Whether an eating disorder is present or not, middle age in women marks a time of increased risk for osteoporosis due to menopause. For reasons only partly understood, regular monthly cycles protect the strength and pliability of bones. Thus, when a woman's periods stop, she loses bone. As she does, she may join the growing numbers of postmenopausal women who collectively experience 1.5 million osteoporotic fractures each year.
Women with a history of either anorexia nervosa or bulimia experience a higher risk of osteoporosis in midlife. The main instigator is lack of normal monthly menstruation. By the age of 3, girls have already acquired a third of their bone mineral. At puberty, the body adds another 20 percent. Adolescence marks the peak; the body lays down and stores up the remaining 45 percent of bone mineral. After menopause, a woman can only maintain or lose the bone density she has. If a woman had anorexia or some form of bulimia during puberty or adolescence, she did not acquire the necessary bone density that she should have.
How much higher is a woman's risk? That depends on when the eating disorder began, how severe it was, and how long it lasted. Studies show that patients who develop their eating disorder before puberty fare worse than those who acquire their eating disorder after their first period. Also, those who recovered and resumed their periods were healthier than those who recovered partially and did not regain their periods. In fact, women who recovered and began menstruating again increased their bone mass by 20 percent. Those with a subtype of anorexia, in which they do not binge and purge, also lost less bone than those who did.
In one study, those with anorexia who vomited the most had the lowest bone mineral density of all. Current technology can measure bone density through dualenergy X-ray densitometry (DEXA) to show whether bone composition is dense like a tree trunk or thinning and gap-ridden like phyllo dough. Women in midlife with histories of eating disorders have implicit risks. In one study, researchers measured the bone density of nineteen women with histories of anorexia nervosa, twenty-one years after recovery. The women still showed reduced bone density in their thigh bones.
The physicians could not prescribe exercise, as is the norm for postmenopausal women at risk for osteoporosis, because women with histories of eating disorders are prone to compulsive overexercise. These doctors also could not reverse the bone loss with estrogen, calcium, or mineral supplements. In fact, more recent evidence, coming from a study of more than 36,000 middle-aged women, casts doubts on the long-held belief that calcium supplements work to prevent osteoporosis in even healthy postmenopausal woman.
Thus, if a woman has had an eating disorder previously or if she is suffering from one now in midlife, she would do well to take steps to prevent bone density loss. A good place to start is a heartto- heart talk with her doctor about the eating disorder. She can first ask for a bone density test. The results produce a measurement known as a T score: the lower the number, the bigger the problem. A T score between –1 and –2.5 means osteopenia, the forerunner of osteoporosis. Below –2.5, the diagnosis is osteoporosis. Based on this number, a doctor will choose from a spectrum of treatments, from aggressive use of drugs such as Fosamax to simple monitoring of her bone density over the years to see if there is a loss of bone mass and at what rate.
Researchers do not know if the standard treatments for osteoporosis will work for women with a history of eating disorders. There is hope on the pharmaceutical horizon, however. Doctors are experimenting with a hormone called leptin, which is involved in body weight regulation and appetite control. Leptin is made by fat cells.
When those shrink, leptin becomes scarce and the body signals hunger, slows metabolism, and shuts menstruation until an individual eats. For women with eating disorders, who make scant leptin supplies, doctors hypothesized that leptin supplementation, while possibly suppressing appetite, would nonetheless stimulate menstrual cycling. The hormone did. After receiving leptin injections twice daily for up to three months, three of eight premenopausal women, who had not been menstruating due to eating problems or excessive exercise, began to ovulate and menstruate.
Two others showed signs of egg development in their ovaries; and all eight women increased their reproductive, thyroid gland, and growth hormone activity. While leptin has not been tested in women with a history of anorexia who are now of peri- and postmenopausal age, it may have some benefit on the health of their bones. As evidence, the younger women in the study did show a marked increase in biochemical components involved in bone formation. While studies such as these continue, eating disorders experts say the best advice for underweight, middle-aged women with histories of eating disorders is weight gain and sound nutrition. Of course, recovery from the eating disorder can address these goals. As always, the quicker the recovery from symptoms, the less severe the damage to the body.
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