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Anorexia Nervosa: Analysis of
Trabecular Texture with CT1
Azadeh Tabari, MD
Martin Torriani, MD
Karen K. Miller, MD
Anne Klibanski, MD
Mannudeep K. Kalra, MD
Miriam A. Bredella, MD
Materials and
1
 From the Department of Radiology (A.T., M.T., M.K.K.,
M.A.B.) and Neuroendocrine Unit (K.K.M., A.K.), Mas-
sachusetts General Hospital and Harvard Medical School,
55 Fruit St, Yawkey 6E, Boston, MA 02114. Received April
26, 2016; revision requested June 20; revision received
July 25; accepted August 16; final version accepted
August 26. Address correspondence to M.A.B. (e-mail:
mbredella@mgh.harvard.edu).
Supported by National Institutes of Health (grants
K23 RR-23090, M01 RR01066-27S1, M01 RR01066,
R01 MH083657, R01 DK052625, R01 HL-077674,
R03 DK59297, T32 DK 007028, UL1 RR025758, 8UL1
TR000170, 1UL1 TR001102).
q
 RSNA, 2016
Radiology: Volume 000: Number 0—   2017  n  radiology.rsna.org
Original Research  n  Musculoskeletal
Purpose: To determine indexes of skeletal integrity by using com-
puted tomographic (CT) trabecular texture analysis of the
lumbar spine in patients with anorexia nervosa and nor-
Imaging
mal-weight control subjects and to determine body com­
position predictors of trabecular texture.
This cross-sectional study was approved by the institu-
Methods: tional review board and compliant with HIPAA. Written
informed consent was obtained. The study included 30
women with anorexia nervosa (mean age 6 standard de-
viation, 26 years 6 6) and 30 normal-weight age-matched
women (control group). All participants underwent low-
dose single-section quantitative CT of the L4 vertebral
body with use of a calibration phantom. Trabecular tex-
ture analysis was performed by using software. Skewness
(asymmetry of gray-level pixel distribution), kurtosis
(pointiness of pixel distribution), entropy (inhomogeneity
of pixel distribution), and mean value of positive pixels
(MPP) were assessed. Bone mineral density and abdom-
inal fat and paraspinal muscle areas were quantified with
quantitative CT. Women with anorexia nervosa and nor-
mal-weight control subjects were compared by using the
Student t test. Linear regression analyses were performed
to determine associations between trabecular texture and
body composition.
Results: Women with anorexia nervosa had higher skewness and
kurtosis, lower MPP (P , .001), and a trend toward lower
entropy (P = .07) compared with control subjects. Bone
mineral density, abdominal fat area, and paraspinal mus-
cle area were inversely associated with skewness and
kurtosis and positively associated with MPP and entropy.
Texture parameters, but not bone mineral density, were
associated with lowest lifetime weight and duration of
amenorrhea in anorexia nervosa.
Conclusion: Patients with anorexia nervosa had increased skewness
and kurtosis and decreased entropy and MPP compared
with normal-weight control subjects. These parameters
were associated with lowest lifetime weight and duration
of amenorrhea, but there were no such associations with
bone mineral density. These findings suggest that trabec-
ular texture analysis might contribute information about
bone health in anorexia nervosa that is independent of
that provided with bone mineral density.
 RSNA, 2016
q
1
MUSCULOSKELETAL IMAGING: Trabecular CT Texture Analysis in Anorexia Nervosa Tabari et al
A
norexia nervosa is a prevalent eat-
ing disorder associated with low
bone mineral density (BMD) and
impaired bone microarchitecture and
bone strength, resulting in increased
fracture risk (1–4). Skeletal sites con-
taining predominantly trabecular bone,
such as the lumbar spine, are the most
severely affected, and patients with
anorexia nervosa have an increased risk
for spinal compression fractures (5,6).
Dual-energy x-ray absorptiometry
(DXA) is most commonly used to assess
BMD; however, it is influenced by body
size (7), which provides a diagnostic
challenge in anorexia nervosa because
prolonged undernutrition can lead to
reduced muscle and fat mass. In ad-
dition, bone microarchitecture affects
bone strength independent of BMD.
Studies examining the distal radius in
female patients with anorexia nervosa
have shown impaired trabecular and
cortical microarchitecture (as assessed
with high-spatial-resolution flat-panel
computed tomography [CT] [1] and
high-spatial-resolution peripheral CT
[8,9]) and decreased bone strength (as
assessed with finite element analysis
[4]), despite normal BMD as shown
with DXA (1). Although these data
have provided valuable insights into
bone microarchitecture at peripheral
sites, there is no reliable technique with
which to assess trabecular architecture
Advances in Knowledge
nn CT trabecular texture analysis of
the lumbar spine is a feasible
technique with which to deter-
mine skeletal integrity in
anorexia nervosa.
nn Patients with anorexia nervosa
have increased skewness and
kurtosis and decreased entropy
and mean value of positive pixels
compared with normal-weight
control subjects, which is sug-
gestive of impaired skeletal
integrity.
nn Texture parameters but not bone
mineral density are associated
with lowest lifetime weight and
duration of amenorrhea in
anorexia nervosa.
2 radiology.rsna.org  n Radiology: Volume 000: Number 0—   2017
of the lumbar spine—the site most
profoundly affected by bone loss in
anorexia nervosa.
CT texture analysis is an objective
approach to quantifying tissue gray-lev-
el patterns by using computer-assisted
measurements that are independent of
subjective visual interpretation (10).
Most studies have used CT texture
analysis in patients with neoplasms to
differentiate benign from malignant le-
sions, assess tumor grade, or predict
survival in patients with cancer (11–
15), but, to our knowledge, no stud-
ies have performed in vivo CT texture
analysis of the lumbar spine to assess
trabecular bone.
The purpose of our study was to
determine indexes of skeletal integrity
by using CT trabecular texture analysis
of the lumbar spine in patients with
anorexia nervosa and normal-weight
control subjects and to determine clin-
ical and body composition predictors
of trabecular texture. We hypothesized
that women with anorexia nervosa have
CT trabecular texture that reflects im-
paired skeletal integrity compared with
that of normal-weight control subjects
and that body mass index (BMI), fat
mass, and muscle mass are positively
associated with skeletal integrity as-
sessed with CT texture analysis.
Materials and Methods
Our prospective study was approved by
the institutional review board and com-
pliant with the Health Insurance Porta-
bility and Accountability Act. Data were
acquired after all participants provided
written informed consent before our
study.
Participants
Our study was performed at a clinical
research center at an academic institu-
tion. We studied a convenience sample
of 60 women—30 with anorexia nervosa
Implication for Patient Care
nn Trabecular texture analysis can
be used to help assess skeletal
integrity in patients with
anorexia nervosa.
and 30 without anorexia nervosa and of
normal weight and frequency matched
for age (62 years)—who were partic-
ipants in clinical trials from November
12, 2004, to July 12, 2011, at our in-
stitution. Participants with anorexia
nervosa were referred by eating dis-
orders care providers or recruited by
means of advertisements, and normal-
weight control subjects were recruited
by means of advertisements. Inclusion
criteria for both groups were as follows:
age 18–45 years and female sex. All par-
ticipants were non-Hispanic and white.
Participants with anorexia nervosa met
weight and psychiatric criteria from
the Diagnostic and Statistical Manual
of Mental Disorders, fifth edition (16).
The normal-weight participants had a
BMI of at least 19 kg/m2 and less than
25 kg/m2, were healthy, had regular
menses, and had no history of amen-
orrhea or an eating disorder (Fig 1).
None of the women with anorexia ner-
vosa or normal-weight control subjects
were receiving estrogen or oral contra-
ceptives, osteoporosis medication, or
other medication that could affect bone
metabolism, such as glucocorticoids,
gonadal steroids, or anticonvulsants.
Exclusion criteria for both groups were
pregnancy and presence of a chronic
disease (other than anorexia nervosa).
Clinical characteristics and abdominal
Published online before print
10.1148/radiol.2016160970  Content codes:
Radiology 2017; 000:1–8
Abbreviations:
BMD = bone mineral density
BMI = body mass index
DXA = dual x-ray absorptiometry
MPP = mean value of positive pixels
Author contributions:
Guarantors of integrity of entire study, M.K.K., M.A.B.; study
concepts/study design or data acquisition or data analysis/
interpretation, all authors; manuscript drafting or manu-
script revision for important intellectual content, all authors;
manuscript final version approval, all authors; agrees to
ensure any questions related to the work are appropriately
resolved, all authors; literature research, A.T., A.K., M.K.K.,
M.A.B.; clinical studies, M.T., K.K.M., A.K., M.A.B.; experi-
mental studies, A.T., A.K., M.A.B.; statistical analysis, A.T.,
M.A.B.; and manuscript editing, all authors
Conflicts of interest are listed at the end of this article.
MUSCULOSKELETAL IMAGING: Trabecular CT Texture Analysis in Anorexia Nervosa Tabari et al

fat cross-sectional areas have been pre-
viously reported in a subset of study
participants (17–20); however, no data
on trabecular texture analysis have
been described.
CT Examinations
A 16–detector row CT scanner (Light-
Speed Pro; GE Healthcare, Waukesha,
Wis) was used to acquire a single sec-
tion through the mid-L4 vertebral body
in each participant. Participants were
placed supine in the CT scanner on a
calibration phantom (Mindways Soft-
ware, Austin, Tex), and scanning was
performed by using the following pa-
rameters: 80 kV, 70 mA, gantry rota-
tion time of 2 seconds, 144-mm table
height, and axial scanning mode. The
reconstructed section thickness and
field of view were kept constant at 1
cm and 48 cm, respectively. Volume CT
dose index, dose-length product, and
estimated effective dose were recorded.
Figure 1
Figure 1:  Study flowchart. QCT = quantitative CT.
Trabecular BMD
Analyses were performed by a post-
doctoral research fellow with 2 years of
experience (A.T.), who was supervised
by a musculoskeletal radiologist with 11
years of experience (M.A.B.).
Trabecular BMD (in grams per
cubic centimeter) of the L4 vertebral
body was determined from quantita-
tive CT by drawing a circular region
of interest measuring 700 mm2 within
trabecular bone; cortical bone and
basivertebral veins were avoided. The
mean attenuation of the vertebral body
(in Hounsfield units) and the attenua-
tion of the calibration solutions were
used to calculate the mineral equivalent
BMD by using the following equation:
milligrams per milliliter of sample =
(CT number in Hounsfield units 2 in-
tercept of calibration line)/slope of cal-
ibration line.
Trabecular BMD was compared
with a young female normal reference
database to calculate T scores (21).
Trabecular Texture Analysis
Texture analysis was performed on the
quantitative CT images by using com-
mercially available software (TexRAD,
Cambridge, England). The circular
area within trabecular bone of the L4
vertebral body that was used for tra-
becular BMD assessment was also
used for trabecular texture analysis.
The following texture parameters were
obtained on 12-bit images (4096 gray
levels) (Fig 2): skewness (asymmetry
of gray-level pixel distribution), kurto-
sis (pointiness or peakedness of pixel
distribution), entropy (inhomogeneity
of pixel distribution), and mean value
of positive pixels (MPP) (the average
attenuation value of pixels of greater
than 0, without application of filters)
(22,23).
Body Composition
Abdominal adipose tissue and paraspi-
nal muscle compartments were quan-
tified at the level of L4. Thresholding
methods were applied to identify adi-
pose tissue by using a threshold set for
250 to 2250 HU, as described by Bor-
kan et al (24). Manual delineation was
used to separate abdominal subcutane-
ous adipose tissue and visceral adipose
tissue. Cross-sectional areas (in square
centimeters) of subcutaneous adipose
tissue and visceral adipose tissue were
obtained. Paraspinal muscle cross-sec-
tional areas (in square centimeters)
were determined as the sum of erec-
tor spinae, psoas major, and quadra-
tus lumborum muscles. Analyses were
performed by using software (Osirix,
version 3.2.1; Pixmeo SARL, Geneva,
Switzerland).
Statistical Analysis
Statistical analysis was performed by
using software (JMP, version 11; SAS

Figure 2

Figure 2:  Histogram characteristics. (a) Kurtosis is a measure of pointiness or peakedness of a distribution relative to a normal distribution. Positive kurtosis indi-
cates a histogram that is more peaked, and negative kurtosis indicates that histogram is flatter than a normal distribution. (b) Skewness is a measure of asymmetry
of a distribution. Negative skewness reflects a distribution with a tail that is longer on left, and positive skewness reflects a distribution with a tail that is longer on right.

Radiology: Volume 000: Number 0—   2017  n  radiology.rsna.org 3

MUSCULOSKELETAL IMAGING: Trabecular CT Texture Analysis in Anorexia Nervosa Tabari et al
Institute, Cary, NC). Groups were com-
pared by using the Student t test. All
variables were tested for normality of
distribution by using the Shapiro-Wilk
test. Variables that were not normally
distributed (age, BMI, skewness, kur-
tosis, visceral adipose tissue, subcu-
taneous adipose tissue, and paraspi-
nal muscle cross-sectional area) were
logarithmically transformed and then
subjected to the t test. Pearson correla-
tions were conducted to determine as-
sociations between different variables
for normally distributed data and after
logarithmic transformation of data that
were not normally distributed. Multi-
ple standard least-squares regression
modeling was performed to control for
BMI and age. Analyses were adjusted
for multiple comparisons by using the
Bonferroni method. Data are expressed
as means and standard deviations. P ,
.05 was considered indicative of a sta-
tistically significant difference.
Results
Participant characteristics, abdominal
fat and muscle cross-sectional areas,
and CT trabecular texture parameters
of the anorexia nervosa and normal-
weight groups are shown in Table 1.
Study participants ranged in age from
19 to 45 years (mean age, 27 years 6
7) and in BMI from 13.3 to 24.9 kg/m2
(mean BMI, 19.7 kg/m2 6 3.0).
Duration of anorexia nervosa
ranged from 5 to 324 months (mean,
142 months 6 92). Sixteen women
with anorexia nervosa had amenorrhea
(time of amenorrhea ranged from 4 to
144 months [mean, 41 months 6 38]).
As expected, women with anorexia
nervosa had lower abdominal fat and
paraspinal muscle cross-sectional
areas compared with normal-weight
control subjects (P , .001). Radiation
dose descriptors, namely volume CT
dose index, dose-length product, and
estimated effective doses, were 4.66
mGy, 4.66 mGy · cm, and 0.07 mSv,
respectively.
All CT examinations were ade-
quate for BMD and trabecular texture
analysis. Women with anorexia nervosa
had lower BMD and lower T scores than
4 radiology.rsna.org  n Radiology: Volume 000: Number 0—   2017
Table 1
Clinical Characteristics, Body Composition, and Trabecular Texture of Study
Participants
Variable Patients with Anorexia Nervosa (n = 30)* Control Subjects (n = 30)* P Value
Age (y)† 26 6 6 28 6 7 .2
Weight (kg) 45.5 6 5.0 61.3 6 6.9 ,.001‡
Height (cm) 163.2 6 5.8 165.8 6 7.2 .1
BMI (kg/m2)† 17.0 6 1.2 22.3 6 1.8 ,.001‡
VAT CSA (cm2)† 15.9 6 10.5 37.9 6 16.9 ,.001‡
SAT CSA (cm2)† 72.5 6 37.3 183.3 6 86.5 ,.001‡
Paraspinal muscle CSA (cm2)† 61.3 6 7.6 70.6 6 10.3 ,.001‡
BMD (g/cm3) 123.7 6 33.7 160.1 6 22.9 ,.001‡
T score 22.0 6 1.3 20.6 6 0.9 ,.001‡
Skewness† 2.48 6 0.66 1.82 6 0.44 ,.001‡§
Kurtosis† 9.52 6 4.40 4.90 6 2.54 ,.001‡§
Entropy 5.42 6 0.15 5.49 6 0.15 .07§
MPP 267.0 6 74.5 357.3 6 43.1 ,.001‡§
Note.—CSA = cross-sectional area, SAT = subcutaneous adipose tissue, VAT = visceral adipose tissue.
* Data are means 6 standard deviations.
†
Comparison was performed on log-transformed data.
‡
Significant after controlling for multiple comparisons.
§
Significant after controlling for log BMI and log age.
normal-weight control subjects (P , with women with anorexia nervosa who
.001); however, the difference lost sig- did not have amenorrhea; there was no
nificance after adjustment for log BMI difference in entropy or MPP (P = .7
and log age. Women with anorexia ner- and P = .9, respectively).
vosa had higher skewness and kurtosis Lowest lifetime weight correlated
and lower MPP compared with normal- positively with entropy (r = 0.45, P =
weight control subjects (P , .001), and .02) but not BMD (P = .1). No associa-
there was a trend toward lower entropy tions between duration of anorexia ner-
(P = .07) (Figs 3–5). After adjustment vosa and trabecular texture parameters
for log BMI and log age, the difference or BMD were observed (P . .4).
in all four trabecular texture parame-
ters was significant between the groups
(Table 1). Discussion
BMD was inversely associated with We reported on the use of CT texture
skewness and kurtosis and positively analysis for the assessment of trabecu-
associated with entropy and MPP. BMI lar bone in anorexia nervosa, which has
and abdominal fat and paraspinal mus- not been established in the literature.
cle cross-sectional areas were inversely We showed that trabecular texture
associated with skewness and kurtosis analysis of the lumbar spine by using
and positively associated with MPP and single-section CT is a feasible technique
entropy (Table 2). to determine skeletal integrity. Patients
Within the anorexia nervosa group, with anorexia nervosa have increased
duration of amenorrhea was inversely skewness and kurtosis and decreased
associated with MPP (r = 20.53, P = entropy and MPP compared with nor-
.03) but not BMD (P = .07). Women mal-weight control subjects, and these
with (n = 16) and those without (n = parameters are strongly associated
14) amenorrhea showed similar BMD with low BMD. These findings suggest
(P = .9). However, women with amen- that this constellation of trabecular tex-
orrhea had higher skewness (P = .04) ture parameters reflects impaired skel-
and higher kurtosis (P = .05) compared etal integrity. BMI and abdominal fat
MUSCULOSKELETAL IMAGING: Trabecular CT Texture Analysis in Anorexia Nervosa Tabari et al

Figure 3 Figure 4

Figure 3:  Quantitative CT scan at level of L4 in 34-year-old woman of nor- Figure 4:  Quantitative CT scan at level of L4 in 35-year-old woman with
mal weight (BMI, 22 kg/m2) for assessment of trabecular BMD (139 mg/cm3). anorexia nervosa (BMI, 18 kg/m2) reveals trabecular BMD similar to that of
patient in Figure 3 (BMD, 133 mg/cm3).

Figure 5 and MPP was inversely associated with

duration of amenorrhea; no such asso-
ciations were seen with BMD.
Anorexia nervosa is a common eat-
ing disorder that usually affects adoles-
cents and young women, and patients
with anorexia nervosa demonstrate
multiple hormonal abnormalities that
may alter bone turnover, leading to
impaired bone accrual, bone loss, and
fractures (2,3,25–27). Increasing ef-
forts have been made to develop imag-
ing biomarkers on the basis of DXA or
CT to assess skeletal integrity and pre-
dict fracture risk in anorexia nervosa.
Skeletal architecture and measures of
bone strength are crucial factors for
predicting fracture risk independent
of BMD determination with DXA (28–
31). Donaldson et al (32) used trabec-
ular bone score, a gray-level texture
parameter obtained from DXA images
of the lumbar spine, in adolescents
Figure 5:  Histograms from trabecular texture analysis of patient with anorexia nervosa in Figure 4 (purple) with anorexia nervosa and found pos-
and normal-weight control subject in Figure 3 (pink) demonstrate higher skewness, indicated by left shift itive correlations between this score
of histogram toward lower CT attenuation (2.63 vs 1.63), higher kurtosis with higher peak of histogram, and BMD obtained with DXA but no
indicating lower variation of pixel intensities (10.33 vs 3.33), lower MPP, as indicated by fewer pixels with CT correlation with fractures. The accu-
attenuation of more than 0 HU (233.1 vs 375.9), and slightly lower entropy, suggesting decreased complexity racy of DXA in assessing BMD is influ-
of pixel values (5.4 vs 5.7) in patient with anorexia nervosa compared with normal-weight control subject. enced by body size (7), and phantom
studies have shown that even small ex-
and muscle cross-sectional areas were with entropy and MPP. In patients with traosseous soft-tissue heterogeneities
inversely associated with skewness anorexia nervosa, entropy correlated can increase inaccuracies in BMD as-
and kurtosis and positively associated positively with lowest lifetime weight sessment (33). Therefore, the use of

Radiology: Volume 000: Number 0—   2017  n  radiology.rsna.org 5

MUSCULOSKELETAL IMAGING: Trabecular CT Texture Analysis in Anorexia Nervosa Tabari et al
Table 2
Correlation between CT Trabecular Texture Analysis, Body Composition, and BMD
Variable
Log BMI
Log VAT CSA
Log SAT CSA
Log paraspinal muscle CSA
BMD
Note.—CSA = cross-sectional area, SAT = subcutaneous adipose tissue, VAT = visceral adipose tissue.
* Significant after controlling for multiple comparisons.
DXA and DXA-derived markers of tra-
becular integrity is limited in anorexia
nervosa. Several studies have used
peripheral quantitative CT, which is
less influenced by body composition,
to assess microarchitecture of the dis-
tal radius in adolescents and adults
with anorexia nervosa. These studies
revealed impaired trabecular and cor-
tical microarchitecture and impaired
bone strength at finite element analysis
in patients with anorexia nervosa com-
pared with normal-weight control sub-
jects (1,4,8,9). Phan et al (34) used
C-arm CT to assess bone microarchi-
tecture of the lumbar spine in patients
with anorexia nervosa. However, C-
arm CT is limited by a small field of
view and thus is feasible only in very
thin patients; it is also associated with
a higher radiation dose (0.7 mSv) (34)
than the single-section CT used in our
study (0.07 mSv).
Texture analysis is a technique that
allows quantification of the spatial ar-
rangement of pixel intensities by using
a statistical evaluation of image inten-
sities in a region of interest and can
be performed with different imaging
modalities. Most studies of CT texture
analysis have focused on the assess-
ment of neoplasms to determine tumor
grade, treatment response, or survival.
These studies have reported greater
correspondence of heterogeneous tu-
mor texture with higher grade of ma-
lignancy and lower overall treatment
response and survival (11–14,35).
Some studies have performed
texture analysis of bone by using
6 radiology.rsna.org  n Radiology: Volume 000: Number 0—   2017
skewness in anorexia nervosa suggests
that most pixels are skewed toward
lower CT attenuation.
In our study,
Log Skewness Log Kurtosis Entropy MPP trabecular texture parameters showed
correlation with BMI and fat and mus-
r Value P Value r Value P Value r Value P Value r Value P Value
cle cross-sectional areas. These findings
20.45 ,.001* 20.45 ,.001* 0.25 .05 0.52 ,.001* are important because anorexia ner-
20.21 .1 20.22 .09 0.07 .6 0.20 .1 vosa is a model of malnutrition-induced
20.37 ,.004* 20.39 .002* 0.32 .01* 0.40 .001* bone loss. Furthermore, BMI and fat
20.29 .04 20.33 .02 0.10 .6 0.33 .02 and muscle mass are known to be pos-
20.54 ,.001* 20.50 ,.001* 0.24 .07 0.79 ,.001* itively associated with BMD and bone
health in this population. We found that
lowest lifetime weight correlated posi-
tively with entropy and that duration
of amenorrhea was inversely associ-
ated with MPP, whereas there were no
radiography, magnetic resonance imag- such associations with BMD. In addi-
ing, and ex vivo high-spatial-resolution tion, women with anorexia nervosa and
CT. Thevenot et al (36) performed amenorrhea had higher skewness and
texture analysis on hip radiographs kurtosis compared with women with-
and determined texture parameters out amenorrhea, despite similar BMD.
that could be used to identify patients These findings suggest that trabecular
at risk for femoral fracture. Link et al texture analysis might contribute infor-
(37) performed high-spatial-resolution mation on bone health in anorexia ner-
CT of cadaveric spine specimens with vosa that is independent of BMD.
1-mm-thick sections to assess basic Our study had several limitations.
texture parameters and microarchitec- First, the cross-sectional design limits
ture. Microarchitecture was a stron- our ability to determine causality. Sec-
ger predictor of bone strength than ond, we did not follow up patients to
trabecular texture (37). MacKay et al assess whether trabecular texture
(38) assessed tibial subchondral bone analysis can help predict fracture risk.
in patients with osteoarthritis and Third, differences in body size and
found that trabecular texture, but not weight may affect trabecular texture
microarchitecture parameters, helped analysis. We therefore controlled our
accurately classify patients with and pa- analyses for BMI.
tients without osteoarthritis. In conclusion, trabecular texture
We identified a combination of tex- analysis of the lumbar spine with sin-
ture parameters assessed with single- gle-section CT is a feasible technique
section quantitative CT that reflect with which to determine skeletal integ-
skeletal integrity in anorexia nervosa. rity. Patients with anorexia nervosa had
In our study, higher skewness and increased skewness and kurtosis and
kurtosis and lower entropy and MPP decreased entropy and MPP compared
were associated with decreased BMD. with normal-weight control subjects.
Lower MPP reflects a lower number These parameters were associated with
of pixels with CT attenuation values lowest lifetime weight and duration of
of more than 0, which can be seen in amenorrhea, whereas there were no
bone loss. Similarly, low entropy in- such associations with BMD. These
dicates decreased complexity of pixel findings suggest that trabecular texture
values, which suggests impaired skele- analysis might contribute information
tal integrity. Higher kurtosis reflects a on bone health in anorexia nervosa
histogram that is narrower than a nor- that is independent of information pro-
mal Gaussian distribution, indicating vided by BMD. Longitudinal studies are
a lower variation of pixel intensities. needed to investigate whether trabec-
Positive skewness is consistent with ular texture analysis can improve the
a histogram with a tail that is longer prediction of fracture risk in anorexia
on the right, and our observed higher nervosa.
MUSCULOSKELETAL IMAGING: Trabecular CT Texture Analysis in Anorexia Nervosa Tabari et al
Disclosures of Conflicts of Interest: A.T. dis-
closed no relevant relationships. M.T. disclosed
no relevant relationships. K.K.M. disclosed no
relevant relationships. A.K. disclosed no rele-
vant relationships. M.K.K. Activities related to
the present article: disclosed no relevant rela-
tionships. Activities not related to the present
article: received nonfinancial support from Sie-
mens Healthcare; received personal fees from
Bracco. Other relationships: disclosed no rele-
vant relationships. M.A.B. disclosed no relevant
relationships.
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