Medical Dangers of Eating Disorders
A wide variety of medical complications are associated with eating disorders, many of which are serious enough to result in death. Sadly, eating disorders represent a real and significant mortality risk for both adolescents and adults.
Patients with eating disorders may require hospitalization to treat the medical complications that they can develop. These complications are often related to the effects of rapid or severe weight loss, malnutrition, fluid and electrolyte abnormalities, and purging. All of these can cause serious problems with heart function, as well as complications to many of the body’s other organ systems.
Some of the most common and concerning medical problems caused by eating disorders include complications to the following body systems: cardiovascular (heart), CNS (Central Nervous System)/brain, gastrointestinal, musculoskeletal, hematological (blood), and reproductive, as well as problems with the skin and hair.
Cardiovascular (heart) System
The cardiovascular system is seriously affected by an eating disorder. As the heart becomes malnourished, it becomes smaller and is unable to function with its normal strength. As this occurs, the heartbeat becomes weaker and slower, and its electrical rhythm may become disturbed. Arrhythmias, bradycardia (slowed heart rate), decreased blood pressure, heart attacks, QTc prolongation (a potentially deadly type of arrhythmia), and sudden cardiac death may result. Signs of complications in the cardiovascular system may include weakness, dizziness, passing out, and poor circulation including acrocyanosis (a blueness in the hands & feet). However, many patients with severely weakened, sick hearts do not show any obvious physical symptoms. Moreover, contrary to popular belief, a low heart rate (<50 beats per minute) is a sign of heart weakness and not a sign of athletic fitness - studies have shown that the majority of well-trained athletes do not have heart rates less then 50 beats per minute during the day.
Congestive heart failure (CHF) is one of many potentially fatal cardiovascular complications that can be caused by an eating disorder. CHF usually occurs when the body is refed and rehydrated too quickly - a condition known as “refeeding syndrome”. During refeeding syndrome, the weakened heart muscle must suddenly respond to the newly increased blood volume caused by rapid re-nourishment. Without the capacity or strength to do this effectively, the heart becomes backed up with blood, causing a further back-up into the lungs and body. This backup forces fluid from the blood vessels into the lungs and body tissues, creating a potentially deadly congestion of the heart and lungs.
Cardiac disturbances may appear to develop suddenly, without warning, and can get progressively worse. The malnutrition, purging, diuretic and laxative abuse common in eating disorders can severely damage the heart, making it weaker and unable to sustain a normal rhythm - potentially leading to sudden cardiac death. Fortunately, with the return to and maintenance of a healthy weight, the majority of the damage done to the heart by an eating disorder is fully reversible.
An examination of the cardiovascular system for patients with eating disorders typically includes: listening to the heart for signs of an irregular heartbeat and/or bradycardia (slowed heartbeat), checking the blood pressure for hypotension or hypertension (low or high blood pressure), examining an electrocardiogram for arrhythmias or other irregularities, and examining the extremities for blueness or other signs of poor circulation.
Gastrointestinal System
Eating disorders affect the gastrointestinal system in many different ways, depending on the specific symptoms of the eating disorder. In individuals who severely restrict food intake, the stomach can fail to deliver food properly to the intestines and the motility of the intestines themselves can become severely impaired. This overall slowing of the gastrointestinal system can result in many complications such as patients’ feeling very full with minimal food intake, acid reflux, and severe constipation. A loss of the ability to sense hunger, fullness and even abdominal pain may occur. Severe malnutrition caused by eating disorders can also cause pancreatitis, as the pancreas begins to digest itself.
In individuals who purge, additional complications may occur. Repeated vomiting brings up harsh digestive acids into the esophagus and mouth, eroding tooth enamel and the lining of the esophagus, as well as the mouth and gums. Salivary glands can also become overstimulated, causing a mumps-like swelling in the cheeks.
The hand or instrument used to induce vomiting can cut or tear the fragile lining of the mouth and throat, and the repeated pressure and acid from purging may tear through the esophagus causing potentially fatal bleeding. Induced vomiting may also cause a loss of the natural “gag reflex” – the protective reflex which keeps food, liquids, or vomitus from entering the lungs. If foreign substances do enter the lungs, they can cause choking, severe difficulty in breathing, pneumonia, and even death. In addition, the sphincter, which separates the esophagus from the stomach, may loosen, allowing acid from the stomach to enter the esophagus. This condition is known as acid reflux.
Excessive laxative use may result in severe constipation and a reliance on artificial stimulation of the bowels in order to have a bowel movement. In extreme circumstances, the intestines may become so impacted with stool that they can rupture.
An examination of the gastrointestinal system typically includes examining the inside of the mouth for sores, cuts, tooth enamel erosion and the presence of a gag reflex. The parotid (salivary) glands should be checked for enlargement and the abdominal area should be examined to look for signs of constipation or pain over the stomach or intestines. If there is any reason for concern, an X-ray of the stomach and/or intestines may be required.
Musculoskeletal (bone and muscle) system
Malnutrition can cause a severe weakening of the bones and muscles. This is because most of the structure of our bones comes from certain minerals (calcium and phosphorus) being deposited into bone tissue. Without adequate nutritional intake, these minerals cannot be deposited into the bones. As a result, the bones end up losing their mass and strength.
The inability of malnourished bodies to maintain enough bone mass has two main causes. First of all, a person who is malnourished probably does not take in enough calcium through food - thus, calcium is simply not available to be put into their bones. Secondly, certain hormones (such as estrogen) are needed to put the calcium that they do receive into their bones. Because these hormones are made from fat, they cannot be made if a person does not have enough body fat. Without the production of these hormones, the bones don’t get their calcium, and so they weaken. Purging can also disrupt the production of these hormones, causing a loss of bone mass.
More than half of adult bone calcium is deposited during the teenage years, so this is a crucial time of life for developing strong and healthy bones. Many adolescents with eating disorders develop a loss of bone mass called osteopenia, a condition which places them at greater risk for fractures and early onset osteoporosis.
Another way that malnutrition affects the bones is by delaying or stopping their linear growth. This causes the adolescent patient to stop growing taller, and may prevent them from ever reaching their full adult height. In a malnourished body, the bones do not receive enough nutrition to grow because all of the body’s energy is being used to simply stay alive. There is also a decrease in growth hormone, one of the hormones that stimulates the bones to grow longer.
The muscles are also affected by malnutrition. When a body loses weight in an unhealthy way, it looses not only fat, but overall muscle mass. The lack of calories, protein, and essential electrolytes like potassium, may cause muscle weakness, cramping, and overall muscle atrophy.
To examine the bones, a bone density scan called a DEXA scan may be done to look for osteopenia. If the patient is young and there is a concern about growth delay, a test to check “bone age” and potential growth may be done.
Central Nervous System/ brain
Organic brain syndrome, a type of cognitive impairment secondary to malnutrition, may occur in patients with eating disorders. This is characterized by a “slowing” of brain function. Although they may continue to do well in school, patients with organic brain syndrome tend to have significant difficulty with decision-making, including “simple” decisions like what to eat or when to schedule a meeting.
On CT scan, it has been shown that malnourished patients have a decreased amount of actual brain tissue. Malnourished patients also commonly exhibit symptoms of depression (sometimes due to deficiencies of minerals like Zinc) and rigid thoughts and rituals regarding food and meal preparation. Rarely, patients may develop seizures, due to decreased levels of sodium and/or decreased blood sugar.
CNS/brain function may be tested by a physical exam to test how the adolescent or adult interacts and focuses on neurological tasks. If he or she has a seizure, we will also check a CT scan (scanned images of the brain) and an EEG (a tracing of brain waves) to look for other problems that may have caused the seizure.
Reproductive System
Malnutrition causes a decrease in the production of “sex hormones”. This can affect the reproductive system by causing: an arrest in sexual development (i.e., failure to begin or complete the changes of puberty), a loss of menstrual periods or failure to begin menstruation, breast atrophy, loss of wet dreams, and loss of erections.
On history and physical exam, female patients’ menstrual history is taken and adolescents are checked to ensure that they are going through all of the normal physiological changes of puberty. If problems are detected, hormone levels may be checked to make sure that these problems are being caused by the malnutrition and not by any other medical problems.
Hematological (blood) System
The hematological system is also affected by malnutrition. Patients may develop anemia due to a lack of iron, B12, and folate in the diet. Fatigue and easy bruising may result. Patients also may also have a decrease in the production of platelets in their blood. This decreases the ability of the blood to clot and therefore causes easy bruising, gum bleeding and nose bleeds. The production of white blood cells is also impaired by malnutrition. White blood cells are what the body uses to fight infections. When one is not producing enough white blood cells, they are highly susceptible to infections, such as those from bacteria and viruses.
To check the hematologic system, a complete blood count is done to determine the quantity of red blood cells, white blood cells, and platelets.
Systemic
Fatigue, cold intolerance, and dizziness are systemic problems common to people with eating disorders. These are due to an overall lack of nutrition as well as inadequate amounts of body fat. In some patients, starvation can induce a release of endorphans in the brain, producing a type of “high”. For this reason many patients seem to have a normal or even increased energy level despite being extremely malnourished.
Skin and Hair
The lack of essential fatty acids, vitamins, and minerals in malnourished patients with eating disorders can cause rashes and visible damage to the skin and hair. The hair and nails become dry and brittle, and the hair on the head may fall out. Because of a lack of body fat, a downy “fur” called lanugo can begin to grow on the body as an attempt to conserve heat and energy.