The medical complications encountered in the treatment of the eating disorder patient.

1. EATING DISORDERS
Medical Complications
Nomi Fredrick MD
Medical Director
Pacific Shores Hospital
Rader Programs

2. Morbidity & Mortality
eating disorders have the highest mortality of any
psychiatric illnesses—higher than depression,
schizophrenia, or bipolar disorder
cardiac complications are the most common cause of
death, with suicide being second in the younger population
lifetime mortality rates peak at 15–18%, approaching the
death rates of certain cancers
the mortality rate for AN is more than 12 times higher than
the general population of 15- to 24-year-old females

3. Morbidity & Mortality
BN has an overall lower mortality rate than restricting AN
EDNOS is the most populated diagnostic group, and may
carry a higher mortality and complication rate than either
AN or BN
a substantial number of ED patients are dangerously
overlooked if clinicians only consider at risk those who
fulfill strict diagnostic criteria
overall death rates from ED approach 20%

4. Signs & Symptoms
General
marked weight loss, gain or fluctuations
weight loss, weight maintenance or failure to gain expected
weight in a child or adolescent who is still growing
cold intolerance
weakness
fatigue or lethargy
dizziness and syncope
hot flashes and sweating episodes

5. Signs & Symptoms
Oral & Dental
oral lacerations and ulcers from mechanical
trauma, immunodeficiences and vitamin
deficiences
dental erosion and dental caries
perimolysis
salivary gland hypertrophy and impactation

6. Signs & Symptoms
lanugo hair
Dermatological
hair loss
yellowish discoloration of skin
poor skin turgor and healing
impaired capillary refill
calluses or scars on the dorsum of the hands
pellagra

7. Signs & Symptoms
Metabolic
hypokalemia from vomiting or diuretic or laxative
abuse leading to a metabolic alkalosis but some
laxatives can cause a metabolic acidosis
hypoglycemia may be severe and life threatening
because glycogen stores in the liver are depleted in
starvation
hyperglycemia and diabetic ketoacidosis are common
in diabulimia
hyponatremia, hypophosphatemia, hypomagnesemia,
hypocalcemia

8. Signs & Symptoms
chest pain and heart palpitations Cardiovascular
diminished peripheral circulation and acrocyanosis
bradycardia
arrythmias and QT prolongation with increased risk of
sudden death
shortness of breath
edema and ascites
orthostatic hypotension

9. Signs & Symptoms
Hematologic
all components of the bone marrow are diminished the
order in which is wbcs > rbcs > platelets related to the total
body fat mass loss
anemia may be from several sources including chronic
disease, blood loss, vitamin and/or iron deficiencies -
ferritin may be falsely elevated when there is hepatic
breakdown from starvation!
the immune system is compromised with decrease in cd8 t
cells and neutrophils
absolute neutrophil count should be calculated and infection
precautions institued if anc < 1000

10. Signs & Symptoms
Renal
increased incidence of chronic kidney disease because of dehydration
and chronic malnutrition
creatinine may be increased because of renal insufficiency or failure
or decreased because of decreased muscle mass
normal creatinine may be relatively elevated given the decreased
muscle mass and may indicate impending renal insufficiency -
creatinine clearance should always be done!
hyperkalemia is an impending sign of renal problems because
normally the potassium is low because of purging
diabulimics have more of the secondary effects of diabetes with renal
insufficiency and failure because of poorly controlled blood sugars
and misuse of insulin

11. Signs & Symptoms
Gastrointestinal
epigastric discomfort
early satiety, delayed gastric emptying, gastroparesis
gastroesophageal reflux and ulcers
esophageal strictures leading to dysphagia
barrett’s esophagitis
hematemesis and Mallory Weiss tears
superior mesenteric artery syndrome

12. Signs & Symptoms
Gastrointestinal
pancreatitis
fatty infiltration of liver and elevated
transaminases
constipation, small bowel obstruction and
impaction
hemorrhoids and rectal prolapse
hematochezia
increased incidence of IBS

13. Signs & Symptoms
Endocrine
hypothalamic pitutitary gonadal axis is underactive
and levels are low of fsh and lh in females causing
low levels of estrogen and progesterone leading to
secondary ammenorhea and irregular menses
in males this causes low androgen levels and
impotence
loss of libido
low bone mineral density and increased risk of
osteopenia, osteoporosis and fractures

14. Signs & Symptoms
Endocrine
abnormal responses of gut hormones: leptin, ghrelin, peptide yy,
gastric inhibitory peptide, glucagon-like peptide 1, amylin,
pancreastic polypeptide, cholecystokinin and insulin
one year after losing weight appetite regulating hormones don’t
return to baseline
anorexics have abnormal responses and levels of leptin and ghrelin
which in over 50% of cases do not return to normal baseline one
year after weight restoration
increased risk of diabetes II in bulimia and binge eating
with diabulimia there is an increased risk of serious complications
in diabetes i because of noncompliance with insulin to lose weight

15. Signs & Symptoms
Neuropsychiatric
seizures
deficits in memory tasks, flexibility and inhibitory
tasks
cerebral atrophy and the ventricular spaces and
sulci increase
greater risk of Alzheimer’s in females because of
prolonged state of estrogen deficiency
abnormal responses to high calorie images with
increased activation in the amygdala and insula

16. Signs & Symptoms
Neuropsychiatric
insomnia
self harm
suicidal ideation/ suicide attempt
increased risk of mood and anxiety disorders
increased risk of OCD, AN>>BN
increased risk of Borderline PD, BN>>AN
increased risk of substance abuse in BN and AN with
purging

17. Signs & Symptoms
Illnesses That Mimic EDs
chronic disease or infection
gastrointestinal disorders: celiac disease, ulcerative
colitis, chronic parasitic or bacterial infections,
malabsorption
endocrine disorders: diabetes mellitus, addison’s
disease, hyperthyroidism, hypopituitarism
cancers
superior mesenteric artery syndrome (can also be a
consequence of an eating disorder)

18. Signs & Symptoms
Illnesses Associated With EDs
diabetes mellitus
celiac disease
gastric bypass
conditions that require increased attention
toward or regulation of food intake
attention deficit hyperactivity disorder

19. Laboratory Values
glucose: ↓ poor nutrition,↑insulin omission
Metabolic
sodium: ↓ water loading or laxative abuse
potassium: ↓ vomiting, laxatives, diuretics, refeeding
chloride: ↓ vomiting, laxatives
blood bicarbonate: ↑ vomiting, ↓ laxatives
blood urea nitrogen: ↑dehydration
creatinine: ↓ dehydration, renal dysfunction, poor muscle mass,
normal may be “relatively elevated given low muscle mass
calcium: slightly ↓ poor nutrition at the expense of bone

20. Laboratory Values
Metabolic
phosphate: ↓ poor nutrition or refeeding
blood bicarbonate: ↑ vomiting, ↓ laxatives
magnesium: ↓ poor nutrition, laxatives, refeeding
total protein/albumin: ↑ early in malnutrition at the expense
of muscle mass, ↓ in later malnutrition
total bilirubin: ↑ liver dysfunction, ↓ poor rbc mass
sgot, sgpt: ↑ liver dysfunction
amylase: ↑ vomiting, pancreatitis
lipase: ↑ pancreatitis

21. Laboratory Values
Complete Blood Count
leukopenia, neutropenia, anemia or thrombocytopenia
anemia may be microcytic if iron deficiency is present,
macrocytic if alcohol abuse or vitamin b12/folate deficiency
present and/or anemia of chronic disease
bone marrow biopsy may be necessary if blood dyscrasias do
not resolve with nutritional rehabilitation
consider IV iron if not responding or unable to tolerate po
supplementation because of worsening constipation
neutropenia may be present and an ANC should be calculated
hypercoagulable states may be present because of prolonged
states of immobility and dehydration and INR followed

22. Laboratory Values
Thyroid Functions
low to normal thyroid stimulating hormone and
normal or low thyroxine is typical of sick
euthyroid syndrome typical in both eating
disorders and depression
if after compliance with nutritional rehabilitation
there isn’t an effective resolution of tfts, consider
replacement with levothyroxine or liiothyronine
t3 levels are inversely correlated with the degree
of cerebral atrophy and nutritional deficits

23. Laboratory Values
Gonadotropins & Sex Steroids
low luteininzing hormone and follicle
stimulating hormone
low estradiol in females
low testoterone and dhea in males

24. Laboratory Values
Lipid Panel
very often elevated in bulimia and binge eating
disorder and may require treatment
particularly in older patients, follow over time
with nutritional normalization
not useful in anorexia since cholesterol may be
elevated in early malnutrition and low in
advanced malnutrition

25. Laboratory Values
Imaging Studies
patients with anorexia and bulimia are at risk of low bone
mineral density (bmd). there is no evidence that hormone
replacement (estrogen/progesterone in females or
testosterone in males) improves bmd, except for some
recent studies with the organophosphate, risedronate.
older patients with binge eating frequently have
osteoarthritis severe for their relative ages
nutritonal rehabilitation, normalization of weight and
endogenous steroid production are the treatments of choice
measure bone mineral density with dexa scan in patients
with ammenorhea for 6 months or longer

26. Laboratory Values
Imaging Studies
mri and ct and functional imaging studies, including
fmri, spect and pet, have been useful in elucidating
the underlying abnormalities in neuroanatomy,
neurophysiology and neurochemistry
pathognomonic of anorexia and bulimia nervosa
these studies have no useful purpose in the routine
clinical workup of these patients unless there is a
strong index of suspicion of dementia or the
neurological exam is focal

27. Laboratory Values
Electrocardiogram
bradycardia
low voltage
inverted T waves
U waves
various degrees of heart block
prolonged QT interval
increased QT dispersion

28. Laboratory Values
Electrocardiogram
ST segment depression, elevation, and non-specific
changes
ventricular premature complexes
ventricular tachycardia
torsades de pointes (an ominous form of
ventricular tachycardia)
ventricular fibrillation
asystole (cardiac arrest)

29. Laboratory Values
Other Cardiac Findings
decreased cardiac muscle mass
diminished cardiac output
weak, thready pulses
acrocyanosis
weak, medially displaced PMI
decreased heart sounds from decreased cardiac dynamics
increased heart sounds from decreased chest wall thickness
increased heart murmurs Friction rub (from pericardial effusion)
myofibrillar degeneration

30. Laboratory Values
Other Cardiac Findings
decreased ventricular volume
decreased cardiac output
autonomic dysregulation
hypotension
increased peripheral resistance
mitral valve prolapse
pericardial effusions
heart failure
elevated cardiac enzymes (without coronary artery disease)

31. Refeeding Syndrome
Definition
refeeding syndrome describes a potentially fatal shift
of fluid and electrolytes that can occur when refeeding
(orally, enterally or parentally) a malnourished patient
patients with refeeding syndrome may have a non-
specific presentation and so diagnosing this syndrome
may be challenging
the serious consequences of refeeding syndrome
include cardiac, hepatic, renal, respiratory failure,
gastrointestinal problems, delirium and in some cases
multi-system organ failure and death

32. Refeeding Syndrome
Definition
the serious consequences of refeeding
syndrome include cardiac, hepatic, renal and/
or respiratory failure and in some cases
respiratory failure, gastrointestinal problems,
delirium and in some cases multi-system organ
failure and death
refeeding syndrome is a potentially fatal
syndrome requiring specialized treatment on an
inpatient unit

33. Refeeding Syndrome
Risk Factors
PATIENT HAS ONE OR MORE OF THE
FOLLOWING:
BMI less than 16 kg/m2
unintentional weight loss greater than 15% within
the last 3–6 months
little or no nutritional intake for more than 10 days
low levels of potassium, phosphate or magnesium
prior to feeding

34. Refeeding Syndrome
Risk Factors
PATIENT HAS TWO OR MORE OF THE
FOLLOWING:
BMI less than 18.5 kg/m2
unintentional weight loss greater than 10% within
the last 3–6 months
little or no nutritional intake for more than 5 days
a history of alcohol abuse or drugs including
insulin, chemotherapy, antacids or diuretics

35. Refeeding Syndrome
Management Of The High Risk Patient
starting nutrition support at a maximum of 10
kcal/kg/day, increasing levels slowly to meet or
exceed full needs by 4–7 days
using only 5 kcal/kg/day in extreme cases (for
example, BMI less than 14 kg/m2 or negligible
intake for more than 15 days)
monitoring cardiac rhythm continually in these
people and any others who already have or
develop any cardiac arrhythmias

36. Refeeding Syndrome
Management Of The High Risk Patient
restoring circulatory volume and monitoring
fluid balance and overall clinical status closely
providing immediately before and during the
first 10 days of feeding: oral thiamine 200–300
mg daily, vitamin B complex 1 or 2 tablets, three
times a day (or full dose daily intravenous
vitamin B preparation, if necessary) and a
balanced multivitamin/trace element
supplement once daily

37. Refeeding Syndrome
Management Of The High Risk Patient
providing oral, enteral or intravenous
supplements of potassium (likely requirement
2–4 mmol/kg/day), phosphate (likely
requirement 0.3–0.6 mmol/kg/day) and
magnesium (likely requirement 0.2 mmol/kg/
day intravenous, 0.4 mmol/kg/day oral) unless
pre-feeding plasma levels are high
pre-feeding correction of low plasma levels is
unnecessary

38. Refeeding Syndrome
Management Of The Low Risk Patient
25–35 kcal/kg/day total energy (including that
derived from protein)
0.8–1.5 g protein (0.13–0.24 gm nitrogen)/kg/
day
30–35 ml fluid/kg (with allowance for extra
losses from drains and fistulae, for example,
and extra input from other sources – for
example, intravenous drugs)

39. Aim at heaven and you will get earth thrown in. Aim at earth
and you get neither.
C.S. LEWIS