Anorexia nervosa can cause lifelong endocrine problems
Overweight and obese patients are not the only patient group that needs lifestyle modification.
Among all the conditions that endocrinologists may encounter, anorexia nervosa presents a serious problem, leading to death in about 10% of patients with the disease.
Because of the condition’s unique combination of extreme mental and physical illness, it is often difficult to diagnose and more difficult to treat.
Although few patients will be referred to an endocrinologist with a diagnosis of anorexia nervosa, endocrinologists should be aware of symptoms and consequences of the disease when examining patients.
“Many patients early in the syndrome present only with amenorrhea,” Michelle P. Warren, MD, professor of medicine and obstetrics and gynecology at Columbia University Medical Center, told Endocrine Today. “If endocrinologists suspect an eating disorder, early intervention is often simple.”
Warren said that if a patient is not too far into denial, guidance from a nutritionist may be enough to reverse the condition in its earliest phases.
“Too often, however, the diagnosis is missed,” Warren said. One possible reason is that the subject of anorexia nervosa and anorexic patients is not thoroughly covered in endocrine fellowships. It is obvious when a patient has lost a lot of weight; however, because patients and patients’ families are often in denial about the presence of an eating disorder, the diagnosis may be hard to make, Warren said.
When to diagnose
It is important to be on the lookout for large drops in weight. “Once the weight starts falling to below 85% of normal, there are dangerous medical conditions that may ensue,” Warren said. “You have to make a decision about how stable the patient is.”
Warren said that often if a patient continues to lose weight and refuses to see a psychiatrist they are falling into a “danger zone.”
“These patients are not going to respond to outpatient directive therapy without some severe intervention,” she said. If the weight continues to decrease the patient will probably have to be hospitalized. “Getting them to agree is sometimes difficult, but endocrinologists need to be aware of where the danger zone is.”
Patients whose weight falls below 85% of ideal body weight are known to have sudden arrhythmias, in addition to other dangerous complications of anorexia nervosa.
What to look for
If an endocrinologist has a patient with anorexia nervosa or one who is recovering from anorexia nervosa there are certain associated conditions to look for, Warren said.
“The most severe and enduring [condition] is osteoporosis,” she said. “These patients have a significant loss of bone that puts them at risk for fractures and progressive osteoporosis when they hit menopause.”
Warren said that the incidence of fractures in this population when they are younger is up to eight times that of the normal population. “There is a high incidence of vegetarianism along with anorexia nervosa that may also contribute to osteoporosis because of fat avoidance and low protein, calcium and vitamin D intake,” Warren said. This problem is best treated nutritionally. With a return to a normal weight significant increases in bone density are seen and fractures will also stop, she said.
In addition, a lack of estrogen may also contribute to this extensive bone loss. Hormone replacement or oral contraceptives can be used as a secondary measure but appear to help only if that patient is eating well and near a normal weight.
Another common problem in women with anorexia nervosa is infertility. Many patients with eating disorders will not ovulate. Warren said that although patients may present with a fertility problem, endocrinologists should be sure that any underlying nutritional problem is resolved before a patient is encouraged to conceive. “You can help patients to conceive using drugs, but it is really not recommended until they have a normal BMI,” she said. “There is a higher incidence of miscarriage in these patients and higher incidence of low-weight babies due to intrauterine growth retardation.”
If the return to a normal weight does not solve the fertility problems, endocrinologists should also consider a premorbid hormonal imbalance. Warren said that some patients who have had anorexia nervosa may also have an anovulatory disorder like polycystic ovary syndrome. “Patients are overweight and then lose too much weight,” she said. “As they gain back weight they return to their premorbid anovulatory state and although they may be making estrogen, they are not ovulating on a regular basis.”
Patients with anorexia nervosa may also present with symptoms that appear to be endocrine disorders but may in fact be a result of altered nutritional intake.
“Sometimes patients have low thyroxine and triiodothyronine,” Warren said. “They present with pseudohypothyroidism. It may be very mild, but endocrinologists have to be aware that this syndrome may present and it is not really hypothyroidism. It is just a reaction to severe nutritional deprivation.”
In addition, because patients with eating disorders may be compulsive water drinkers, they may also develop hyponatremia. “You have to look very carefully at how much [water] they are drinking,” she said.
Finally, if endocrinologists notice an increase in the levels of cortisol in these patients, it may be an adverse effect of nutritional deprivation as well. According to Warren, the increase in cortisol is normally small and should revert back to normal once patients are re-fed.
In all, endocrinologists have to be aware of the nutritional component involved in anorexia nervosa or any eating disorders. Warren recommended soliciting the help of a nutritionist and of a psychiatrist or psychologist who specializes in eating disorders.
This need may be even greater among men with anorexia nervosa. “Men [with anorexia nervosa] tend to have a higher incidence of severe psychopathology, severe obsessive compulsive disorder and schizophrenia,” Warren said. – by Leah Lawrence