By Suzanne Dooley-Hash, MD, FAED
Caring for someone with an eating disorder can be challenging in many ways. One of these is in understanding the impact of eating disorders on physical health and when to seek medical evaluation.
Individuals with eating disorders are at risk of serious medical complications, regardless of their weight. These complications can affect every organ of the body and many are potentially life-threatening. In fact, eating disorders have one of the highest mortality rates of any psychiatric disorder. In addition, just as individuals with eating disorders may not recognize the seriousness of their illness, they also often minimize or don’t recognize the seriousness of the physical symptoms they may be experiencing. Therefore, caregivers must watch for concerning signs and symptoms and be able to recognize the need for urgent evaluation by a healthcare provider.
Having a medical provider, preferably one who is familiar with eating disorders, as part of the treatment team is critical for individuals with eating disorders. A medical examination should be part of the initial evaluation of all individuals with a known or suspected eating disorder. Regular follow up visits should also be scheduled throughout treatment, with frequency determined by the severity of malnutrition, medical concerns and ongoing eating disorder behaviors such as purging or over exercise.
Individuals with eating disorders may report many different symptoms. These symptoms result from the effects of eating disorder behaviors, such as restriction of food and/or fluid intake, binge-eating, purging and over-exercise. It is important to remember, however, that serious medical conditions can also be present without any reported or obvious physical signs or symptoms. While many other symptoms are possible, some of the most commonly seen include:
— Feeling cold all the time
— Dizziness, often when standing up from sitting
— Heart palpitations (feeling of fluttering in chest or heart racing)
— Swelling of ankles, hands or feet
— Abdominal pain and/or bloating
— Early fullness when eating
— Absent or irregular periods
— Changes in behavior – moodiness, irritability, depression
— Poor concentration
— Suicidal thoughts, plans or attempts
— Hair loss
— Brittle hair and nails
— Lanugo hair (fine hair growth on the body and face)
— Dry cracked lips, dry skin
Symptoms that are sometimes seen in individuals who purge by self-induced vomiting include injuries to the mouth, throat or teeth, cavities or erosion of enamel (especially on the backs of the front teeth), swelling of the cheeks (due to salivary gland enlargement), blood in vomit and calluses or scars on the back of the hand. With the exception of blood in vomit, which can represent a serious condition, these symptoms are not life-threatening, but can serve as clues to presence of purging behaviors.
Complications seen in longstanding eating disorders (those that have been present for at least 6-12 months) may include low bone mineral density (osteoporosis) with resultant stress fractures and infertility. While these are not necessarily medical emergencies, they are indicators of chronic malnutrition and may not resolve with improvement of nutritional status.
One other consideration for individuals with significant malnutrition who are undergoing nutritional rehabilitation is refeeding syndrome (RS). Refeeding syndrome refers to the effects of a series of electrolyte abnormalities that can occur during nutritional restoration of a severely malnourished individual and that can result in a potentially fatal condition. Symptoms of RS include swelling of legs, face or hands, shortness of breath, nausea and vomiting, muscle weakness, and confusion. Refeeding syndrome can occur in patients of any age and weight. Individuals who are at increased risk of RS include those with severe malnutrition (70% median BMI in adolescents, BMI 15 in adults), chronic malnourishment with little or no intake for 10 days, rapid or profound weight loss regardless of weight (10-15% of total body weight in 3-6 months), a history of alcohol, diuretic, laxative or insulin misuse, abnormal electrolytes prior to refeeding, history of refeeding syndrome, and post-bariatric surgery patients with rapid weight loss. Anyone at risk of RS should have a thorough medical evaluation prior to initiation of nutritional restoration as should anyone undergoing treatment who develops symptoms ofthe condition.
So, with all of the possible medical complications of eating disorders how do you know when to seek medical care? In general, it is always better to err on the side of caution. While many of the symptoms you may see may represent relatively minor problems, it can be difficult even for trained medical professionals to tell the difference between minor and potentially serious complications. Therefore, if you’re concerned, contact your doctor immediately or go to your local emergency department. The following symptoms that should always prompt urgent evaluation:
– Shortness of breath
– Severe abdominal pain
– Blood in vomit
– Persistent nausea and vomiting preventing oral intake
– Confusion, lethargy, other changes in mental status
– Moderate to severe swelling (more than sock lines at the ankles or mild puffiness at the end of the day)
– Suicidal thoughts or attempt
– Uncontrollable behaviors such as self-harm, purging or restricting
For more information, the Academy for Eating Disorders’ Medical Care Standards Guide, “EATING DISORDERS: CRITICAL POINTS FOR EARLY RECOGNITION AND MEDICAL RISK MANAGEMENT IN THE CARE OF INDIVIDUALS WITH EATING DISORDERS”, is an excellent resource on the medical complications of eating disorders that provides guidelines for caregivers and that can be shared with medical professionals without expertise in caring for individuals with eating disorders.