You are on page 1of 4
Skeletal and body-composition effects of anorexia nervosa1’2 Richard B Mazess, Howard S Barden, and Elizabeth S
Skeletal
and body-composition
effects
of anorexia
nervosa1’2
Richard
B
Mazess,
Howard
S Barden,
and
Elizabeth
S Oh/rich
ABSTRACT
Eleven
female
patients
(aged
18-46
y)
with
tion
of
amenorrhea,
and
fracture
history
(a
hip
fracture
at
age
Downloaded from www.ajcn.org by guest on February 9, 2011
anorexia
nervosa
were
measured
by
use
ofdual-photon
absorp-
37
y).
An
additional
young
woman
with
bulimia
is
also
re-
tiometry
for
1)
bone
mineral
content
(BMC,
in
g)
and
bone
ported
separately
(aged
23
y,
3y amenorrheic,
161
cm
height;
mineral
density
(BMD,
in
g/cm2)
of
the
total
skeleton
and
its
46
kg
weight).
All
subjects
were
moderately
malnourished
regions,
2)
BMD
ofthe
lumbar
spine
and
the
proximal
femur,
compared
with
published
weights
of
anorectic
women
(which
and
3)
total
body
soft-tissue
composition.
The
patients
weighed
are
typically
%#4#{216}kg)(l-l0).
44.4
kg,
15
kg
less
than
normal
peers
(n
22).
The
fat
mass
=
Densitometry
(3.35
kg) and
content
of
soft
tissue
(7.8%)
were
four
and
three
times
lower
(p
<
0.001)
respectively,
than
those
in
normal
Measurements
of
total
body
composition
and
bone
mineral
women
(1 5.
1 kg
and
26%,
respectively).
The
total
skeletal
mm-
were
done
with
a commercial
scanner
(DP4,
Lunar
Radiation,
eral
(192
1 g)
was
-.‘25%
less
than
that
ofyoung
normal
women.
Madison,
WI).
The
‘53Od
source
emitted
radiation
at
7 and
16
The
BMC
as
a fraction
ofthe
lean
tissue
mass
was
-4.9%
in
t:i.
The
radiation
dose
from
the
total
body
scan
and
regional
the
patients
and
5.9%
in normal
women.
Total
body
and
femo-
scans
was
low
(10
SOy,
which
is
‘-2%
ofa
chest
x
ray).
Source
ral
BMD
averaged
only
10%
and
13%
lower
than
those
of
nor-
activity
ranged
from
13
to
25
OBq
during
the
period
when
the
mal
women,
respectively;
however,
spinal
BMD
was
particu-
patients
were
measured.
Regional
measurement
of
DPA
pro-
larly
reduced
(“-25%;
p<
0.00
1).
Am
J
C/in
Nutr
1990;52:
vided
bone
mineral
densities
(BMDs
in
g/cm2)
in
the
lumbar
438-4
1.
spine
(L2-L4)
and
in
the
proximal
femur
(femoral
neck).
The
usual
precision
of
total
body
BMD
is
the
preci-
KEY
WORDS
Anorexia,
body
composition,
bone,
osteo-
sion
error
of
spine
and
femoral
BMDS
is
1% whereas
‘- - 2%
(14,
15).
We
porosis,
bone
densitometry
used
DPA
to
calculate
the
lean
tissue
mass
(LTM),
fat
mass
(FM),
and
total
tissue
mass
as
well
as
the
percentage
of
fat
in
total
tissue
(%FM).
%FM
is
different
from
total
body
fat
and
Introduction
LTM
is
different
from
the
conventional
“lean
body
mass,”
Anorexia
nervosa
is
an
eating
disorder
characterized
by
cx-
which
includes
LTM
plus
bone
mineral
content
(BMC).
The
precision
error
for
total
body
%FM
was
±3%
(12).
cessive
weight
loss.
Loss
is
particularly
marked
in
body
fat;
it
is
not
clear
ifmuscle
wasting
occurs
(1 ,
The
distribution
of
skeletal
mineral
and
soft
tissue
from
the
2).
There
have
been
some
output
ofthe
scanner
is shown
in Figure
1. Soft-tissue
composi-
indications
that
bone
is
compromised
in
anorexia
as
a
conse-
quence
ofnutrition
deprivation,
cortisol
elevation,
and
hypoes-
tion
is
determined
from
the
50%
of
the
pixels
in
a
total
body
scan
that
do
not
contain
bone.
In
these
pixels
the
ratio
ofthe
7
trogenia
(3-10).
We
have
used
the
method
of
dual-photon
ab-
sorptiometry
(DPA)
with
‘53Od
to
characterize
both
the
soft
Er attenuation
to
that
at
16
El
gives
the
R
value.
It
has
been
tissue
and
skeletal
distribution
in
women
with
this
disorder
shown
that
the
R
value
determined
from
DPA
is
directly
pro-
portional
to
the
lean
and
fat
composition
ofsoft
tissue
in
areas
(11-13).
where
bone
is
not
present
(1 1-
13).
Measurements
of
composi-
tion
from
DPA
correlate
highly
(r
0.95,
SEE
2.5%
for
body
=
Subjects
and
methods
fat)
with
body
composition
from
underwater
weighing,
and
with
other
indices
ofcomposition
(12-16),
whereas
total
skele-
Subjects
tal
BMC
correlates
highly
(r
0.96,
SEE
187
g)
with
total
=
Eleven
women
aged
18-46
y( 10
aged
18-27
y,
1 aged
46
y;
body
calcium
from
neutron-activation
analysis
(16,
17).
All
21 ±3
y,
SD)
were
measured
within
2 wk
of
the
outset
of
measurements
were
approved
by
the
Committee
for
Protection
their
treatment
in
an
eating
disorders
clinic.
The
average
height
ofHuman
Subjects.
and
weight
were
16 1±
7
cm
and
44
±5
kg,
respectively,
(41
kg
on
admission,
or
-30%
less
than
control
subjects,
a
com-
From
the
Department
ofMedicab
Physics
and
the
Eating
Disorders
I
parison
group
of22
normal
women
aged
19-29
y weighing
59.5
Clinic,
University
of
Wisconsin,
and
Lunar
Radiation
Corporation,
kg).
None
was
receiving
estrogens
at
the
time
of
examination.
Madison,
WI.
All
women
had
a>
l-y
history
ofanorexia;
10
of
11
had
a
his-
2 Address
reprint
requests
to
RB
Mazess,
Lunar
Radiation
Corpora-
tory
ofamenorrhea
ranging
from
1 to
8y (3.
2
y);
the
oldest
tion,
3 13 West
Beltline
Highway,
Madison,
WI
53713.
patient
had
been
amenorrheic
for
22
y.
The
data
for
the
latter
Received
July 6, 1989.
patient
are
treated
separately
because
ofthe
subject’s
age,
dura-
Accepted
for
publication
October
25,
1989.
438
Am
J
C/in
Nuir
1990;52:438-41.
Printed
in
USA.
©
1990
American
Society
for
Clinical
Nutrition

Downloaded from www.ajcn.org by guest on February 9, 2011

 

BODY

 

COMPOSITION

 

AND

BONE

IN

ANOREXIA

 

439

 
BODY COMPOSITION AND BONE IN ANOREXIA 439 FIG I . The images on the left show
 
 

FIG

I.

The

images

on

the

left

show

 

an

anorectic

women

(bone

plus

tissue,

and

tissue

alone)

and

those

on

the

right

 

show

a normal

woman.

 
 

Comparisons

 

of

spine

and

femur

 

BMD

were

 

made

with

a

leaner

than

the

arms

or

legs

(the

latter

included

 

the

buttocks

population

 

of

normal

young

women

(n

=

284),

aged

20-39

y,

region

lateral

to

the

pelvis).

that

 

has

been

 

measured

repeatedly

in

our

laboratory.

Total

 

There

was

an

absolute

decrease

of

-25%

in

the

total

body

body

determinations

ofcomposition

 

were

made

with

the

com-

BMC

compared

with

normal

young

women.

The

total

body

parison

kg

 

group

 

of

22

normal

women.

These

 

women

weighed

BMD

was

10%

(p

<

0.01)

bower

than

normal,

indicating

that

‘-. 2

less

than

the

larger

sample

 

used

for

axial

densitometry.

 

the

amount

ofbone

was

low

even

when

low-density

pixels

were

Measurements

 

ofskeletal

distribution

 

were

compared

 

with

the

excluded

(Table

2).

There

was

marked

density

diminution

normal

 

values

 

published

by

Gallagher

et

al

(1

8)

using

the

same

from

the

combined

thoracolumbar

spinal

region

(27%

less

than

model

instrument.

 

The

total

skeletal

BMC

was

divided

by

the

that

ofcontrol

subjects;

p<

0.001).

Detailed

measurements

of

number

 

of

pixels

containing

 

a

significant

 

amount

of

bone

the

lumbar

spine

confirmed

this

osteopenia,

although

the

de-

(>

0.

1 g/cm2),

 

thereby

giving

an

approximate

 

BMD.

This

pro-

crease

was

less

evident

in

the

lumbar

spine

(22%,

p<

0.001)

cedure

 

is

often

 

used

to

normalize

 

total

body

BMC

results,

but

than

for

the

total

spine.

The

femoral

neck

BMD

was

13%

(p

it

is

not

identical

to

dividing

by

a

true

skeletal

 

area.

 

<

0.00

1) below

the

average

for

normal

young

women.

There

 

were

not

significant

differences

for

arm

or

leg

BMD.

 

The

older

anorectic

 

patient

showed

an

even

more

marked

Results

 

osteopenia

(34%

less

for

total

body

BMD

and

- 50%

less

for

 

the

spine

and

femoral

neck

BMD).

The

bulimic

patient

had

a

 

The

physical

 

characteristics

 

of

the

patients

 

are

outlined

in

normal

skeleton

(within

10%

ofcontrol

subjects).

 

Table

 

1.

The

patients

 

averaged

15

kg

less

body

weight

than

did

our

normal

 

sample

(p

<

0.001),

but

the

difference

 

of2

kg

(5%)

 

in

LTM

(39.1

±

4.6

vs

41.3

±

5.2

kg,

p>

0.2)

was

not

Discussion

 

significant.

 

There

was

only

‘- -7.7

±

5.4%

FM

(3.35

kg)

in

the

anorectic

 

women

compared

with

26.4

±

7.3%

 

FM

(1 5.

4.9

Our

anorectic

women

were

similar

in

height

to

reported

val-

kg)

in

the

normal

 

women.

These

differences

 

were

highly

sig-

ues

but

were

slightly

higher

in

body

weight

(1-9).

We

found

nificant

 

(p

<

0.001).

The

trunk

of

the

patients

was

slightly

a

low

fat

content

as

expected

and

a

slight

but

not

significant

TABLE

1

Tissue

 

analysis

 

in

young

anorectic

 

Total

tissue

mass

Lean

 

tissue

mass

Fat

mass

(FM)

FM

Bone

mineral

content

 

g

g

g

%

g

Arms

 

4

145±

939

3694±

592

451

±

437

9.4±7.7

244±

28

Legs

12948±2

176

11 735±2003

 

1212±

960

9.0±6.8

 

674±

93

Trunk

21 734±2254

20234±2327

1500±

969

6.9±4.5

564±

110

Total

42484±4952

39 137±4649

3346±2448

7.7±5.4

 

1921±250

 

5i±SD:n=

 

10.

440 MAZESS ET AL TABLE 2 radius BMD in anorectic women. Newman and Halmi (10) re-
440
MAZESS
ET
AL
TABLE
2
radius
BMD
in
anorectic
women.
Newman
and
Halmi
(10)
re-
BMD
values
in young
anorectic
women,
in
one
older
anorectic
ported
aI 5%
vertebral
BMD
deficit
in
anorectic
women
who
woman
with
hip
fracture,
and
in
one
bulimic
patient5
were
9%
below
ideal
weight
at
the
time
ofassessment.
A major
part
ofthe
bone
loss
may
occur
within
the
first
year
of anorexia
Woman
(6).
Our
study
confirmed
the
10%
reduction
in
overall
bone
Anorectic
women
with hip
Bulimic
density,
but
we
saw
preferential
spinal
osteopenia.
Biller
et al
(n=
10)
fracture
woman
(3)
saw
no
bone
diminution
in
the
forearm
but
reported
32%
g/cin2
(%)
and
2 1%
reductions
of
spine
BMD
by
using
single-energy
and
dual-energy
quantitative
computed
tomography,
respectively;
Head
1.97 ±0.26t
1.22
2.16
this
brackets
our
finding
ofa
22-27%
reduction.
Arms
0.74
±
0.04
(99.5
±
5.9)
0.49
(66.4)
0.79(106.1)
Legs
I.03
It
is
not
uncommon
to
find
preferential
spinal
osteopenia
in
±
0.09
(94.
8.2)
0.67
(60.6)
1.22
(110.8)
Trunk
0.77
±
0.05
(76.8
±
4.6)
0.62
(62.0)
0.87(86.0)
patients
with
metabolic
bone
disease
(19).
The
femoral-neck
Downloaded from www.ajcn.org by guest on February 9, 2011
Spine
0.83
±
0.06
(72.8
±
5. 1)
0.60
(53.6)
0.98
(87.2)
BMD
in
anorectic
women
is
at
the
upper
limit
of normal
for
Total
0.99
±
0.06
(90.3
±
5.0)
0.73
(66.
1)
1.
I3 (102.7)
elderly
women,
but
the
average
spine
BMD
was
identical
to
that
for
70-y-old
females.
On
this
basis
anorectic
women
as
a
Spine
(L2-L4)
0.99
±
0.08
(78.5
±
6.6)
0.60
(48.0)
1.19(94.5)
group
may
be
at
particular
risk
for
spine
fractures,
but
a
low
Femur
(neck)
0.87
±
0.09
(86.9
±
9.8)
0.54
(54.
1)
I .01
(101.5)
femoral
BMD,
such
as
in
the
older
anorectic
woman
we
re-
BMD
values
are
given.
in parentheses,
as
a percentage
ofthose
es-
ported,
will
also
increase
risk
for
hip
fracture.
Interestingly,
the
S
tablished
ti ±SD.
for
young
normal
women.
single
bulimic
patient
did
not
demonstrate
the
marked
os-
teopenia
evident
in
the
anorectic
patients.
Bone
loss
is
not
char-
acteristic
ofbulimia
(10).
Estimates
of
body
composition
from
indirect
methods
that
diminution
in
LTM.
Of
the
15-kg
difference
in
body
weight,
assume
mineral
as
a constant
fraction
of
lean
body
mass
or
of
12
kg
could
be
ascribed
to
FM,
2
kg
to
LTM
and
0.6
kg
to
LTM
will
overestimate
the
fat
content
ofanorectic
patients
just
BMC.
Anorectic
women
who
lose
>
15
kg
below
ideal
weight
as
they
overestimate
the
fat
content
in
older
women
or
in osteo-
(ie,
<
40
kg
body
wt)
are
probably
losing
lean
tissue
alone,
be-
porotic
patients
who
have
a diminished
bone
mineral
(12,
20).
cause
3
kg
is about
the
minimal
level
for
fat
content.
The
25%
reduction
oftotal
body
BMC
in
our
anorectic
sample
Vaisman
et
ab
(1)
observed
6.5
kg
(17%)
body
fat
in
adoles-
as
compared
with
the
values
of
Gallagher
et
al
(18),
coupled
cent
anorectic
females;
their
calculated
fat
mass
was
double
with
the
5%
decrease
in
LTM,
changed
the
BMC
as
a fraction
what
we
observed.
Mayo-Smith
et
al
(2)
used
computed
tomog-
of
LTM
from
the
value
of
5.9
±
0.53%
in
normal
women,
to
raphy
to
show
that
adult
anorectic
females
who
were
similar
in
4.9
1± 0.53%.
In
older
women
a similar
decrease
ofBMC
with-
weight
to
our
group
had
13%
body
fat.
There
was
a
fivefold
out
a decrease
of
LTM
would
reduce
the
BMC
percentage
to
decrease
of
subcutaneous
fat
and
only
a twofold
decrease
in
-4.5%.
Such
skeletal
boss
will
decrease
the
overall
density
of
intraabdominal
fat
compared
with
normal
volunteers
(29%
the
lean
body
mass
from
1.063
g/cm3
in
normal
subjects
to
fat).
We
were
unable
to
differentiate
between
these
two
zones
1.055
and
1.05
1 g/cm3
in anorectic
and
osteoporotic
subjects,
with
DPA,
but
we
did
find
an
overall
threefold
decrease
of
respectively.
The
effect
on
fat
derived
from
underwater
density
%FM
compared
with
normal
women
(7.7%
vs
26%).
The
mass
or
from
dilution
methods
will
be
to
thereby
increase
the
appar-
and
percentage
of
body
fat
we
observed
in
anorectic
women
is
ent
fat
content
by
-4-6%
fat
(12).
clearly
lower
than
in
these
two
studies.
The
higher
fat
content
Total
body
DPA
measurements
indicate
the
distribution
of
seen
by
Mayo-Smith
al
(2)
may
reflect
the
small
area
of
the
fat,
lean,
and
bone
tissue.
This
may
aid
nutrition
assessment
of
Ct
abdomen
sampled
with
their
method.
The
higher
fat
content
and
intervention
for
patients
with
eating
disorders
(2
1).
DPA
observed
by
Vaisman
et
ab
(1) may
reflect
overestimation
of
fat
results
also
might
have
a
role
in
reinforcing
modification
of
from
skinfold
measurements
in
adolescent
females
or
underes-
aberrant
eating
behaviors.
The
new
method
of
dual-energy
x-
timation
of
lean
tissue
from
“#{176}Kin
malnourished
patients.
In
ray
absorptiometry
(22,
23)
provides
results
equivalent
to
adult
anorectic
patients
skinfold
measurements
indicated
a
DPA,
but
the
use
of
an
x-ray
tube
rather
than
‘53Od
reduces
I 3%
fat
content
(3).
However,
the
issue
offat
content
can
only
the
scan
time
from
70
mm
to
10
mm.
We
have
observed
better
be
resolved
through
more detailed
studies
ofanorectic
subjects
precision
both
for
bone
(0.7%
vs
1.0%)
and
LTM
(0.7
vs
2.7
kg)
with
use
ofmultiple
methods.
with
an
even
lower
radiation
dose
(0.
The
exact
magnitude
ofbone
diminution
in anorexia
has
not
ment
should
make
absorptiometry
1 Oy)(24).
more
This
develop-
useful
for
clinical
been
apparent
because
most
measurements
to
date
have
fo-
management.
13
cused
on
either
a very
limited
area
ofthe
forearm,
representing
‘-0. 1%
of
the
compact
bone,
or
on
a
small
portion
of
the
tra-
References
becular
bone
of
the
spine
by
using
quantitative
computed
to-
mography,
representing
“-0.04%
ofthe
total
skeleton
and
only
1.
Vaisman
N,
Corey
M,
Rossi
M,
Goldberg
E,
Pencharz
P. Changes
0.5%
ofspinal
trabecular
bone.
This
is
the
first
report
of
total
in
body
composition
during
refeeding
of
patients
with
anorexia
skeletal
distribution
in
such
patients
and
the
first
report
of
total
nervosa.
J Pediatr
I988:
113:925-9.
body
composition
by
use
of
absorptiometry.
2.
Mayo-Smith
W,
Hayes
CW.
Biller
BMK,
Klibanski
A,
Rosenthal
The
finding
of
bone
diminution
in
anorectic
patients
is
not
H,
Rosenthal
DI.
Body
fat distribution
measured
with
CT:
corre-
surprising.
Rigotti
et
al
(8)
found
a
10%
decrease
in
BMD
of
lations
in healthy
subjects,
patients
with
anorexia
nervosa,
and
pa-
the
radius.
Treasure
et
al
(9)
observed
a
20%
decrease
of
BMD
tients
with
Cushing
syndrome.
Radiology
1989:
170:515-8.
from
the
spine
and
proximal
femur
and
a
small
decrease
of
3.
Biller
BMK,
Saxe
V.
Herzog
DB.
Rosenthal
DI,
Hobzman
S.
Kli-

Downloaded from www.ajcn.org by guest on February 9, 2011

 

BODY

COMPOSITION

 

AND

 

banski

A.

Mechanisms

of

osteoporosis

in

adult

and

adolescent

women

with

anorexia

nervosa.

J

Clin

Endocrinob

Metab

1989:68:

548-54.

  • 4. Crosby

LO,

Kaplan

FS,

 

Pertschuk

Mi,

Mullen

JL.

The

effect

of

 

anorexia

nervosa

on

bone

morphometry

in

young

women.

Clin

Orthop 1985:201:271-7.

 

5.

Ayers

JWT,

Gidwani

OP.

Schmidt

IMV,

Gross

M. Osteopenia

in

hypoestrogenic

young

women

with

anorexia

 

nervosa.

Fertil

Steril

I984:41:224-8.

  • 6. Ruegsegger

P.

Muller

A,

Dambacher

MA,

Ittner

J,

Wibli

J,

Kopp

 

HG.

Bone

boss in anorexia

nervosa.

Schweiz

med

Wschr

I988:

118:

233-8

(in

German).

  • 7. in

Szmukber

01.

Premature

loss ofbone

chronic

 

anorexia

nervosa.

 

Br Med

J 1985:290:26-7.

  • 8. Rigotti

NA,

Nussbaum

 

SR.

Herzog

DB,

Neer

RM.

Osteoporosis

 
 

in

women

with

anorexia

nervosa.

N

Engl

J

Med

1984;

31 1:

1601-6.

  • 9. Treasure

J,

Fogelman

I, Russell

GFM.

Osteopenia

 

ofthe

lumbar

 

spine

and

femoral

neck

in

anorexia

nervosa.

Scott

Med

J

1986:

3I(3):206-7.

10.

Newman

MM,

Habmi

KA.

Relationship

ofbone

density

to

estra-

diob

and

cortisol

in

anorexia

nervosa

and

bulimia.

Psychol

Res

1989:29:105-12.

I1.

Peppler

WW,

Mazess

RB.

Total

body

bone

mineral

and

lean

body

mass

by

dual-photon

absorptiometry.

I. Theory

 

and

measurement

procedure.

CalcifTissue

Int

198 1; 33:353-9.

12.

Mazess

RB,

Peppler

WW,

Gibbons

M.

Total

body

composition

by

dual-photon

‘53Gd

absorptiometry.

Am

J

Clin

Nutr

1984;40:

834-9.

I3.

Gotfredsen

A,

Jensen

J,

Borg

J,

Christiansen

C.

Measurement

of

lean

body

mass

and

total

body

fat using

dual

photon

absorptiome-

try.

Metabolism

1986:35:88-93.

 

14.

Mazess

RB,

Hanson

J, Sorenson

J,

Barden

HS.

Accuracy

and

pre-

cision

ofduab-photon

absorptiometry.

In:

J Dequeker,

P Geusens,

HW Wahner,

eds.

Bone

mineral

measurements

 

by photon

absorp-

BONE

IN

ANOREXIA

441

 

tiometry:

methodological

 

problems.

 

Leuven,

Belgium:

 

Leuven

University Press. 1988:157-64.

 

I 5.

Nijs

J, Geusens

P. Dequeker

J,

Verstraeten

A.

Reproducibility

 

and

intercorrebations

oftotal

bone

mineral

and

dissected

 

regional

BMC

measurements.

In:

JV

Dequeker,

P Geusens,

HW

Wahner,

eds.

Bone

measurements

by

photon

absorptiometry:

 

methodological

problems.

Leuven,

Belgium:

Leuven

University

 

Press,

 

1988:

45

1-3.

  • 16. Heymsfield

SB,

Wang

J,

Kehayias

ii,

Pierson

RN.

Dual-photon

 

absorptiometry:

comparison

of

bone

mineral

and

soft-tissue

 

mass

measurement

in

vivo

with

established

 

methods.

Am

J

Clin

Nutr

I 989;49: 1283-9.

 
  • 17. Mazess

RB,

Peppler

WW,

Chestnut

 

CH,

NeIp

WB,

Cohn

SH,

 

Zanzi

I.

Total

body

bone

mineral

and

lean

body

mass

by

dual-

photon

absorptiometry.

II.

Comparison

with

total

body

calcium

by neutron

activation

analysis.

CalcifTissue

mt

198

1; 33:361-3.

 
  • 18. Gallagher

JC,

Gobdgar

D, Moy

A.

Total

body

calcium

 

in

normal

 

women:

effect

of

age

and

menopause

status.

J

Bone

Mm

Res

I987:2:491-6.

 
  • 19. Mazess

RB,

Peppler

WW,

Chesney

RW,

Lange

TW,

Lindgren

U,

 

Smith

E.

Total

body

and

regional

bone

mineral

by

dual-photon

absorptiometry

in

metabolic

 

bone

disease.

Calcif

Tissue

Int

1984:36:8-13.

 
  • 20. Baker

PT.

Human

bone

mineral

variability

and

body

composition

 
 

estimates.

In:

J Brozek,

ed.

Techniques

 

for

measuring

body

com-

position.

Washington,

DC:

National

Academy

Press,

196 1:162-7.

21 .

Treasure

JL,

Russell

GFM.

Reversible

bone

loss

in anorexia

ncr-

vosa.

Br Med J l987;295:474-5.

 

22.

Sartoris

DJ,

Resnick

D. Dual-energy

radiographic

absorptiometry

for

bone

densitometry:

 

current

status

and

perspective.

 

AJR

1989; 152:241-6.

 
  • 23. Coblick

Mazess

RB,

B,

Trempe

J,

Barden

H,

Hanson

 

J.

Perfor-

 

mance

evaluation

ofa

dual-energy

x-ray

bone

densitometer.

 

Calcif

Tissue

Int

l989;44:228-32.

 
  • 24. RB,

Mazess

Barden

HS,

Bisek

JP,

Hanson

JA.

Dual-energy

 

x-ray

 

absorptiometry

for

total-body

 

and

regional

bone-mineral

 

and

soft-

tissue

composition.

Am

J Clin

Nutr

1990:5

1:1106-1

112.