Being too overweight is not good for you — being too underweight isn’t either

It is hard to pick up a medical journal, or even the local newspaper, and not find an article or more devoted to obesity and its effects on health and longevity.

Much less attention is given to the other end of the spectrum, yet disorders resulting in a very low BMI — anorexia, bulimia, the “female athlete triad” — seem much more difficult to manage.

The biggest obstacle I have faced is getting the patient to accept that there is something wrong. Recently, such a patient was referred because of a stress fracture in the hip that she first became aware of near the end of her daily 2.5-hour gym workout. When I explained the biology of what was happening to her and indicated that she would have to give up her daily routine for a while, her first response was, “How about I cut down to just two hours a day?” Things did not get much better until that stress fracture became a true fracture. She finally got the message, but at what price?!

The earliest clinical clue is menstrual irregularity followed by amenorrhea. Estradiol levels are low and so are the gonadotropins. Brain imaging to make certain there is no pituitary lesion is necessary, but is rarely helpful. Estrogen replacement does not appear to be of benefit unless the patient is able to gain weight. How to achieve weight gain is the challenge. Patience and counseling by someone experienced in this field, if you can get the patient to accept counseling, does lead to some success, but overall the path of getting patients to lose weight is brighter.