W5-medical complications of eating disorders

• Malnutrition

  A deficit of macronutrients or micronutrients
• Low BMI

  <80% of median BMI or BMI Z-score of <-1
• Significant weight loss

  >10% loss of body weight
• Severe malnutrition

  >20% of body weight in 1 year or >10% in 6 months
• You can be malnourished even with a normal or high BMI
• Amount of weight lost, and how fast you lost it, is a more important determinant of malnutrition severity than weight/BMI
• Effects on metabolism: The Desert Island

  Body thinks it is helping you to survive when you deprive it of food source/energy till rescue comes (i.e. lower heart rate, lower temp.; runs out of steam the longer it is deprived)
• Systems affected by eating disorders

  • Cardiovascular
  • Fluids and electrolytes
  • Neuropsychiatric
  • Gastrointestinal
  • Reproductive
  • Musculoskeletal/Growth
  • Hematologic/Immunologic
  • Head and neck
  • Dermatologic (skin and hair)
  • Respiratory
  • Dental
• Cardiovascular effects

  • Bradycardia (low HR)
  • Structural changes to the heart (decreased ventricular wall mass and thickness inefficient pump)

  
• Bradycardia + inefficient pump

  Decreased cardiac output
• Cardiovascular effects

  • Hypotension (low BP) dizziness, fainting
  • Orthostatic changes (↓BP, compensatory ↑HR) symptoms with standing
  • Poor peripheral perfusion cold and blue hands and feet ("acrocyanosis")
  • Hypothermia (low temperature) always cold
• Fluids and electrolyte causes

  • Poor oral intake of fluids
  • Vomiting
  • Laxative use
  • Diuretic use
  • "Refeeding Syndrome"
• Refeeding Syndrome

  Changes in metabolism that occur when body changes from "starvation mode" to "rebuilding mode"
• Electrolytes primarily affected

  Phosphorus, potassium, magnesium
• Electrolyte abnormalities

  Fatigue, muscle pain, heart failure or cardiac arrest, death
• Water Loading

  Dilution of electrolytes, particularly sodium
• Water Loading

  • Mild: lethargy, fatigue, dizziness, nausea
  • Severe: seizure, coma, permanent neurological injury, death
• Neuropsychiatric effects

  • Cognitive (memory, learning, organization, judgment, concentration)
  • Psychiatric (Anxiety, Depression, Psychosis, Suicide)
• Structural changes in the brain are potentially irreversible
• Gastrointestinal effects

  • Constipation
  • Delayed gastric emptying fullness and bloating after meals
  • Acid reflux
  • Hematemesis (blood in vomit), esophagitis, esophageal rupture
  • Increased liver enzymes
  • Pancreatitis
  • Gallstones
• Gastrointestinal effects tend to be reversible, except maybe chronic laxative use
• Reproductive effects


  • Suppression of pubertal axis at the level of the hypothalamus
  • Incomplete pubertal development: Pubertal delay/arrest - *potentially irreversible*
  • Complete pubertal development: Absent menstrual periods, infertility
• Musculoskeletal effects


  • Height stunting - *potentially irreversible*
  • Decreased bone density - *potentially irreversible*
  • Diffuse muscle wasting
  • Weakness
  • Pain
• Only known effective cure for musculoskeletal effects: weight restoration
• Hematologic effects


  • Anemia (iron, folate, B12, chronic disease)
  • Immune suppression
  • Low WBCs
  • Poor wound healing
  • Sometimes low platelets
• Head and neck effects


  • Parotid hypertrophy
  • Dental erosion
  • Oral abrasions
• Dermatologic effects


  • Lanugo
  • Poor wound healing
  • Skin breakdown and ulcers
  • Dry skin
  • Hair loss
  • Beta carotenemia
  • Russell Sign
• Beta carotenemia is not necessarily a sign of malnourishment
• Respiratory effects include aspiration pneumonia and respiratory sequelae of heart failure
• All medical complications are reversible with weight restoration EXCEPT those that involve a "critical window" for growth and development
• Eating disorders have the highest mortality rate of any psychiatric illness, approximately 10%
• Most common causes of death are cardiac and suicide
• When is hospitalization required?


  • HR <50 bpm awake, <45 bpm asleep
  • BP <90 mmHg systolic, <50 mmHg diastolic
  • Temperature <96 degrees Farenheit
  • Significant postural changes in HR or BP (>30 bpm increase in HR or >20/10 mmHg decrease in BP)
  • Low body weight (e.g. <75% IBW or significant weight loss)
  • Dehydration
  • Electrolyte abnormalities
  • EKG abnormalities
  • Food refusal
  • Failure of outpatient treatment
  • Psychiatric emergency
• Goals of inpatient treatment


  • Bedrest, cardiac monitoring
  • Correction of dehydration or electrolyte derangement
  • Gradual increase in calories, daily monitoring of electrolytes (refeeding syndrome), electrolyte supplementation if necessary
  • Weight restoration (at least 75%-85% IBW, depending on discharge plan)
  • Behavioral support (oral feeding, meal supervision, symptom interruption)
  • Psychiatric safety precautions
  • Parent and family support
• You don't need a low BMI to be malnourished
• Changes in metabolic rate contribute to many medical complications of malnutrition
• Every organ system in the body is affected by malnutrition
• Most medical complications of malnutrition are reversible, but some are not (usually related to growth/development)
• Eating disorders have a high associated mortality
• Hospitalization is required for the most life-threatening complications