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A systematic review and meta-analysis of the association between eating disorders and bone density

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Abstract

This meta-analysis investigates the effect of an eating disorder on bone mineral density in two eating disorder subtypes. Following conflicting findings in previous literature, this study finds that not only anorexia nervosa, but also bulimia nervosa has a detrimental effect on BMD. Key predictors of this relationship are discussed. This systematic review and meta-analysis investigates bone mineral density (BMD) in individuals with anorexia nervosa (AN) and bulimia nervosa (BN) in comparison to healthy controls (HCs). AN has been associated with low BMD and a risk of fractures and mixed results have been obtained for the relationship between BN and BMD. Deciphering the effect these two ED subtypes on BMD will determine the effect of low body weight (a characteristic of AN) versus the effects of periods of restrictive eating and malnutrition which are common to both AN and BN. We conducted a systematic search through the electronic databases MedLine, EMBASE and PsychInfo and the Cochrane Library to investigate and quantify this relationship. We screened 544 articles and included 27 studies in a random-effect meta-analysis and calculated the standardised mean difference (SMD) in BMD between women with a current diagnosis of AN (n = 785) vs HCs (n = 979) and a current diagnosis of BN (n = 187) vs HCs (n = 350). The outcome measures investigated were spinal, hip, femoral neck and whole body BMD measured by DXA or DPA scanning. A meta-regression investigated the effect of factors including age, duration since diagnosis, duration of amenorrhea and BMI on BMD. The mean BMI of participants was 16.65 kg/m2 (AN), 21.16 kg/m2 (BN) and 22.06 kg/m2 (HC). Spine BMD was lowest in AN subjects (SMD, −3.681; 95 % CI, −4.738, −2.625; p < 0.0001), but also lower in BN subjects compared with HCs (SMD, −0.472; 95 % CI, −0.688, −0.255; p < 0.0001). Hip, whole body and femoral neck BMD were reduced to a statistically significant level in AN but not BN groups. The meta-regression was limited by the number of included studies and did not find any significant predictors. This meta-analysis confirms the association between low BMD and AN and presents a strong argument for assessing BMD not only in patients with AN, but also in patients with BN.

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Authors and Affiliations

  1. Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK

    L. Robinson, V. Aldridge & N. Micali

  2. Musculoskeletal Research Unit, University of Bristol, Bristol, UK

    E. M. Clark

  3. Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, 02114, USA

    M. Misra

  4. Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA

    N. Micali

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  1. L. Robinson
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  2. V. Aldridge
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  3. E. M. Clark
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Funded by CHRAT (Child Health Research Appeal Trust) Studentship: 2014–2017

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Supplementary Table 1

PRISMA 2009 Checklist. The PRISMA checklist is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. (DOC 63 kb)

Supplementary Figure 1

SMD in Whole Body BMD in the AN Group. A forest plot to show the standardised mean difference in whole body BMD between AN groups and HCs. Zero is the line of no effect, and all points to the left of zero indicate a reduction in whole body BMD in AN vs. HCs. SMD standardised mean difference. (GIF 19 kb)

High Image Resolution (TIF 36664 kb)

Supplementary Figure 2

SMD in Hip BMD in the AN Group. A forest plot to show the standardised mean difference in hip BMD between AN groups and HCs. Zero is the line of no effect, and all points to the left of zero indicate a reduction in hip BMD in AN vs. HCs. SMD standardised mean difference. (GIF 18 kb)

High Image Resolution (TIF 35116 kb)

Supplementary Figure 3

SMD in Femoral Neck BMD in the AN Group. A forest plot to show the standardised mean difference in femoral neck BMD between AN groups and HCs. Zero is the line of no effect, and all points to the left of zero indicate a reduction in femoral neck BMD in AN vs. HCs. SMD standardised mean difference. (GIF 16 kb)

High Image Resolution (TIF 35303 kb)

Supplementary Figure 4

SMD in Whole Body BMD in the BN Group. A forest plot to show the standardised mean difference in whole body BMD between BN groups and HCs. Zero is the line of no effect, and all points to the left of zero indicate a reduction in whole body BMD in BN vs. HCs. SMD standardised mean difference. (GIF 13 kb)

High Image Resolution (TIF 31905 kb)

Supplementary Figure 5

SMD in Spinal BMD in BN Group. A forest plot to compare results of BN participants with and without a history of AN. A forest plot to show the standardised mean difference in spinal BMD between BN with a history of AN and HCs (AN-BN), and BN groups with no history of AN and HCs (BN). Zero is the line of no effect, and all points to the left of zero indicate a reduction in spinal BMD in BN vs. HCs or AN-BN vs. HCs. SMD standardised mean difference. (GIF 16 kb)

High Image Resolution (TIF 34395 kb)

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Robinson, L., Aldridge, V., Clark, E.M. et al. A systematic review and meta-analysis of the association between eating disorders and bone density. Osteoporos Int 27, 1953–1966 (2016). https://doi.org/10.1007/s00198-015-3468-4

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  • DOI: https://doi.org/10.1007/s00198-015-3468-4

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