Women With Anorexia Nervosa at High Risk for Bone Fractures

woman with fractured arm
Cropped image of beautiful mature woman with her arm in gypsum sitting at the traumatologist
A study found that patients with anorexia nervosa have a particularly high risk for hip, vertebral, and upper arm fractures.

Women with anorexia nervosa (AN), but not those with bulimia nervosa (BN) or other specified feeding or eating disorders (OSFED), have an increased risk of bone fracture, according to a Danish study published in the International Journal of Eating Disorders. A number of complications are associated with decreased bone mineral density in AN, including hypogonadism, hypercortisolemia, and growth hormone resistance. The risk of fracture in women with AN is approximately twice that of healthy individuals.

Jacob Frølich, MD, of the Centre for Eating Disorders, Odense University Hospital, Odense, Denmark, and colleagues examined 803 female emergency department (ED) patients referred for specialized ED treatment between 1994 and 2004. In 2016, they obtained data on fractures from the Danish National Registry of Patients and investigated the rate of fracture in patients with AN (n = 424), BN (n = 251), or OSFED (n = 128), as well as those in remission vs those with active disease. Researchers recruited healthy control participants for the sake of comparison.

For patients with AN, the researchers observed a significantly elevated fracture risk compared to healthy controls (incidence rate ratio [IRR], 2.2), but not for patients with BN (IRR, 1.3) or OSFED (IRR, 1.8). Patients with AN had a particularly high risk for hip fractures (IRR, 6.6), as well as vertebral fractures (IRR, 3.8) and upper arm fractures (IRR, 3.0).

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In patients with remission of AN (IRR, 1.7), the risk of fracture was lower compared to those with active disease (IRR, 2.6), but higher than healthy controls (IRR, 1.7). Patients’ age at start of disease (odds ratio [OR], 1.10; 95% CI, 1.05-1.15; P <.001), nadir body mass index (OR, 0.88; 95% CI, 0.80-1.00; P <.05), and pretreatment disease duration (OR, 1.10; 95% CI, 1.045-1.16; P <.001) independently predicted fracture risk. The study found no significantly elevated type of fracture risk in BN or OSFED, and remission did not influence facture risk in these groups.

The study was limited by the lack of a widely accepted definition of remission and data on behavioral factors such as physical activity, as well as the inability to monitor compliance in patients advised to reduce excessive physical activity. The researchers concluded by noting that targeting “early nutritional rehabilitation and weight gain” may be an effective means of reducing the risk of fracture in women with AN.


Frølich J, Winkler LA, Abrahamsen B, Bilenberg N, Hermann AP, Stoving RK. Fractures in women with eating disorders—incidence, predictive factors, and the impact of disease remission: cohort study with background population controls [published online January 10, 2020]. Int J Eat Disord. doi:10.1002/eat.23223