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Osteoporosis and Eating Disorders: What’s the Connection?

When young people have eating disorders, it can lead to osteoporosis much later in life

With Nikhil Nayak MD and Rebecca Jaspan RD

Eating disorders are not a choice, according to the National Eating Disorders Association. They are bio-psycho-social diseases, which means that genetic, biological, environmental, and social elements all play a role.

Osteoporosis is a condition that causes bones to become weak and brittle. This happens because bones are actually living tissues that break down and are remade by the body. In fact, the skeleton itself regenerates (this is known as “remodeling”) on a decade by decade basis. However, remodeling slows after the early 20s.

When a person has osteoporosis, the body doesn’t create new bone as quickly as old bone is lost. Before osteoporosis sets in, a person may have osteopenia, or weakened bones, which is also known as brittle bone disease.

Most of the time, you won’t even know you have osteopenia or osteoporosis. It’s considered a “clinically silent” disease, according to Nikhil Nayak MD. “Overall, osteoporosis has no symptoms until fracture — and spine fractures are the most common. They frequently come to clinical attention after a  patient gets an X-ray for something else.” Fractures to the hip and wrist are also common.

How nutrition protects bone health

"Nutrition is key in order to optimize bone growth to prevent issues later on," says Kathleen Cody, executive director of American Bone Health.

Getting the right nutrition needs to start early. This is especially important for very active or athletic kids, adolescents, and teens who might not be fueling up as necessary, Cody says. “If you’re not getting enough food, your body starts shutting down things that are “non-essential” — which includes estrogen production. This is what can happen to adolescents and teens with eating disorders. In some cases, their bone building stops.”

Between the age of nine to 15, children will build 80 percent of the bone density they’ll have in their lifetime, she says. “If they don’t optimize that, they’ll have a lower threshold of bone mass.”

How eating disorders can cause osteoporosis

Young women are also more at risk for creating down-the-road bone health issues, as males typically have two growth spurts in their teens, while females ususally have one. This means young women only get one chance to optimize their skeletal health, and, unfortunately, that time overlaps with years when eating disorders are most prevalent.

In women, estrogen plays a role in bone formation. An osteoblast is a cell that helps in bone formation, but when estrogen deficiency occurs, the osteoblast can’t play its role. This occurs in menopausal women who naturally lose estrogen and also in young women who have eating disorders. When a person restricts food, their period can become irregular or go away entirely, leading to a loss in estrogen levels, which in turn can lead to bone loss.

Unfortunately, eating disorders hinder girls’ chance to improve bone health from the get-go. As the National Eating Disorders Association (NEDA) reports, in one study of 496 girls, up to 13.2% had an eating disorder (as per the Diagnostic and Statistical Manual of Mental Disorders definition) by age 20. Young people between the ages of 15 and 24 who have anorexia have 10 times the risk of dying as other people their age. Sadly, the incidence of eating disorders is on the rise.

Seeking treatment for eating disorders

If you are struggling with an eating disorder, know that you are not alone — and that your doctor and your therapist can work together to find a treatment plan for you that will protect your health now and in the future.

Cody says that the key to helping people is making sure they have good nutrition. “Most of the treatment plans now try to help people figure out the root cause of the disorder so that they don’t have bone issues when they get older. For someone with an eating disorder, they have to uncover that psychological-emotion situation so they can improve their nutrition,” she says.

Rebecca Jaspan RD, a nutritionist with a focus on helping clients with eating disorder recovery, says she focuses on helping her clients find self-compassion, self-love, and self-worth beyond their physical body. She says she also uses Cognitive Behavioral Therapy (CBT) to work with clients on identifying the thoughts, feelings, and behaviors around food.

More so, she offers her clients education around nutrition and osteoporosis, helping them to understand why food is so important. Jaspan also recommends her clients get a bone density scan  — which can show risk for osteoporosis several years in advance.

Signs and symptoms of eating disorders

Eating disorders are not a choice, according to NEDA. “They are bio-psycho-social diseases, which means that genetic, biological, environmental, and social elements all play a role.”

There are several variables at play when it comes to why a person develops an eating disorder. Anyone experiencing an eating disorder deserves compassion and education around how their condition may affect them in the short and long-term.

According to  Jaspan, who is a nutritionist with a focus on helping clients with eating disorder recovery, eating disorders show up in a variety of ways, including, “Any preoccupation with weight and calories which gets in the way of everyday life, being uncomfortable eating around others, refusing to go to social situations where they’d be uncomfortable around food, refusal to eat certain foods, or elimination of certain groups of foods.”

Sometimes, the signs of an eating disorder might not be eliminating food or binging food, but “any sort of fad dieting or frequently and repeatedly trying new practices to change the number on the scale or change the way the body looks.”

There are also specific physical symptoms of eating disorders, Jaspan says. “Notable or drastic fluctuation in weight gain or weight loss, menstrual irregularity, feeling cold all of the time, fainting, brittle hair and nails, and immune issues.”

Diagnosis of eating disorders

The most common eating disorders include:

  • Anorexia Nervosa: An eating disorder focused on weight loss
  • Bulimia nervosa: An eating disorder focused on binge eating and purging
  • Binge eating disorder: An eating disorder focused on eating a great amount of food
  • Orthorexia: An eating disorder characterized by extreme or obsessive focus on healthy eating
  • Eating Disorder Not Otherwise Specified (EDNOS): This can include any person who doesn’t meet strict diagnostic criteria of previously mentioned eating disorders, but who still has an eating disorder that disrupts their life
  • Many more eating disorders exist, including the abuse of laxatives, obsessive exercise, and ruminating on food and calorie intake.

As mentioned above, there are several factors at play when it comes to eating disorders. Genetics certainly have a hand. For example, white and Asian women (particularly after menopause) are especially at risk for the condition. A person can also be born with a biological predisposition that is later triggered by external factors or a pressure to lose weight or be thin.

Environmental issues, such as a traumatic experience, or a parent who calls their child “fat” can also play a role in someone’s development of an eating disorder. Having a mental health issue, such as anxiety or obsessive-compulsive disorder, is also linked to eating disorders. 

Treatments for osteoporosis

  • Taking vitamin D and calcium. These include cholocalciferok and calcitrol,
  • Quitting smoking and limiting your alcohol intake.
  • Taking part in weight-bearing exercise. Studies have shown that women who do weight-bearing exercise actually improve bone strength and bone density. Free weights, resistance bands, and weight machines count, but so do activities like walking and Pilates that use your own body weight.
  • Take part in aerobic activities such as dancing, stairclimbing, and hiking. These will strengthen your legs and lower spine.
  • Avoid jumping and running, and focus more on controlled movements, especially if your bones are already frail. Be sure to avoid exercises that force you to twist (think golf or some yoga poses) or bend forward too often. This may cause compression fractures.
  • Ask your doctor if you would benefit from bisphosphonates, a type of medication used to help prevent bone density loss. They can also inhibit osteoclasts, which can break down bones. These could include Alendronate (Fosamax), Risedronate (Actonel) or Zoledronic acid (Reclast), and others.
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