Associations between exercise, bone mineral density, and body composition in adolescents with anorexia nervosa
To identify the effect of duration of weight-bearing exercise and team sports participation on bone mineral density (BMD) and body composition among adolescents with anorexia nervosa (AN).
We retrospectively reviewed electronic medical records of all patients 9–20 years old with a DSM-5 diagnosis of AN evaluated by the Stanford Eating Disorders Program (1997–2011) who underwent dual-energy X-ray absorptiometry.
A total of 188 adolescents with AN were included (178 females and 10 males). Using multivariate linear regression, duration of weight-bearing exercise (B = 0.15, p = 0.005) and participation in team sports (B = 0.53, p = 0.001) were associated with higher BMD at the hip and team sports (B = 0.39, p = 0.006) were associated with higher whole body BMC, controlling for covariates. Participation in team sports (B = − 1.06, p = 0.007) was associated with greater deficits in FMI Z-score. LBMI Z-score was positively associated with duration of weight-bearing exercise (B = 0.10, p = 0.018) and may explain the relationship between exercise and bone outcomes.
Duration of weight-bearing exercise and team sports participation may be protective of BMD at the hip and whole body BMC, while participation in team sports was associated with greater FMI deficits among adolescents with AN.
Level of evidence
Level V, descriptive retrospective study.
KeywordsEating disorders Dual-energy X-ray absorptiometry DXA Bone density Bone health Body composition Exercise Sports
The authors thank Laura Bachrach for advice in study design; Audrey Chang, Alaina Critchlow, and Jessica Kao for help with data collection; and Nicole Capdarest-Arest for help with the literature searches.
Supported by the National Institutes of Health (K23DK100558 to RP, K23 MH115184 to SM, and 5R01HD08216602 to NG); the Pediatric Scientist Development Program (K12 HD000850) supported by the American Academy of Pediatrics and American Pediatric Society to JN; and the Hilda and Preston Davis Foundation to RP.
Compliance with ethical standards
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
All procedures performed in this study were in accordance with the ethical standards of the university’s Institutional Review Board and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Because data were retrospectively collected and anonymized, a waiver of informed consent was approved by the Stanford University Committee on Human Research (IRB).
- 4.Solmi M, Veronese N, Correll CU, Favaro A, Santonastaso P, Caregaro L, Vancampfort D, Luchini C, De Hert M, Stubbs B (2016) Bone mineral density, osteoporosis, and fractures among people with eating disorders: a systematic review and meta-analysis. Acta Psychiatr Scand 133:341–351. https://doi.org/10.1111/acps.12556 CrossRefPubMedGoogle Scholar
- 7.Faje AT, Karim L, Taylor A, Lee H, Miller KK, Mendes N, Meenaghan E, Goldstein MA, Bouxsein ML, Misra M et al (2013) Adolescent girls with anorexia nervosa have impaired cortical and trabecular microarchitecture and lower estimated bone strength at the distal radius. J Clin Endocrinol Metab 98:1923–1929. https://doi.org/10.1210/jc.2012-4153 CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Nagata JM, Golden NH, Leonard MB, Copelovitch L, Denburg MR (2017) Assessment of sex differences in fracture risk among patients with anorexia nervosa: a population-based cohort study using the health improvement network. J Bone Miner Res 32:1082–1089. https://doi.org/10.1002/jbmr.3068 CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Misra M, Katzman DK, Cord J, Manning SJ, Mickley D, Herzog DB, Miller KK, Klibanski A (2008) Percentage extremity fat, but not percentage trunk fat, is lower in adolescent boys with anorexia nervosa than in healthy adolescents. Am J Clin Nutr 88:1478–1484. https://doi.org/10.3945/ajcn.2008.26273 CrossRefPubMedPubMedCentralGoogle Scholar
- 20.American Psychiatric Association (1990) Diagnostic and statistical manual of mental disorders. American Psychiatric Association, WashingtonGoogle Scholar
- 21.Centers for Disease Control, C.D.C (2000) Growth charts. http://www.cdc.gov/growthcharts/
- 22.Society for Adolescent Health and Medicine, Golden NH, Katzman DK, Sawyer SM, Ornstein RM, Rome ES, Garber AK, Kohn M, Kreipe RE (2015) Position Paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health 56:121–125. https://doi.org/10.1016/j.jadohealth.2014.10.259 CrossRefGoogle Scholar
- 24.Ak E, Bulut SD, Bulut S, Akdag HA, Oter GB, Kaya H, Kaya OB, Sengul CB, Kisa C (2015) Evaluation of the effect of selective serotonin reuptake inhibitors on bone mineral density: an observational cross-sectional study. Osteoporos Int 26:273–279. https://doi.org/10.1007/s00198-014-2859-2 CrossRefPubMedGoogle Scholar
- 26.Zemel BS, Kalkwarf HJ, Gilsanz V, Lappe JM, Oberfield S, Shepherd JA, Frederick MM, Huang X, Lu M, Mahboubi S et al (2011) Revised reference curves for bone mineral content and areal bone mineral density according to age and sex for black and non-black children: results of the bone mineral density in childhood study. J Clin Endocrinol Metab 96:3160–3169. https://doi.org/10.1210/jc.2011-1111 CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Zemel BS, Leonard MB, Kelly A, Lappe JM, Gilsanz V, Oberfield S, Mahboubi S, Shepherd JA, Hangartner TN, Frederick MM et al (2010) Height adjustment in assessing dual energy X-ray absorptiometry measurements of bone mass and density in children. J Clin Endocrinol Metab 95:1265–1273. https://doi.org/10.1210/jc.2009-2057 CrossRefPubMedPubMedCentralGoogle Scholar
- 28.Weber DR, Moore RH, Leonard MB, Zemel BS (2013) Fat and lean BMI reference curves in children and adolescents and their utility in identifying excess adiposity compared with BMI and percentage body fat. Am J Clin Nutr 98:49–56. https://doi.org/10.3945/ajcn.112.053611 CrossRefPubMedPubMedCentralGoogle Scholar
- 32.Warden SJ, Mantila Roosa SM, Kersh ME, Hurd AL, Fleisig GS, Pandy MG, Fuchs RK (2014) Physical activity when young provides lifelong benefits to cortical bone size and strength in men. Proc Natl Acad Sci U S A 111:5337–5342. https://doi.org/10.1073/pnas.1321605111 CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP, American College of Sports Medicine (2007) American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 39:1867–1882. https://doi.org/10.1249/mss.0b013e318149f111 CrossRefPubMedGoogle Scholar
- 40.Vancampfort D, Vanderlinden J, De Hert M, Soundy A, Adamkova M, Skjaerven LH, Catalan-Matamoros D, Lundvik Gyllensten A, Gomez-Conesa A, Probst M (2014) A systematic review of physical therapy interventions for patients with anorexia and bulemia nervosa. Disabil Rehabil 36:628–634. https://doi.org/10.3109/09638288.2013.808271 CrossRefPubMedGoogle Scholar
- 48.Wren TA, Shepherd JA, Kalkwarf HJ, Zemel BS, Lappe JM, Oberfield S, Dorey FJ, Winer KK, Gilsanz V (2012) Racial disparity in fracture risk between white and nonwhite children in the United States. J Pediatr 161:1035–1040. https://doi.org/10.1016/j.jpeds.2012.07.054 CrossRefPubMedPubMedCentralGoogle Scholar