Eating Disorders Treatment: Your Doctor’s Role

Eating disorders can affect just about every organ system and have a wide array of medical consequences that range in severity from mildly annoying to extremely grave. Your health care provider plays an integral part in not only screening for and treating serious health consequences, but also addressing the bothersome side effects that can interfere with psychological and nutritional treatment.

Medical complications of eating disorders are very much related to the type of eating disorder behaviors present. We organize eating disorders, into diagnoses such as anorexia nervosa, bulimia nervosa, and binge eating disorder. But, from a medical standpoint, the specific diagnosis is less important than the eating disorder behaviors in which a patient is engaged. Medical complications of restricting or limiting food tend to be a direct result of starvation – either anatomical changes from weight loss, or the body’s compensatory mechanisms in response to limited energy resources. Purging related medical complications are related to the mode (e.g. self-induced vomiting, laxative abuse, diuretic abuse) and frequency of purging. Medical correlates of binge eating are, for the most part, similar to those of obesity (even if obesity is not present) as well as the mechanical consequences of consuming large volumes of food at once.

The list of possible consequences of eating disorders is a long one – too long for this article. Below are some important ones for your doctor to be aware of, as you undergo your medical evaluation.

Cardiovascular System

Patients with anorexia nervosa commonly have cardiac manifestations of their disease, with low heart rate, low blood pressure and severe swings in heart rate or blood pressure (orthostatic changes) upon position change, being the most typical. More serious complications include arrythmias, pericardial effusions, myocardial fibrosis, as well as mitral valve prolapse and cardiac insufficiency as their hearts shrink in size from malnutrition. Patients who purge are at risk for dehydration associated orthostatic hypotension, electrolyte imbalances causing life-threatening arrhythmias, as well as cardiomyopathy. Patients who engage in frequent binge eating are at risk for high blood pressure, atherosclerosis and cardiac insufficiency. Your health care provider will determine which of these consequences requires immediate hospitalization and which can be watched on an outpatient basis.

Gastrointestinal System

Gastrointestinal complaints are probably the most commonly seen with eating disorders. The malnourished patient can struggle with difficulty swallowing, delayed gastric emptying, constipation, even an extreme complication of starvation called superior mesenteric artery syndrome. It is important for clinicians to realize that their patient’s complaints of bloating, nausea, discomfort and fullness after eating may not all be “in their heads.” When severe, these symptoms can interfere with psychological and nutritional therapy, and should be treated so that a patient can fully engage in recovery. Those who engage in binge eating are more likely to have lipid abnormalities in their blood even in the absence of obesity, and those who are malnourished can, paradoxically, have elevated cholesterol and fatty liver, as well as elevated liver enzymes. Those who engage in regular self-induced vomiting can have dental carries, dental enamel erosion, difficulty swallowing, parotid gland swelling, gastro-esophageal reflux, esophagitis, vascular tears in the esophagus, and even rare but life-threatening esophageal rupture. Those who abuse certain laxatives are likely to encounter severe constipation and laxative dependence and are at risk for permanently damaging the colon so it no longer functions at all. Binge eating can cause gastroesophageal reflux, pancreatitis, gastric dilation, and rarely gastric rupture.

Endocrine System

The endocrine system, a network of interconnecting hormones, is especially sensitive to malnutrition and starvation. An altered release of reproductive hormones, growth hormones, thyroid hormones, and adrenal hormones, among others, can lead to symptoms such as pubertal delay or stagnation, menstrual irregularities, cold intolerance, hypothermia, dry skin, brittle hair, stunted linear growth and decreased bone density, known as osteopenia or osteoporosis. While most of these symptoms fully resolve with weight restoration and typically do not require hormonal supplementation or manipulation, impaired bone density is not reversible with re-nourishment alone, and is therefore of particular concern to health care providers. Doctors should do what they can to prevent osteoporosis, which can lead to disabling spontaneous fractures, and when present, consider medical therapies, such as transdermal estrogen or bisphosphonates (in males or older adult females) to arrest it. It is clear from years of research that oral contraceptive pills are not effective for osteoporosis treatment or prevention.

Other Systems

Some other notable manifestations of eating disorders can be found in the blood. Production of all three blood cell lines – red blood cells, white blood cells, and platelets – can be impaired in malnutrition and should be followed by the medical doctor. Blood electrolytes can be altered as a result of self-induced vomiting, laxative abuse, diuretic abuse, or starvation with refeeding, and can have dangerous effects on the cardiovascular system. As such, electrolytes should be monitored regularly in those actively engaged in their eating disorder behaviors or in the process of refeeding. A low blood glucose is a sign of significant starvation and usually requires hospitalization.

Medical Evaluation

When you visit a health care provider, you should expect him or her to take a detailed history and perform a thorough physical exam, looking for the various signs and symptoms of an eating disorder. A visit will include an accurate height and weight (clothes removed, wearing a paper gown) measurement, blood pressure and heart rate measurements in two positions (lying/sitting and standing), and a temperature assessment. A urine sample for urinalysis and an EKG (electrocardiogram) might be included as well. Your doctor should order the following blood tests:

  • Complete metabolic panel
  • Complete blood count with differential
  • Lipid panel
  • Magnesium and phosphorous
  • Thyroxine (T4) and Thyroid Stimulating Hormone (TSH)
  • Amylase and lipase
  • Vitamin D (25-hydroxy)

Additionally, a DEXA scan might be indicated to assess bone density. This should be ordered for anyone with a nine to twelve month history of anorexia nervosa, or in females, with a six month history of loss of menses. Adolescents should get this study at a center that reports a z-score, which takes into account average values for age and sex.

Based on findings of the complete medical evaluation, your doctor may prescribe medications for specific symptoms or supplements, like calcium and vitamin D. He or she may send you to a subspecialist for further evaluation, or may recommend more intensive treatment such as an eating disorder treatment program or even hospitalization for medical stabilization.

The most urgent task of medical care is correcting severe, life-threatening consequences of an eating disorder. Also of concern to your health care provider is addressing uncomfortable symptoms which could potentially interfere with psychological or nutritional therapy, as well as preventing long-term consequences that may persist after treatment. Your doctor knows, however, that the best “medicine” for most complications of your eating disorder is regular, nutritional eating without binging or purging.

 

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About The Author:

Dr. Kaplan is a pediatrician specializing in adolescent and young adult medicine, with over 17 years of experience serving the special medical needs of patients with eating disorders. She currently has a private practice in Calabasas, California specializing in the unique medical care of patients with eating disorders and is thrilled to be able to offer her medical expertise and passion to those who struggle with this complex disorder.

After receiving her medical degree from the U.C.L.A, she went on to a Pediatrics Residency at Kaiser Permanente, Los Angeles and a fellowship in Adolescent Medicine at Children’s Hospital, Los Angeles. She currently treats students at the Pepperdine University Student Health Center and serves as the Medical Director of the university Eating Disorder Treatment Team. In past years, she has worked at the Teen Clinic at Kaiser Permanente Medical Center Woodland Hills, where she helped establish and run the adolescent eating disorder clinic, and as medical supervisor at a local residential eating disorder treatment program.

She enjoys working with other professionals to establish individual treatment teams for each patient.

She lives in Encino, California with her husband and 3 teenage daughters.

References:

Mehler, P.S., & Anderson, A.E. (Eds.). (2017). Eating Disorders: A Guide to Medical Care and Complications. (3rd ed.). Baltimore: Johns Hopkins University Press.

Birmingham, C.L. & Beumont, P.J.V. (2004). Medical Management of Eating Disorders. Cambridge, United Kingdom: University Press, Cambridge

Campbell, K. & Peebles, R. (2014). Eating Disorders in Children and Adolescents: State of the Art Review. Pediatrics, 134(3). Published online 2014 Sept 1. doi: 10.1542/peds.2014-0194

Misra, M. & Klibanski, A. (2014). Anorexia Nervosa and Bone. Journal of Endocrinology, 221(3), R163-R176. doi: 10.1530/JOE-14-0039

Mehler, P.S., Krantz, M.J., & Sachs, K.V.,(2015).Treatments of Medical Complications of Anorexia Nervosa and Bulimia Nervosa, Journal of Eating Disorders, 3. Published online 2015 Apr 5. doi: 10.1186/s40337-015-0041-7

Written – 2018