COMPLICATIONS OF ANOREXIA NERVOSA

Endocrine/Reproductive Complications

MENSES

To meet the criteria for diagnosis with anorexia nervosa, women must have at least three consecutive months of amenorrhea,

The amenorrhea of anorexia is marked by

• low circulating luteinizing hormone (LH) and follicles stimulating
  

hormone (FSH) despite low estrogen, may affect follicular development

• a pre-pubertal pattern of release of LH and FSH,
  
• diminished response to luteinizing hormone–releasing hormone,
  
• the absence of withdrawal bleeding after a progesterone challenge.
  

This hormone disturbance is mainly an effect of starvation and malnutrition rather than just low weight, as amenorrhea can precede weight loss in up to 1/3 of patients, and menstruation does not always correlate with weight gain.

OVARIES

The pre-pubertal hormonal state in anorexia is associated with smaller

ovaries. With severe malnourishment and low body mass index (BMI), ovaries appear small or undetectable, and have no follicles.

With resumption of eating and weight gain, ovaries can grow and develop multiple follicles until finally one follicle becomes dominant and ovulation and menstruation resume.

Pelvic ultrasound is useful to determine ovarian size.

FERTILITY

Studies report that a high number of women presenting to infertility

clinics had an undiagnosed eating disorder. In one study, five out of 14

women getting ovulation induction had an eating disorder.

PREGNANCY

Anorexia is associated with worse outcomes in pregnancy.

• There is a higher rate of cesarean-section,
  
• a 40% rate of low birth weight (LBW) infants,
  
• 2X increased rate of premature delivery.
  

These outcomes are surprisingly also the same for women with remitted anorexia.

Babies born small for gestational age were more likely to have mothers with

• lower pre pregnancy weight,
  
• lower desired weight in pregnancy,
  
• lower weight gain during pregnancy,
  
• greater than average concern about overeating,
  
• and who smoked.
  

Other endocrinal disturbances.

• Reproductive hormones, including estrogen and dehydroepiandrosterone (DHEA), are lower. Estrogen is important for healthy hearts and bones. DHEA, a weak male hormone, may also be important for bone health and for other functions.
  
• Thyroid hormones are lower. Signs of Sick Euthyroid Syndrome, probably resulting from chronic malnutrition. Labs show low T3, low or normal T4, and normal TSH. This finding can act as a marker of the systemic effects of the restricted eating, but it does not require treatment. Anorexia can also affect the hypothalamic-pituitary-adrenal axis (HPA or HTPA axis), s a complex set of direct influences and feedback interactions among the hypothalamus , the pituitary gland , and the adrenal glands .The interactions among these organs controls reactions to stress and regulates many body processes, including digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure.
  
• Stress hormones (cortisol, norepinephrine) are higher.
  
• Growth hormones are lower. Children and adolescents with anorexia may experience retarded growth.
  

  
  

  Skeletal Complications
  

  Almost 90% of women with anorexia experience osteopenia and up to 50% of patients with anorexia suffer from osteoporosis.
  

  Development of osteoporosis are dependant on the length of amenorrhea and estrogen deficiency.
  

  Factors that correlate with the presence of osteoporosis are:
  

  • Low BMI (body mass index)
    
  • Past weight history, including minimum weight,
    

  Other factors that contribute to increased risk for osteoporosis include
  

  • smoking and alcohol consumption,
    
  • low calcium,
    
  • low oestrogen levels
    
  • high cortisol (stress hormone),
    
  • DHEA and low testosterone level boys
    
  • and a family history.
    

  The long-term risk for bone fractures is 2.9 times that of controls, and occurs especially in vertebrae, wrist, hip, humerus, and tibia.
  

  
  

  Up to two-thirds of children and adolescent girls with anorexia fail to develop strong bones during their critical growing period. Boys with anorexia also suffer from stunted growth.
  

  Only achieving regular menstruation as soon as possible can protect against permanent bone loss. The longer the eating disorder persists the more likely the bone loss will be permanent.
  

  
  

  Cardiovascular
  

  Complications
  

  Approximately half of deaths in anorexic patients are due to cardiovascular complications. Over 80% of
  

  patients have electrocardiogram (EKG) changes, especially bradycardia,
  

  Other cardiac complications of anorexia include:
  

  • decreased oxygen uptake,
    
  • and decreased exercise capacity
    

  
  

  HEART DISEASE
  

  Heart disease is the most common medical cause of death in people with severe anorexia. The effects of anorexia on the heart are:
  

• Dangerous heart rhythms, including slow rhythms known as bradycardia, may develop. Such abnormalities can show up even in teenagers with anorexia.
  
  

  Bradycardia is a slowness of the heartbeat, usually at a rate under 60 beats per minute (normal resting rate is 60 - 100 beats per minute).
  

• Heart rates decrease and blood pressure falls as an adaptive response to starvation. Patient may have orthostatic changes. May cause cardiac collapse if patient exerts himself.
  
• Blood flow is reduced.
  
• The heart muscles starve, losing size ie. reduced left ventricular mass, thinning of the left ventricular wall.
  

  
  

  
  

  A primary danger to the heart is from abnormalities in the balance of minerals, such as potassium, calcium, magnesium, and phosphate, which are normally dissolved in the body's fluid. The dehydration and starvation that occurs with anorexia can reduce fluid and mineral levels and produce a condition known as electrolyte imbalance. Electrolytes (calcium and potassium) are critical for maintaining the electric currents necessary for a normal heartbeat. An imbalance in these electrolytes can be very serious and even life threatening unless fluids and minerals are replaced.
  

  
  

  
  

  
  

  GASTROINTESTINAL SYSTEM
  

  The effects of anorexia on the gastrointestinal (GI) system are important both psychologically and physiologically.
  

  
  

  Psychologically
  

  • Anorexics have an exaggerated sense of the size of their stomach in terms of
    
    • Outward appearance
      
    • How they imagine their stomach appears inside their body.
      
  • When they eat, they picture their stomach ballooning out.
    
  • They have prolonged sense of fullness after a meal due to delayed gastric emptying after a period of restricted eating.
    
  • In their minds, the feeling of being "full" becomes equated with being "fat," which reinforces their fear of eating regular meals.
    

  
  

  Physiologically
  

  • Constipation, due mostly to drastically reduced calorie intake, invariably accompanies weight loss in anorexia nervosa.
    
  • Most anorexics have a period (about 2 weeks) when they begin eating regular amounts of food where they have stomach pain, nausea, gastric bloating, cramps, and diarrhea before the GI system starts to readjust.
    
  • Not only the stomach, but the whole GI tract can suffer from decreased motility. Constipation is common.
    
  • Starvation can also cause a nutritional hepatitis with decreased total protein, elevated transaminases, and increased bilirubin. It usually does not lead to severe liver disease unless the person also abuses alcohol.
    
  • Anorexics cannot be given too large a glucose or carbohydrate load as a large amount of phosphate will be rapidly consumed as it is used to metabolize glucose, and phosphate levels can fall dangerously low. The low phosphate can cause cell breakdown and milder symptoms of muscle weakness, fatigue, nausea, and vomiting.
    
  • In more severe cases, it can cause life threatening epilepsy, cardiomyopathy, hemolytic anemia, respiratory failure, coma, and even death.
    
  • Pancreatitis can also occur during refeeding, and starvation-induced hepatitis may also worsen initially during re-feeding.
    

  
  

  COMPLICATIONS IN ADOLESCENTS WITH TYPE 1 DIABETES
  

  A study of over 2,000 women found that bulimia, or a combination of bulimia and anorexia, was more common among women with type 1 diabetes.
  

  The complications of eating disorders that affect all patients are even more dangerous in this group of patients. Low blood sugar, for example, is a danger for anyone with anorexia, but it is a particularly dangerous risk for those with diabetes.
  

  • If patients do not take their insulin, high blood sugar, which is also very dangerous, can occur. Unfortunately, patients with eating disorders may skip or reduce their daily insulin in order to decrease their intake of calories. Extremely high blood sugar levels can cause diabetic ketoacidosis, a condition in which acidic chemicals (ketones) accumulate in the body. This condition can lead to coma and death.
    

  
  

  Hematologic
  

  Complications
  

  DecreasedWBCoccurs in up to60% of patients with anorexia.8,23 Patients' BMI is correlated with leucocyte and neutrophil count.23 Anemia, which is usually normocytic,23 and thrombocytopenia occur in 30% of patients.
  

  Anemia is a common result of anorexia and starvation. A particularly serious blood problem is pernicious anemia, which can be caused by severely low levels of vitamin B12. If anorexia becomes extreme, the bone marrow dramatically reduces its production of blood cells, a life-threatening condition called pancytopenia.
  

  PSYCHOLOGICAL EFFECTS AND SUICIDE
  

  Adolescents with eating behaviors associated with anorexia (fasting, frequent exercise to lose weight, and self-induced vomiting) are at high risk for anxiety and depression in young adulthood. Alcohol and drug abuse are more common in patients with anorexia. Suicide has been estimated to account for as many as half the deaths in anorexia with studies showing up to a fifth of anorexic patients attempting suicide.
  

  
  

  Dermatological alterations
  

  • Brittle hair, eyelash and nails
    
  • Loss of hair and eyebrow
    
  • A dystrophic aspect of the skin (related to nutitional deficiencies)
    
    • Looks dry and scaling
      
    • Pale or yellowish (due to hypercarotenaemia)
      
  • Skin often covered by a fine, downy-like hair defined as lanugo, growing especially on the face, superior lip, back, arms and legs (possibly linked to hypothyroidism).
    
  • Poor wound healing
    
  • Facial dermatitis, seborrheic dermatitis and acne are occasionally observed

Neurological

• seizures
• disordered thinking
• numbness or odd nerve sensations in the hands or feet (peripheral neuropathy)
• Abnormalities in brain structure and function are seen in the early course of the ilness in adolescents.
• Enlarged ventricles with reduction in white matter
• Regional cerebral blood fllow is reduced, predominantly in the temporal lobe but also lesser extent in the parietal, and orbitofrontal lobes.
• May be only partially reversed with weight gain