National Eating Disorders Association

Identifying Eating Disorders: Medical Food for Thought

Philip S. Mehler, MD, FACP, FAEP and Russell Marx, MD

While both anorexia nervosa and bulimia nervosa are associated with a litany of medical complications , with timely and successful treatment the vast majority of these complications do not leave permanent residual sequelae (conditions that are the result of a previous disease). 

Eating disorders can be devastating diseases; anorexia nervosa and bulimia nervosa are both associated with excess mortality . Young people afflicted by anorexia nervosa and bulimia nervosa have mortality rates ten times that of age-matched controls. In anorexia nervosa the actual morbidity and mortality is secondary to excessive weight loss and malnutrition. However, in bulimia nervosa, the excessive mortality is attributable to the mode and frequency of purging behaviors. The mortality rate and medical complications associated with these diseases underscores an impelling need to diagnose early and intervene effectively.

In order to successfully detect and intervene, there must be attention paid to signs and symptoms which speak to the possibility of an underlying eating disorder. Herein are described potential hints to the presence thereof; “food for thought” which should prompt at least consideration that there may be lurking eating disordered behavior.

Medical Hints of Anorexia Nervosa

The incidence of medical complications increases as the weight loss becomes increasingly severe. In general, people with anorexia nervosa present with progressive weight loss or poor growth in the adolescent population. While they may attempt to hide their weight loss by wearing baggy clothes, ultimately such weight loss should prompt further inquiry. It is worth noting that patients with anorexia nervosa are not worried by their weight loss, whereas those with a medical cause for the weight loss often seek help precisely because unintentional weight loss is concerning to those afflicted. People with anorexia nervosa often try to avoid eating meals with family and friends to distract attention, and they often grossly over exercise at unusual hours of the day.

In the younger population, pubertal milestones are often not achieved in a timely manner, including the onset of menses or the development of secondary sexual characteristics such as facial hair and deepening voice in males or breast developments in females. Similarly, the cessation of previously established menses is also worthy of inquiry as to why this occurred, especially if accompanied by weight loss. Noting excessively dry skin, bluish discoloration of fingertips and new complaints of cold intolerance are also potential hints of anorexia nervosa, as are complaints of brittle nails, facial hair growth or thinning scalp hair. With regard to the gastrointestinal system, new complaints of early satiety during meals, difficulty swallowing, coughing while eating, bloating, constipation and upper abdominal pain may be due to the progression of complaints associated with anorexia nervosa.

Long bone fractures or back pain in the absence of significant trauma, i.e., “fragility fracture,” should raise suspicion for loss of bone mineral density (osteopenia-osteoporosis) in a young person with weight loss. Of note, of all the litany of medical complaints known to occur with anorexia nervosa, osteoporosis is the main one which, if undetected, can lead to permanent loss of bone mineral density and increased lifetime risks of fractures in the long bones and spine.

Bouts of fainting related to low blood pressure and slowed pulse are associated with anorexia nervosa. The insidious onset of exertional fatigue, inability to exercise, heart fluttering or chest pain can be due to cardiovascular complications of anorexia nervosa and sudden cardiac death is a known complication of severe anorexia nervosa.

Mood changes, inability to concentrate, suddenly poor academic performance and irritability are all seen with anorexia nervosa as a direct result of malnutrition and its effect on brain function. This can result in permanent cognitive decline if the weight loss is severe and persists for an extended period of time. 

Lastly, the finding on routine blood tests of hypoglycemia, low blood counts or elevated liver function tests may be due to anorexia nervosa. Also, abnormalities in thyroid function, low vitamin D levels or low sex hormone levels, such as testosterone or estradiol, may similarly be associated with anorexia nervosa.

Medical Hints of Bulimia

As opposed to anorexia nervosa where the progressive emaciation will call attention to the possible presence of anorexia nervosa, in bulimia nervosa people are able to hide their purging behaviors for long periods of time or weight loss might not be present. Yet, there are medically subtle hints that should raise suspicion of the presence of bulimia nervosa.

As mentioned above, the medical complications of bulimia nervosa are directly attributable to the mode and frequency of purging behaviors being utilized. Thus, with self-induced vomiters, excessive amounts of cavities, broken teeth and other dental problems  may be found due to the acidic content of vomitus. A history of recurrent scleral hemorrhage, nosebleeds or facial swelling from salivary gland enlargement may also be due to this purging behavior. The presence of acid reflux complaints in a young person should raise said concern since this is atypical in a young population.  

If the covert mode of purging involves stimulant laxative , potential signs of such might include rectal bleeding, hemorrhoids or excessive diarrhea for which no medical cause can be found. Rectal prolapse is another complication of laxative abuse—however, it is much rarer.

In addition, from a historical prospective, reports of abrupt leaving of the table during meals, odors of vomitus on the breath or in living quarters, along with the consumption of large amounts of calories without weight gain, should prompt inquiry for the presence of covert bulimia nervosa. Also, the presence or history of edema formation in the legs and feet could be due to a complex pathophysiological process which causes edema in people who purge.

Lastly, all modes of purging behaviors, when engaged in more than very infrequently, will result in dehydration and electrolyte abnormalities. Hypokalemia (low potassium), hyponatremia (low sodium) or metabolic alkalosis on a blood test, in an otherwise healthy individual, are fairly specific indicators of covert bulimia. Too often the urgent care center, emergency department or school health clinic provider will adeptly correct and replete the blood test abnormality, while not further inquiring why this person had it, especially given the intricate human safeguards to maintain blood electrolyte homeostasis.

Because eating disorders have serious medical consequences associated with them, it is important for family members to become increasingly familiar with the different signs and symptoms which might hint at the presence of these eating disorders. Moreover, because the disorders tend to affect younger individuals, at a time when from a medical vantage point the aforementioned complications would be very atypical, there is an impelling need for additional inquiry as to why a particular complication occurred in a very young person rather than merely treating the abnormality and failing to ask why. It is imperative that providers and family members “screen” for eating disorders by understanding medical signs and symptoms, so that early recognition and aggressive treatment can be rendered to prevent medical complications and chronicity.