What is Anorexia and how to handle it

Introduction & Types

Anorexia Nervosa is a devastating eating disorder that is characterized by weight loss, an inability to maintain an appropriate body weight, fear of weight gain, and a distorted self-image of one’s body. Anorexia has the potential to be life-threatening and is linked to mental health conditions like anxiety and depression. 

According to the NIMH “the lifetime prevalence of anorexia nervosa in adults was 0.6%…with the prevalence of anorexia nervosa being three times higher among females (0.9%) than males (0.3%).”

Types of Anorexia Nervosa:

 There are two major types of anorexia – binge/purge and restrictive. 

  • Binge/purge anorexia is when the individual eats an increased amount of food in one sitting, and then, due to psychological feelings of guilt and remorse, will purge.  Binging is the consumption of an increased massive amount of food.  Purging is compensation through vomiting, excessive exercise, or the use of laxatives as a means to induce diarrhea.  
  • The second most common type of anorexia is restrictive. When an individual suffers from restrictive anorexia he/she will severely limit their caloric intake and only consume a minimal amount of food.  These individuals are slowly starving themselves by under consuming calories and food.  The key takeaway in identifying a patient who has anorexia is to be aware of their irrational fear of gaining weight, their refusal to consume foods, or their abnormal eating habits.

Causes of Anorexia Nervosa:

Anorexia Nervosa is a complex eating disorder. It stems from biologic, environmental/social and psychological factors.  It can affect both men and women, though statistics have proven that it affects women more often.  Many professionals believe that pre-pubescent patients who develop anorexia do so in an effort to compensate for their inability to control their own lives. These patients seem to lack autonomy, and feel that the only control they have is what they place into their body.  Having control over their food intake and body weight allows for these patients to exert their autonomy in an altered fashion. 

Another common cause of anorexia nervosa is the body image that has been paraded around in magazines and in Hollywood.  The notion that women/men who are a size 0 is normal, and that women who are a size 6 are overweight is an unacceptable perception of the average women/man. Today’s society has set the standard for poor self-image and unattainable expectations. While there have yet to be any published studies on this specific relationship, there have been many personal interviews of those who are in recovery from anorexia that have identified this reason as the root of their disease.  Other environmental factors that may contribute to the development of anorexia nervosa include societal expectation for thin individuals to be a job duty.  For example, in specific industries such as modeling, ballet or other weight-restricted careers there are certain weight requirements that are placed within the contract before hiring.  These types of industries indirectly end up promoting eating disorders. Peer pressure can also be a driving environmental factor for adolescent and teenagers developing anorexia nervosa. 

Biological factors that may contribute to the development of anorexia nervosa include  hormonal imbalance and nutritional/vitamin deficiencies. Anorexia nervosa may have a genetic predisposition, but this relationship is still being heavily researched.  There have been some recent studies that have suggested that twins and triplets may have a higher risk of anorexia if the other twin or one of the other triplets has the disorder.  There are even studies to suggest that the serotonin transporter gene may have specific variations that suggest the relationship between genetics and anorexia.

There are certain medical conditions that have also been linked to anorexia as well.  A few of those disorders usually involve hormonal imbalances or autoimmune diseases.  For example, there has been an association between the development of anorexia and the comorbidity of congenital adrenal hyperplasia and/or systemic lupus erythematosus.

These are just a few of the causes of anorexia.  It is important to remember that there are many social, environmental, biologic, and/or psychological influences that can predispose patients to the development of anorexia nervosa.  It is important to consult a physician to determine if you or someone you know is at risk of developing anorexia. It is a disorder that must be diagnosed in order to prevent life-threatening complications.  Therefore, it is imperative to speak with a healthcare professional to determine the appropriate individualized care necessary for successful treatment of this disease.

Signs/Symptoms of Anorexia Nervosa:

There are many signs and symptoms to be aware of if anorexia nervosa is the suspected disease.  Signs include-

  • Hypotension
  • Bradycardia
  • Hypothermia
  • Dry skin
  • Lanugo body hair
  • Atrophy of breasts
  • Thinning hair
  • Peripheral edema
  • Lanugo body hair (thin, soft non-pigmented hair)

Patients with anorexia may develop hypercarotenemia, which is the orange pigmentation of the skin. It is thought to be a result of either increased carotene and vitamin A intake, or a defect in which the utilization or metabolism of Vitamin A is impaired.  

Acrocyanosis is another sign that can be seen in anorexia nervosa.  It is a blueish color change of extremities that results from the small vessels in the fingers and toes constricting, which is called vasospasm.  The result is that less oxygen delivered through the blood is getting to those peripheral areas. Swelling of the parotid and/or submandibular glands, loss of muscle mass, low blood glucose, decreased parathyroid hormone levels, increased liver function, and diminished WBC count are also signs/symptoms of anorexia. 

When trying to evaluate an individual to determine if they are exhibiting warning signs of anorexia, it is important to pay attention to their behavior over time. Noticing if an individual is dieting chronically or is severely underweight can be the first clue that something isn’t quite right.

Another sign is if the individual has a severe obsession with counting calories or counting grams of fat and refuses to eat. Or if the individual becomes ritualistic when eating their foods. Such behaviors include hiding food, or always eating alone.  

Other behavioral changes that can be observed include flat affect, depressed mood, lethargy, amenorrhea and/or avoidance of activities with family or friends.  If any of these signs/symptoms are noticed, it is important to consult with a healthcare provider to determine the underlying cause so that appropriate treatment can be initiated. 

Diagnosis of Anorexia Nervosa:

Diagnosis can be difficult because in many instances it is the family that wants the patient to seek help, and the patient may be resistant or refuse treatment. It is imperative to get the patient to be open to help and that first step is through diagnosis. 

The length of time that the individual has been suffering undiagnosed with this disorder will determine the amount of complications that may be faced.  For example, if the patient has been suffering from this disease for several years, they will most likely have chronically low electrolyte levels and decreased protein levels.  

These levels can be tested for with routine lab work which may include: CBC, CMP and an urinalysis.  It is imperative to begin with a physical examination by a physician, as well as a mental status evaluation. 

Because anorexia is considered to be a clinical diagnosis with a psychological component, the criteria for diagnosis must meet the DSM-5 requirements, which are as follows:

  • Restriction of food relative to what is necessary to significantly lowered body weight. Significantly low weight is defined as weight that is less than what is minimally required. 
  • Intense fear of gaining weight or becoming overweight.  This behavior interferes with the patient’s ability to thrive because they are already skinny and refuse to eat because of this fear.  
  • A disillusioned idea of what their body actually looks like.  
  • A belief that they are fat, even though they are significantly underweight.  
  • Not acknowledging the severity of their disease, and persistently defending their low body weight. 

If the individual meets these criteria set forth by the DSM-5, then they can be diagnosed with anorexia nervosa. This is a serious diagnosis that must be addressed before severe complications arise. 

Complications of Anorexia Nervosa:

Because anorexia nervosa is an eating disorder it affects many different organ systems.  The consumption of food and liquids is essential to life, and the functioning of all organ systems within the body.  Malnutrition and vitamin/mineral deficiencies are a common complication associated with anorexia.  Starvation leads to protein deficiency and complications in the cardiovascular, renal, gastrointestinal, neurological, endocrine, integumentary, hematologic and reproductive systems.

Cardiovascular system disturbances are responsible for most of the deaths associated with anorexia nervosa.  These worrisome signs include:  hypotension, bradycardia, and decreased left ventricular mass.  Patients who have this disease will likely be hypokalemic.  Low potassium (hypokalemia) can result in QT prolongation, which in turn can result in heart arrhythmias and death.

Endocrinological system disturbances include amenorrhea, infertility, euthyroid sick syndrome, diabetes insipidus, and osteopenia (bone loss).  Gastrointestinal system complications can include constipation, prolonged GI transit, and gastric atrophy. 

Neurological system disturbances can include atrophy of the brain, especially the cerebral portions, loss of brain volume, generalized muscle weakness, and fatigue.  Integumentary system disturbances such as dry scaly skin with brittle hair and nails can also result.  Renal (Kidney) system complications may include dehydration and kidney damage, that results in diminished urine output.  Electrolyte disturbances are very serious and can lead to life-threatening complications.  Vomiting and diarrhea can increase the imbalance of these electrolytes.  For example, vomiting results in the loss of potassium, and low potassium can result in sudden cardiac death.  Calcium, magnesium, and phosphorous are also affected by anorexia nervosa.

These are only a few of the complications that can arise from starvation and nutritional deficiencies secondary to anorexia.  It is a serious disease that must be addressed by a healthcare provider.

Treatment & Prognosis Treatment:

After diagnosis, the goal is to prevent the associated complications that can lead to organ damage or even death. Treatment begins by addressing the underlying metabolic conditions.  It is imperative that these be addressed slowly to avoid the re-feeding syndrome.  

Re-feeding syndrome is life-threatening, and results in heart failure, decreased phosphate, and dangerous changes in potassium, sodium and magnesium.  It is essential that a physician and nutritionist collaborate so that re-feeding can occur without fear of re-feeding syndrome occurring.  

Cardiac failure is most worrisome within the first 2 weeks of re-feeding.  The heart cannot take the sudden increased metabolic demand that occurs with eating after a long period of starving.  Therefore, it is essential that re-feeding occur slowly and with a daily weight gain of 0.2-0.4 kg to reduce the risks of developing this syndrome.

Addressing the psychological component of anorexia nervosa is essential to treating this disease.  Speaking with a psychiatrist to determine an individualized therapy treatment plan that will focus on the underlying issues will allow for sustained recovery.  Involving the patient and their loved ones is a key factor in successful treatment. Family and loved ones can offer support and keep an eye on the patient for relapses in behavior. 

Pharmacotherapy can also be useful in individual cases.  There have been studies that have shown that the use of Fluoxetine in these patients has offered some benefit.  Olanzapine, with adjunct therapy, has also been shown to be useful in treatment.  Each patient is different, so an individualized treatment plan must be established to maximize the probability of a successful recovery.

Prognosis

There is an approximately 50% chance of patients maintaining long term recovery;
which is why it is important people with anorexia have close follow ups. Suicide is a major concern in patients who are suffering from this disease.

Patients who have the disease after age 11 and prior to adulthood have a more favorable outcome than those who were younger than age 11 or who develop the disease in adulthood.  Prognosis is based on the age of onset, length of symptoms, underlying dysfunctional family relationships and inpatient care.

Each individual is different and thus care must be individualized.  With the appropriate intervention and treatment, patients can recover.  It is imperative to remember this is a lifelong disease that must be continually treated through therapy.  Treating the underlying issues will help to prevent the recurrence or development of anorexia nervosa.

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