showed that both anorexia nervosa as well as bulimia nervosa had a significant negative affect on bone mineral density.  The study investigated the bone mineral density in individuals with anorexia and bulimia compared to healthy controls.  The study found that hip, whole body, and femoral neck bone mineral density were reduced by a statistically significant level in anorexia, but not in bulimia groups.  Those with bulimia were at higher risk when having previous history of anorexia or periods of restriction.  This meta-analysis confirms the strong evidence for screening of osteoporosis in clients with both anorexia and bulimia.

Osteoporosis is frequently referred to as a “silent disease” because symptoms may not present themselves for years. While research suggests bone loss is typically not reversable, individuals can prevent further bone loss. Treatment involves working with a dietitian who specializes in eating disorders to address the root cause of the bone loss.  In our practice we help our clients improve their T-scores through adequate nutrition, resumed menses, weight bearing exercise and supplementation. We do see our clients improve their T-scores and prevent further bone loss.

At Laura Cipullo Whole Nutrition, we encourage all of our clients diagnosed with eating disorders and amenorrhea to receive DEXA scans.  We also help to monitor medical labs values including Vitamin D, ionized calcium, calcitriol, and estradiol, to assess risk from a medical nutrition perspective. Focus may also be on increased intake of calcium-rich foods such as dairy and plant-based yogurts, cheese, fortified orange juice, and canned salmon, and the addition of a Calcium/Vitamin D/Magnesium, such as Metagenics Bone Builder with Magnesium.

Osteoporosis is extremely prevalent in eating disorders and can lead to severe problems.  However, when addressed and treated early with proper nutrition, bone mineral loss can be slowed to prevent fractures and other complications in the future. We highly recommend you talk with your RD and or medical doctor about your risk for osteoporosis.

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