10 Physical Complications Of Anorexia Nervosa

Aug 12

With eating disorders having a lifetime prevalence of about 8% for women and 2% for men, why are they not talked about enough (1)? Eating disorders are deadly beasts but often go unaddressed and are not taken seriously.

It seems like the media sometimes glorifies dieting and eating disorders, especially anorexia nervosa (AN), but what often goes unstated are the physical complications of the disorder. This article will cover the not so glamorous sides of AN.

10. Skeletal

Osteopenia and osteoporosis, which are typically found in older folks, are highly common in people with AN due to impaired bone formation and increased bone resorption. Osteopenia is diagnosed as bone mineral density (BMD) declines and can progress into a more serious condition, osteoporosis. Factors may include lower estrogen, increased cortisol, malnutrition or undernutrition, low calcium and vitamin D, and decreased insulin-like growth factor 1(IGF-1).

In a study of over 200 women diagnosed with AN, 52% had osteopenia and 34% had osteoporosis. 36% of these women had a history of multiple fractures, and 42% of those were due to nontraumatic causes, indicating how fragile the bones were (2).

Bone mineral density typically peaks during your mid-20s, but undernutrition can interfere with proper bone formation. This is worrying because AN develops commonly during adolescence and early adulthood. Furthermore, bone mineral density deficits may not be fully reversible, as it’s been found to be lower, even after recovery (3,4).

9. Pulmonary

Pulmonary problems have also been seen in individuals with AN. One study has shown that diffusing capacity for the lung for carbon monoxide and lung diffusion capacity worsened as the length of living with AN increased (5), indicating that the amount of oxygen passing from their lungs to bloodstream was lower than expected.

Two other serious (although rare) conditions that can occur are pneumothorax (lung collapse) and pneumomediastinum (presence of air between the lungs) which can happen suddenly. Spontaneous tension pneumoperitoneum (presence of air within part of the abdominal cavity) and pneumothorax can also occur due to gastric rupture caused by self-induced vomit (6).

8. Anemia and leukopenia

Due to malnutrition, the bone marrow fat atrophies or shrinks and is replaced by gelatinous material. The bone marrow is the production site of blood cells, and this change is associated with leukopenia (low white blood cell count), anemia (low red blood cell count), and thrombocytopenia (low platelet count). White blood cells are important for a person’s immunity, but infection has not been found to have higher rates in individuals with AN despite this. For individuals with anemia, the deficiency is commonly not due to iron, B12, or folate deficiency as well as chronic disease (7). Luckily, gelatinous marrow transformation seems to be reversible with proper nutrition and weight restoration.

7. Cardiovascular

About one third of deaths due to eating disorders are because of cardiac complications. Sinus bradycardia (heart rate less than 60 beats per minute) and hypotension (blood pressure less than 90/60) are common with bradycardia potentially found in up to 95% of patients. Bradycardia may be due to increased vagal tone and decreased metabolic rate due to decreased energy availability. Even in patients who are asymptomatic, bradycardia can lead to having a serious arrhythmia and death (8).

Myocardial (heart muscle) atrophy of the left ventricular mass of the heart is also significant and may contribute to mitral valve prolapse (valves between the upper and lower chambers of the heart aren’t able to close properly) along with bradycardia (9).

6. Menstruation and Reproduction

Amenorrhea or the loss of your period is commonly reported in females along with decreased libido (sex drive). If you do not have enough energy to sustain your body, your body is not prepared to care for a fetus, and this will cause your period to cease. This can usually be gained back with gaining weight which is important not only for fertility but also bone health and hormone balance.

For those who want to have children though, it can also be a struggle. Women with a history of AN have been found to have more miscarriages, cesarean deliveries, and preterm deliveries (10). Lower birth rate, smaller head circumference, small for gestational age (SGA), and microcephaly were also more prevalent in infants of mothers with AN. (11)

5. Impaired linear growth

You know how your parents told you that you need to eat to grow? Well, they weren’t wrong. Individuals with AN can have permanent short stature and impaired linear growth. This risk is higher for people who developed AN before menarche (first time menstruating).

A study showed that gaining weight correlated with catch-up growth, but complete catch-up growth usually did not occur, leading to shorter than expected stature as an adult (12). One reason this may occur is because undernutrition causes IGF-1 production to be inhibited in the liver which leads to the increased levels of growth hormone (GH). However, the GH’s function becomes impaired and leads to decreased growth (Link 13). Shorter stature may also be due to low thyroid hormones, elevated cortisol, and decreased levels of sex hormones.

4. Dermatologic

People with AN commonly have dry and brittle skin, hair, and nails as well as acrocyanosis (blue coloring of their fingertips, nose and ears) which is related to poor circulation and constantly feeling cold. Their bodies also easily bruise and have delayed wound healing (14).

Lanugo or fine, downy hair growth on the body (usually face, back and abdomen) also is characteristic of low energy availability. The hairs are produced in an effort to try to conserve heat and keep their bodies warm.

Lastly, individuals with the binge-purge subtype may develop calluses and scars on the back of their hands due to purging which are also called Russell’s Signs.

3. Neural

Brain atrophy or shrinkage is characteristic of AN and is seen in both gray and white matter and parts of the brain called the insula and thalamus. Magnetic resonance imaging (MRI) scans of the brains of people with severe AN have been comparable to brains of those with Alzheimer’s disease (14). These changes in the brain may lead to abnormalities in taste, smell, thalamic function, temperature regulation, and cognitive processes. However, these seem to be reversible with weight restoration (15), but cognitive deficits may be still present following recovery (16).

2. Gastrointestinal

Gastrointestinal (GI) problems are highly prevalent in people with AN. Due to restricting the body of food, gastrointestinal transit time slows down, causing gastroparesis, meaning food stays longer in your stomach than normal. This may lead to gas, bloating, abdominal pain, and constipation (17). Dysphagia, heartburn, and regurgitation are found in higher rates as well (18). Functional gastrointestinal disorders are also common, especially Irritable Bowel Syndrome (IBS) which is associated with psychosocial factors.

The microbiome (microbes in your gut) is in constant communication with your brain and can affect your mood and vice versa. Differences in the diversity and composition of the gut have been found compared to controls (Link 19). Dysbiosis or an imbalance in microbiota may be a factor in gastrointestinal problems as well as psychological.

All of these GI issues make it more difficult for individuals in recovery due to the discomfort associated with food and their bodies. In addition, they may report early feelings of fullness, possibly due to delayed gastric emptying.

1.Death

If none of the above worries you, how about this? AN has the highest death rate of any psychiatric illness. A follow-up study 21 years after admission to inpatient treatment of AN patients found 16% of them were deceased due to AN related factors. This death rate was about 10 times greater than the general population’s death rate (20). For those without treatment, about 20% of individuals die. Furthermore, every 1 in 5 deaths is due to suicide (21).

Let’s stop idolizing people with AN and other eating disorders and look at the facts. Having an eating disorder is not a game but a serious mental illness that affects you both mentally and physically. If you or someone you know is struggling with an eating disorder, the sooner you/they get help, the better.

Sources:

Link 1: https://pubmed.ncbi.nlm.nih.gov/31051507/

Link 2: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486452

Link 3: https://pubmed.ncbi.nlm.nih.gov/10800020/

Link 4: https://pubmed.ncbi.nlm.nih.gov/26086327/

Link 5: https://pubmed.ncbi.nlm.nih.gov/19581349/

Link 6: https://www.jem-journal.com/article/S0736-4679(07)00482-9/fulltext https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709923/

Link 7: https://search-proquest-com.ezproxy.ups.edu:2443/docview/1324278030/fulltextPDF/F1B843F105124442PQ/1?accountid=1627

Link 8: https://www.ccjm.org/content/87/6/361#sec-11

Link 9: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC483668/

Link 10: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.158.9.1461?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed&

Link 11: https://journals.lww.com/greenjournal/Fulltext/2005/02000/Pregnancy_and_Neonatal_Outcomes_in_Women_With.7.aspx