Caveat: New strategies to manage compromised bone health in adolescents and young adults with eating disorders are lacking. Weight restoration is the most important aspect of supporting bone health, yet it can be unattainable or unsustainable for some, limiting effective treatment options. Additionally, there is minimal research on bone health in individuals assigned male at birth. Below is my current practice following the most updated guidelines. If and when more studies emerge, I will update these practice recommendations:
Why it matters:
Restrictive eating disorders like anorexia nervosa (AN), atypical anorexia nervosa (AAN), and avoidant/restrictive food intake disorder (ARFID) can significantly impact bone health
40-60% of adult bone mass during is typically accrued during the adolescent years
Failing to reach peak bone mass during adolescence can result in fractures, stunted growth, osteopenia, osteoporosis, and bone pain
The bone health of your patients with AN, AAN and ARFID are at higher risk if:
Illness duration > 6 months
Delayed onset or missed period in those with ovaries
Vitamin D deficiency
Family history of osteoporosis
Prior history of stress fractures
Current or historical exposure to medications that may impact bones (ex: glucocorticoids, anticonvulsants, gender affirming hormones)
Tobacco or alcohol use
Next steps in assessing your patient's bone health:
Comprehensive physical exam with review of historical growth curves, and puberty stage
Labs and Imaging: Screen for vitamin D deficiency in all patients. Hormonal labs and imaging are recommended in those with prolonged illness duration, severe weight suppression, missed or lack of menses in those with ovaries, fracture history, or height stunting. Dual Energy X-ray Absorptiometry (DXA) remains the gold standard for evaluating bone density.
What are the treatment options?
Early intervention and comprehensive treatment strategies are crucial for maintaining bone health in those with eating disorders. Despite people reporting feeling well, their bones may be compromised. Taking time to counsel on this aspect is essential due to its often invisible negative impact. Weight restoration is currently our most effective treatment. Calcium and vitamin D supplementation are important but insufficient alone. For some patients, a transdermal estradiol patch with cyclic progesterone may be recommended. Data to support testosterone replacement in adolescents is limited. Treatment plans in adolescents can be nuanced. Don't hesitate to reach out for guidance.
