Contributor: Margherita Mascolo, MD at ACUTE Center for Eating Disorders at Denver Health
Anorexia nervosa is characterized by low body weight, an intense fear of gaining weight, distorted body image, and an extreme focus on shape, weight, and size. It carries the highest death rate of any psychiatric illness, and its complications are a direct consequence of starvation and weight loss. Anorexia recovery is crucial to survival.
While anorexia nervosa is defined by low body weight, it is divided into two types: restricting and binge-purge based on the mechanism used to achieve low body weight. There are many common physical side effects to both types with a few unique consequences in the binge-purge subtype.
Physical Side Effects of Anorexia Nervosa: Restricting and Binge-Purge Subtype
Vital sign abnormalities:
Given the low body weight, the body adapts to have a lower heart rate (bradycardia), lower body temperature (hypothermia), and lower blood pressure (hypotension) in an effort to conserve energy.
These changes usually cause no symptoms although occasionally patients will complain of being cold, tired, or dizzy. During recovery, as weight increases, these changes all normalize.
Physical exam findings:
Patients with anorexia nervosa appear emaciated, have dry skin with a yellow hue, brittle nails, thin scalp hair, lanugo hair which is fine, furry hair found on the face, neck, arms, back, and legs, and purplish-blue hands and feet (cyanosis due to abnormalities in temperature regulation).
They may have pressure sores especially in the sacral area due to lack of body fat and pressure on the skin from protruding bones.
This is seen especially in the ankles, feet, and around the eyes (periorbital). It is caused by hormonal changes brought on by starvation or by purging and is seen in both restricting and binge-purge subtype. Edema can also be seen as patients with anorexia begin to weight restore (refeeding edema).
This is very distressing to patients given their distorted body image and focus on shape and size. Reassurance and continued nourishment are necessary as the edema will resolve as the body heals and gains weight.
Gastroparesis (slowed emptying of the stomach):
With weight loss of even 10-20 pounds due to calorie restriction, the gastrointestinal system slows down. This causes bloating, early fullness, nausea, acid reflux, and even vomiting which often reinforces disordered eating behaviors and causes patients to further restrict their diet essentially worsening the problem.
A switch to a low fiber, liquid diet can be helpful and weight gain of even 10 pounds can drastically improve symptoms. Symptoms completely resolve with continued weight gain which may take close to four to six weeks.
Osteoporosis (bone density loss):
Due to the hormonal changes that go along with malnutrition, there is decreased bone formation and increased bone breakdown in patients with anorexia nervosa. This bone density loss results in frail bones that are at risk of fracturing with any physical activity which can significantly affect lifestyle.
Osteoporosis is the only potentially irreversible consequence of anorexia and malnutrition. These patients should be on life-long calcium, have normal levels of vitamin D (or take supplements to achieve normal levels), and weight restore as it is the only way to stop bone breakdown.
There are certain medications that can stop further bone loss (bisphosphonates) but careful discussion with a physician is necessary to consider risks and benefits.
Physical Side Effects of Anorexia Nervosa Binge-Purge Subtype:
Swollen salivary glands (sialadenosis):
This is commonly seen in people that vomit on a daily basis, even just once daily. The salivary glands enlarge and swell usually two to three days after the last episode of vomiting. This swelling makes the cheeks appear swollen which is very distressing to patients who have body dysmorphia.
Sialadenosis resolves within a few weeks of the last episode of vomiting; however can quickly return if the person re-engages in any vomiting.
Loss of tooth enamel:
Repeated exposure to acidic gastric contents that occurs with frequent vomiting leads to loss of enamel and tooth decay. The gastric contents are very acidic and this acid will chip away at enamel and expose the underlying tooth. This can also lead to caries.
Treatment consists of stopping vomiting behavior and good dental hygiene.
Vomiting leads to acidic stomach contents refluxing up the esophagus into the mouth through a sphincter at the base of the esophagus. With repeated vomiting, the sphincter weakens and remains open leading to acidic gastric juices refluxing up the esophagus.
This causes irritation to the lining of the esophagus (esophagitis) which can cause bleeding and scarring. Patients often complain of a burning sensation in their chest and a sour taste in their mouth.
Electrolyte abnormalities and dehydration:
Vomiting as well as diarrhea induced by laxative abuse lead to changes in electrolytes such as low sodium, low potassium, and low chloride. In addition, patients become very dehydrated as water is lost through vomiting and diarrhea.
These electrolyte changes can lead to weakness, muscle breakdown, cardiac problems, and even death. Treatment involves stopping purging behaviors and gentle replacement of fluids and electrolytes.
- Mehler, PS and AE Anderson. Eating Disorders. Baltimore: Johns Hopkins UP, 2010. Print.
- Mehler, PS. Diagnosis and Care of Patients with Anorexia Nervosa in Primary Care Settings. Ann Int Med. 2001; 134:1048-1059.
- Mehler, PS, Cleary, B, and Gaudiani, JL. Osteoporosis in Anorexia Nervosa. Eat Disord. 2011; 19:194-202.
The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.
Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on February 8, 2018
Published on EatingDisorderHope.com