Wednesday 7/2/2024

PHOTO: Katarina Wolnik Vera

Text: Alejandra Misiolek 

Eating disorders (AN – Anorexia nervosa, BN – Bulimia nervosa and BED – Binge Eating disorder) are body and mind disorders where multidisciplinary work with patients is crucial. Sometimes the medical symptoms of eating disorders can become difficult to understand and confusing. Moreover, we cannot forget that although EDs are caused by psychological difficulties, they can be devastating for somatic health and even deadly to some patients.

Estimates are that yearly over 3.3 million healthy life years worldwide are lost because of eating disorders. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide.

For all the reasons mentioned above, it is very important to take care of the medical symptoms and to do this, we need to first be aware of them.

In this post, I am going to explain what are the medical issues to be taken into consideration when one has or treats an ED.

First of all, where do the medical comorbidities come from in EDs?

The medical comorbidities result mainly from prolonged malnutrition, as well as excessive exercise, binging and purging behaviors, as well as the use of laxatives, enemas and diuretics.

General symptoms that appear early in malnutrition are:

• Fatigue
• Cold intolerance
• Insomnia
• Dizziness or fainting
• Hypotension
• Dehydration
• Swelling and pain

1. The heart and the cardiovascular system

The heart can be affected both at early and late stages of EDs and if it is affected, the consequences can be detrimental. A review found that up to 87% of patients experience cardiovascular compromise shortly following the onset of AN.

Particularly patients with anorexia and also with bulimia have an increased risk of suffering from cardiac failure due to severe malnutrition, dehydration and electrolyte imbalances. The dehydration and electrolyte imbalance appear when patients purge or use laxatives and in consequence may suffer from hypochloremic metabolic alkalosis and hypo or hyperpotassemia, among others, that can affect the rhythm of our heart and cause irregular heartbeat or arrhythmia.

2. Kidneys

Not only our hearts but also our kidneys suffer from dehydration. Hydroelectric alterations, acute kidney failure and hypokalemic nephropathy are among the most frequent comorbidities related to our kidneys.

3. The Gastrointestinal system

The gastrointestinal (GI) system plays a pivotal role in the development, maintenance, and treatment outcomes for EDs. More than 90% of AN patients report fullness, early satiety, abdominal distention, pain, constipation and nausea.

In patients that purge, hypertrophy of salivary glands, esophagitis (inflammation of the esophagus), regurgitations, even esophageal rupture, gastric dilation or even perforation and acute pancreatitis may appear with reasonable frequency.

Findings from a systematic review indicated that structural changes that occurred in the GI tract of patients with AN impacted their ability to swallow and absorb nutrients.

On the other hand, and in terms of treatment possibilities, there has been an emerging focus on the role of the gut microbiome in the regulation of core ED symptoms and psychophysiology. Increased attention is being paid to how the macronutrient composition of nutritional rehabilitation should be considered to maximize treatment outcomes. A review found that high fibre consumption in addition to prebiotic and probiotic supplementation helped balance the gut microbiome and maintained the results of refeeding.

4. Bone health

The high rates of bone resorption observed in patients with AN is a consequence of chronic malnutrition leading to osteoporosis (weak and brittle bones), increased fracture risk and scoliosis. The negative impacts of bone loss are more pronounced in individuals with early-onset AN when the skeleton is still developing and among those who have very low BMI.

5. Oral Health

Purging behavior, particularly self-induced vomiting, has been associated with several oral health dysfunctions in patients with EDs. Wearing off tooth enamel and gingivitis are one of the very common symptoms in patients with bulimia and are related to extreme sensitivity and pain.

6. Vitamin deficiencies

The prolonged periods of starvation, food restriction (of caloric intake and/or food groups), purging and excessive exercise observed across the ED spectrum have detrimental impacts on micronutrient balances. The impact of prolonged vitamin deficiencies in early-onset EDs can also impair brain development, substantially reducing neurocognitive function in some younger patients even after weight restoration. Common micronutrient deficiencies include calcium, fat-soluble vitamins, essential fatty acids selenium, zinc and B vitamins.

7. Cognitive functioning

It appears that some cognitive functions affected by EDs recover following nutritional restoration, whereas others persist. Cognitive functions, such as flexibility, central coherence, decision-making, attention, processing speed and memory, are hypothesized to be impacted by and influence the maintenance of EDs.

8. Reproductive health

Infertility, low or inexistent libido and higher rates of poor reproductive health are strongly associated with EDs, including miscarriages, induced abortions, obstetric complications, and poorer birth outcomes. Although amenorrhea is a known consequence of AN, oligomenorrhea (irregular periods) was common among individuals with BN and BED.  If patients undergo treatment for AN, achieve weight restoration, and continue to maintain wellness, reproductive functions can renormalize.

9. Hematological symptoms

All the blood cells can be affected by malnutrition, therefore causing anemia (red series), leukopenia (white series), and thrombopenia (platelets). Abnormal blood cell count is one of the earliest signs of EDs detected in routine blood tests.

10. Dermatological problems

These are not the most urgent for life but are among those that motivate patients with EDs most to seek recovery. Malnourished patients can experience:

• Xerosis
• Lanugo
• Acne
• Hypercarotinemia
• Skin stretch marks
• Britte hair and nails

12. Pulmonary consequences

Weakness of the respiratory muscles and diaphragm may cause hypoventilation and respiratory acidosis, as well as pneumothorax, all of which are serious health consequences.

12. Neurological 

Among the possible neurological consequences of EDs are headaches, seizures, and neuropathies because of vitamin B deficiency. Depression, concentration difficulties, even brain atrophy, and increased volume of ventricles and interhemispheric sulcus enlargement can be observed in MRI scans.

Can patients with severe eating disorders be treated outpatient or is hospitalization necessary?

Hospitalization is experienced as intrusive by most patients and psychologically can be traumatic. It is always the last resort if a patient’s life is at risk. There are certain hospitalization criteria to be considered and these are:

• Weight<70%,
• BMI<14.
• Serious medical complications like electrolyte imbalance or low glucose levels.
• Outpatient failure.
• Negative to ingestion.
• Uncontrolled abuse of laxatives or diuretics.
• Episodes of voracity and/or emetics.
• Autolytic attempt or suicidal ideation.
• Acute psychiatric pathology.

What is our approach to treating the medical symptoms of EDs?

The treatment for malnutrition is nutrition and always with professional help. Refeeding too quickly can also be dangerous to some patients and it is very important to be accompanied in this process by a professional nutritionist who specializes in eating disorders.

On the other hand, regular blood tests and medical checkups to monitor the symptoms and establish priorities by physicians are crucial. Some symptoms can be treated by supplementing vitamins or micronutrients, electrolytes can be replenished, proper water intake can be established, etc. Other possible comorbidities and consequences can be properly avoided or postponed if proper medical and nutritional care is established.

References:

1. Giovinazzo S, Sukkar S, Rosa G, Zappi A, Bezante G, Balbi M, et al. Anorexia nervosa and heart disease: a systematic review. Eat Weight Disord Stud Anorex Bulim Obes. 2019;24(2):199–207.
2. Harvard T.H. Chan School of Public Health. Report: Economic costs of eating disorders.
3. Hambleton, A., Pepin, G., Le, A. et al.Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. J Eat Disord 10, 132 (2022).
4. van Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Curr Opin Psychiatry. 2020 Nov;33(6):521-527. doi: 10.1097/YCO.0000000000000641. PMID: 32796186; PMCID: PMC7575017.