This article is written more for medical professionals and was published in the Hamdan Medical Journal August 2014. The general message is that the long term physical side effects of eating disorders are only just surfacing, as this is a realtively new disease.
Read full article here: http://www.hamdanjournal.org/journal/index.php?journal=HAMDAN&page=article&op=view&path=312&path=pdf
Doctors today may not think to check bone density / screen for oesophageal cancer. If you can ignore the 'doctor speak' it makes for interesting reading. Cases of oesophageal cancer are already being diagnosed following bulimia. Attached to this page is a check list you may frind useful to use/give to your family doctor to ensure your health is cared for head to toe following a long term eating disorder.)
The Chronic Eating Disorder
As physicians, we witness diseases both in their acute and chronic manifestations. But do we always treat the acute and chronic portion with equal vigor?
Mental health conditions, such as eating disorders, are an example of a disease process with acute versus chronic management. I believe we have become accomplished at caring for the acute physiological presentations and chronic psychological presentations of an eating disordered individual. We are all aware of how to address severely low weight, re-feeding syndromes and more specifically manifestations of disordered potassium. We move on to arrange CBT, refer for psychiatric input and consider use of appropriate medications to ensure a patient’s long term mental health is improved.
As yet, however, little consideration has been made for the long term physical side effects of those suffering with eating disorders. Presently there are no standardized guidelines for their medical follow up either in the UK or overseas, despite long term physical abuse and starvation, often spanning significant developmental periods of a child and/or adolescent’s life.
It has taken until the 1970s for eating disorders to significantly enter the public eye and today it holds the highest mortality rate of all mental illnesses1. Over one half of teenage girls and almost a third of teenage boys use unhealthy weight control behaviours such as skipping meals/ fasting / vomiting/ taking laxatives and smoking cigarettes2. Therefore, as a relatively new, but certainly burdensome disease, the long term physical consequences are only starting to emerge.
In 2007, a ‘27 year old female presented with a one year history of progressively worsening epigastric pain, reflux, and fatigue. She reported a remote history of bulimia nervosa of approximately one year duration at the age of 17 along with smoking 10 cigarettes per day since the age of 20.’ Upper gastrointestinal endoscopy revealed a 10 mm ulcerated lesion with biopsies confirming a poorly differentiated adenocarcinoma3. Metastases were later identified.
It can be argued that in this particular case, the early onset of oesophageal adenocarcinoma is coincidental with the short history of bulimia. Smoking did also provide a further risk factor. Despite this, the pathophysiology does correspond. If corrosive agents such as alcohol can result in oropharngeal and oesophageal cancers, why have we not considered corrosive agents such as gastric acid such as in Barrett’s Oesophagus? Bulimics are known to vomit up to 3 or 4 times a day, 7 days a week, over lengthy periods of their life. Anorexia has an average duration of 7 years4 whilst it is common for bulimia sufferers to cover up their illness for 8-10 years5 before even seeking treatment.
Oesophagitis and Barrett's esophagus are known complications of Bulimia Nervosa6 and the latter, a pre-malignant state. By the end of 2007, 1 young male7, 2 women8 in their 30’s and a woman of 429 (with no further risk factors other than Bulimia Nervosa) had been documented with oesophageal cancer following a history of Bulimia. A further patient was reported to have developed adenocarcinoma of the stomach following a long history of self-induced vomiting10. Although no firm evidence that the link exists, it does suggest further investigation is warranted.
Compounding this, forced vomiting following episodes of bingeing, (quantities recorded up to three times the daily recommended calorific intake) has been known to cause hiatus hernias and hence again, significant ongoing GORD in women within their twenties. I myself suffered an eating disorder for over 10 years and went on to suffer severe gastritis. It took many GP visits and discussions with gastroenterologists to encourage them to consider endoscopy as it ‘did not fit new endoscopy guidelines.’ It was only then that a hiatus hernia could be diagnosed and treated.
This is just one example of the health risks surrounding chronic eating disorder sufferers. Also to be considered are the consequences of secondary amenorrhoea on fertility11, bone health (A study completed in 2001 showed evidence of osteopenia in 54.2% and osteoporosis in 20.8% of all anorexic patients involved12) and general patient well being.
Further still, glucose intolerance following disordered eating, dental caries following vomiting, cathartic colon following laxative abuse13, arrhythmias and thyroid dysfunction following abuse of thyroxine/diet pills14. The list of established physical defects following eating disorders is long and yet presently not recognised amongst many healthcare professionals.
As primary care practitioners will largely be the medical providers for the chronic eating disorder sufferer, I feel emphasis should be placed on ensuring their confidence and awareness of emerging long term physical side effects of such a disease. A proforma or national guideline could be trialed within GP clinics to assist with this, including the most common side effects to look out for and how they may present. It may also be helpful to include local training from psychiatrists and psychologists who regularly meet those suffering with chronic eating disorders to help understand the battles faced following such a long term abusive disease.
Websites such as b-eat.co.uk and something-fishy.org have experienced success in trying to support and educate patients and their families outside of our consultation rooms. It may be useful to direct patients (and possibly ourselves) towards such sites. I have recently begun to produce my own website www.midnightfeast.com which has a section specifically targeted for educating doctors.
Be aware that eating disorders can be chronic and the side effects associated with eating disorders are likely to become more and more apparent as sufferers age. Increasing our awareness and knowledge now may help prevent these patients endure further disabling conditions in the future.
Dr Jenna Burton
DHA – P - 0069319
1 American Journal of psychiatry, vol. 152 (7), July 1995, P.1073-1074, Sullivan, Patrick F.
2 Can we simultaneously work toward the prevention of obesity and eating disorders in children and adolescents? Newmark-Sztainer, D(2005)
4 Risk and protective factors for juvenile eating disorders (2003.) Steiner H, Kwan W, Shaffer TG, Walker S, Miller S, Sagar A, Lock J.
5 Gaskill, D & Sanders, F. (2000). The Encultured Body: Policy Implications for healthy body image and disordered eating behaviours. Faculty of Queensland University of Technology.
6 F Mehler PS, Crews C, Weiner K: Bulimia: medical complications. J Womens Health (Larchmt) 2004, 13(6): 668-675.
7 HNavab F, Avunduk C, Gang D, Frankel K: Bulimia nervosa complicated by Barrett's esophagus and esophageal cancer. Gastrointest Endosc 1996, 44(4): 492-494.
8 GMullai N, Sivarajan KM, Shiomoto G: Barrett esophagus. Ann Intern Med 1991, 114(10): 913
9 Buyse S, Nahon S, Tuszynski T, Delas N: Bulimia nervosa as a risk factor for squamous cell carcinoma of the esophagus?
Am J Gastroenterol 2003, 98(6):1442-1443
10 Walker ES: Bulimia and gastric cancer. Ann Intern Med 1985,103(2): 305
11 J Easter A, Treasure J, Micali N. Fertility and prenatal attitudes towards pregnancy in women with eating disorders: results from the Avon Longitudinal Study of Parents and Children. BJOG 2011; DOI: 10.1111/j.1471-0528.2011.03077
12 J Clin Endocrinol Met. 2001 Nov;86(11):5227-33.Osteoporosis in eating disorders: a follow-up study of patients with anorexia and bulimia nervosa. Zipfel S, Seibel MJ, Löwe B, Beumont J, Kasperk C, Herzog W.
13 K Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed.
14 L Thyroxine Abuse: An Unusual Case of Thyrotoxicosis in Pregnancy H. Wark, E.M. Wallace‡, S. Wigg§, C. TippettArticle first published online: 28 JUN 2008 DOI: 10.1111/j.1479-828X.1998.tb03008.x