Medical Complications of Anorexia Nervosa

Jia Liu, Jeff Hollis, Kara Leach, Millie Plotkin, Philip Sydney Mehler


Anorexia nervosa (AN) is a mental illness which is associated with many different medical complications. A comprehensive medical literature review of the medical complications of AN was undertaken using relevant search terms on PubMed to prepare this manuscript. We demonstrate that every body system is adversely affected by the ravages of AN. As the body mass index becomes progressively lower, the number and acuity of these medical complications increase.  No body system is ultimately immune to medical complications, which most commonly impact the cardiac, gastrointestinal, and endocrine systems. AN has the highest mortality of any psychiatric illness.  About half of the excess mortality risk associated with AN is due to the medical complications which are inextricably tied to AN.  Nutritional rehabilitation and weight restoration attenuate and reverse the long-term medical complications.


anorexia nervosa, medical complications, weight restoration

Full Text:

 Subscribers Only


Klump KL, Bulik CM, Kaye WH, Treasure J, Tyson E. Academy for Eating Disorders position paper: eating disorders are serious mental illnesses. Int J Eat Disord. 2009;42(2):97-103.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-V). American Psychiatry Press, Washington, DC.

Fichter MM, Quadflieg N, Crosby RD, Koch S. Long-term outcome of anorexia nervosa: results from a large clinical longitudinal study. Int J Eat Disord. 2017;50(9):1018-30.

Murray SB, Quintana DS, Loeb KL, Griffiths S, Le Grange D. Treatment outcomes for anorexia nervosa: A systematic review and meta-analysis of randomized controlled trials. Psychol Med. 2019;49(4):535-44.

Spaulding-Barclay MA, Stern J, Mehler PS. Cardiac changes in anorexia nervosa. Cardiol Young. 2016; 26(4):623-8.

Kastner S, Salbach-Andrae H, Renneberg B, et al. Echocardiographic findings in adolescents with anorexia nervosa at beginning of treatment and after weight recovery. Eur Child Adolesc Psychiatry. 2012; 21(1):15-21.

Docx MK, Gewillig M, Simons A, et al. Pericardial effusions in adolescent girls with anorexia nervosa: Clinical course and risk factors. Eat Disord. 2010; 18(3):218–25.

Kircher JN, Park MH, Cheezum MK, et al. Cardiac tamponade in association with anorexia nervosa: a case report and review of the literature. Cardiol J. 2012; 19(6):635-8.

Escudero CA, Potts JE, Lam PY, et al. Echocardiographic assessment of ventricular function during exercise in adolescent female patients with anorexia nervosa. J Am Soc Echocardiogr. 2019;32(3):394-403.e3.

Galetta F, Franzoni F, Cupisti A, et al. QT interval dispersion in young women with anorexia nervosa. J Pediatr. 2002; 140(4):456-60.

Almeida-Jones ME, Suntharos P, Rosen L, et al. Myocardial strain and torsion quantification in patients with restrictive-type anorexia nervosa. J Am Soc Echocardiogr. 2014; 27:B41–B42.

Johnson GL, Humphries LL, Shirley PB, Mazzoleni A, Noonan JA. Mitral valve prolapse in patients with anorexia nervosa and bulimia. Arch Intern Med. 1986; 146(8):1525–9.

Olivares JL, Vázquez M, Fleta J, et al. Cardiac findings in adolescents with anorexia nervosa at diagnosis and after weight restoration. Eur J Pediatr. 2005; 164(6):383-6.

Franzoni F, Galetta F, Cupisti A, et al. Ultrasonic tissue characterization of the myocardium in anorexia nervosa. Acta Paediatr. 2003;92(3):297–300.

Oflaz S, Yucel B, Oz F, et al. Assessment of myocardial damage by cardiac MRI in patients with anorexia nervosa. Int J Eat Disord. 2013; 46(8):862–6.

Lamzabi I, Syed S, Reddy VB, et al. Myocardial changes in a patient with anorexia nervosa: A case report and review of literature. Am J Clin Pathol. 2015; 143(5):734–7.

Farasat M, Watters A, Bendelow T, et al. Long-term cardiac arrhythmia and chronotropic evaluation in patients with severe anorexia nervosa (LACE-AN): A pilot study. J Cardiovasc Electrophysiol. 2020;31(2):432-9.

Biadi O, Rossini R, Musumeci G, et al. Cardiopulmonary exercise test in young women affected by anorexia nervosa. Ital Heart J. 2001; 2(6):462-7.

Lands L, Pavilanis A, Charge TD, et al. Cardiopulmonary response to exercise in anorexia nervosa. Pediatric Pulmonol. 1992; 13(2):101-7.

Kalla A, Krishnamoorthy P, Gopalakrishnan A, et al. Gender and age differences in cardiovascular complications in anorexia nervosa patients. Int J Cardiol. January 2017; 227:55-7.

Krantz MJ, Guadiani JL, Johnson VW, Mehler PS. Exercise electrocardiography extinguishes persistent junctional rhythm in a patient with severe anorexia nervosa. Cardiology. 2011; 120(4):217-20.

Kollai M, Bonyhay I, Jokkel G, Szonyi L. Cardiac vagal hyperactivity in adolescent anorexia-nervosa. Eur Heart J. 1994; 15(8):1113–8.

Shamim T, Golden NH, Arden M, Filiberto L, Shenker IR. Resolution of vital sign instability: an objective measure of medical stability in anorexia nervosa. J Adolesc Health. 2003; 32:73–7.

Sachs KV, Harnke B, Mehler PS, Krantz MJ. Cardiovascular complications of anorexia nervosa: A systematic review. Int J Eat Disord. 2016; 49(3):238-48.

Krantz MJ, Sabel AL, Sagar U, et al. Factors influencing QT prolongation in patients hospitalized with severe anorexia nervosa. Gen Hosp Psychiatry. 2012; 34(2):173–7.

Bomba M, Tremolizzo L, Corbetta F, et al. QT interval and dispersion in drug-free anorexia nervosa adolescents: a case control study. Eur Child Adolesc. Psychiatry 2018; 27:861-6.

Vaurs C, Rollin A, Berard E, Valet M, et al. QT interval is not prolonged in patients with eating disorders. Int J Cardiol. 2014; 177(1):134–5.

Facchini M, Sala L, Malfatto G, et al. Low-K+ dependent QT prolongation and risk for ventricular arrhythmia in anorexia nervosa. Int J Cardiol. 2006; 106(2):170–6.

Gupta MA, Gupta AK. Dissatisfaction with skin appearance among patients with eating disorders and non-clinical controls. Br J Dermatol. 2001; 145(1):110-3.

Strumia R. Bulimia and anorexia nervosa: cutaneous manifestations. J Cosmet Dermatol. 2002; 1(1):30-4.

Dessinioti C, Katsambas A, Tzavela E, et al. Erythema ab igne in three girls with anorexia nervosa. Pediatr Dermatol. 2016; 33(2):e149-50.

Mehler PS, Lezotte D, Eckel R. Lipid levels in anorexia nervosa. Int J Eat Disord. 1998; 24(2):217-21.

Kim ST, Kang JS, Baek JW et al. Acrodermatitis enteropathica with anorexia nervosa. J Dermatol. 2010; 37(8):726-9.

Glorio R, Allevato M, de Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Dermatol. 2000; 39(5):348-353.

Stacher G. Gut function in anorexia nervosa and bulimia nervosa. Scand J Gastroenterol. 2003; 38(6):573-87.

Norris ML, Harrison ME, Isserlin L, et al. Gastrointestinal complications associated with anorexia nervosa: a systematic review. Int J Eat Disord. 2016; 49(3):216-37.

Saleh JW, Lebwohl P. Metoclopramide-induced gastric emptying in patients with anorexia nervosa. Am J Gastroenterol. 1980;74(2):127–32.

Stacher G, Peeters TL, Bergmann H, et al. Erythromycin effects on gastric emptying, antral motility and plasma motilin and pancreatic polypeptide concentrations in anorexia nervosa. Gut. 1993;34(2):166-72.

Chun AB, Sokol MS, Kaye WH, Hutson WR, Wald A. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997; 92(10):1879-83.

Waldholtz BD, Andersen AE. Gastrointestinal symptoms in anorexia nervosa. A prospective study. Gastroenterology. 1990; 98(6):1415-9.

Rosen E, Sabel AL, Brinton JT, et al. Liver dysfunction in patients with severe anorexia nervosa. Int J Eat Disord. 2016 ;49(2):151-8.

Harris RH, Sasson G, Mehler PS. Elevation of liver function tests in severe anorexia nervosa Int J Eat Disord. 2013;46(4):369-74.

Rosen E, Bakshi N, Watters A, Rosen HR, Mehler PS. Hepatic complications of anorexia nervosa. Dig Dis Sci. 2017;62(11):2977-81.

Morris LG, Stephenson KE, Herring S, Marti JL. Recurrent acute pancreatitis in anorexia and bulimia. JOP. 2004 ;5(4):231-4.

Wesson RN, Sparaco A, Smith MD. Chronic pancreatitis in a patient with malnutrition due to anorexia nervosa. JOP. 2008 ;9(3):327-31.

Adson DE, Mitchell JE, Trenkner SW. The superior mesenteric artery syndrome and acute gastric dilatation in eating disorders: a report of two cases and a review of the literature. Int J Eat Disord. 1997 ;21(2):103-14.

Mascolo M, Dee E, Townsend R, Brinton JT, Mehler PS. Severe gastric dilatation due to superior mesenteric artery syndrome in anorexia nervosa. Int J Eat Disord. 2015;48(5):532-4.

Osequeda de Rodriguez EJ, Hernández-Villegas AC, Serralde-Zúñiga AE, Reyes-Ramírez ALDC.. The two sides of superior mesenteric artery syndrome treatment: conservative or surgical management? Nutr Hosp. 2017;34(4):997-1000.

Albano MN, Costa Almeida C, Louro JM, Martinez G. Increase body weight to treat superior mesenteric artery syndrome. BMJ Case Rep. June 2017;2017.

Miller KK. Endocrine dysregulation in anorexia nervosa update. J Clin Endocrinol Metab. 2011;96(10):2939-49.

Lawson EA, Klibanski A. Endocrine abnormalities in anorexia nervosa. Nat Clin Pract Endocrinol Metab. 2008;4(7):407-14.

Schorr M, Miller KK. The endocrine manifestations of anorexia nervosa: mechanisms and management. Nat Rev Endocrinol. 2017;13(3):174-86.

Biller BM, Saxe V, Herzog DB, et al. Mechanisms of osteoporosis in adult and adolescent women with anorexia nervosa. J Clin Endocrinol Metab. 1989;68(3):548-54.

Gold PW, Gwirtsman H, Avgerinos PC, et al. Abnormal hypothalamic-pituitary-adrenal function in anorexia nervosa. Pathophysiologic mechanisms in underweight and weight-corrected patients. N Engl J Med. 1986;314(21):1335-420.

Lawson EA, Donoho DA, Miller KK, et al. Hypercortisolemia is associated with severity of bone loss and depression in hypothalamic amenorrhea and anorexia nervosa. J Clin Endocrinol Metab. 2009;94(12):4710-6.

Misra M, Miller KK, Almazan C, et al. Alterations in cortisol secretory dynamics in adolescent girls with anorexia nervosa and effects on bone metabolism. J Clin Endocrinol Metab. 2004 ;89(10):4972-80.

Kiyohara K, Tamai H, Takaichi Y, Nakagawa T, Kumagai LF. Decreased thyroidal triiodothyronine secretion in patients with anorexia nervosa: influence of weight recovery. Am J Clin Nutr. 1989;50(4):767-72.

Croxson MS, Ibbertson HK. Low serum triiodothyronine (T3) and hypothyroidism in anorexia nervosa. J Clin Endocrinol Metab. 1977;44(1):167-74.

Miyai K, Yamamoto T, Azukizawa M, Ishibashi K, Kumahara Y. Serum thyroid hormones and thyrotropin in anorexia nervosa. J Clin Endocrinol Metab. 1975;40(2):334-8.

Gold PW, Kaye W, Robertson GL, Ebert M. Abnormalities in plasma and cerebrospinal-fluid arginine vasopressin in patients with anorexia nervosa. N Engl J Med. 1983;308(19):1117-23.

Kanbur N, Katzman DK. Impaired osmoregulation in anorexia nervosa: review of the literature. Pediatr Endocrinol Rev. 2011;8(3):218-21.

Grinspoon S, Thomas E, Pitts S, et al. Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Ann Intern Med. 2000;133(10):790-4.

Lawson EA, Miller KK, Bredella MA, et al. Hormone predictors of abnormal bone microarchitecture in women with anorexia nervosa. Bone. 2010;46(2):458-63.

Strokosch GR, Friedman AJ, Wu SC, Kamin M. Effects of an oral contraceptive (norgestimate/ethinyl estradiol) on bone mineral density in adolescent females with anorexia nervosa: a double-blind, placebo-controlled study. J Adolesc Health. 2006;39(6):819-27.

Misra M, Katzman D, Miller KK, et al. Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. J Bone Miner Res. 2011;26(10):2430-8.

Golden NH, Iglesias EA, Jacobson MS, et al. Alendronate for the treatment of osteopenia in anorexia nervosa: a randomized, double-blind, placebo-controlled trial. J Clin Endocrinol Metab. 2005;90(6):3179-85.

Fazeli PK, Wang IS, Miller KK, et al. Teriparatide increases bone formation and bone mineral density in adult women with anorexia nervosa. J Clin Endocinol Metab. 2014; 99(4):1322-9.

Drabkin A, Rothman MS, Wassenaar E, Mascolo M, Mehler PS. Assessment and clinical management of bone disease in adults with eating disorders: a review. J Eat Disord. December 2017;5:42.

Rylander M, Brinton JT, Sabel AL, Mehler PS, Gaudiani JL. A comparison of the metabolic complications and hospital course of severe anorexia nervosa by binge-purge and restricting subtypes. Eat Disord. 2017;25(4):345-57.

Cleary BS, Gaudiani JL, Mehler PS. Interpreting the complete blood count in anorexia nervosa. Eat Disord. 2010;18(2):132-9.

De Filippo E, Marra M, Alfinito F, et al. Hematological complications in anorexia nervosa. Eur J Clin Nutr. 2016;70(11):1305-8.

Bredella MA, Fazeli PK, Miller KK, et al. Increased bone marrow fat in anorexia nervosa. J Clin Endocrinol Metab. 2009;94(6):2129-36.

Takeshima M, Ishikawa H, Kitadate A, et al. Anorexia nervosa-associated pancytopenia mimicking idiopathic aplastic anemia: a case report. BMC Psychiatry. May 2018;18:150.

Charania RS, Kern WF, Charkrabarty S, Holter J. Successful management of gelatinous transformation of the bone marrow in anorexia nervosa with hematopoietic growth factors. Int J Eat Disord. 2011;44(5):469-72.

Osgood #, Muddassir S, Jaju M, et al. Starvation marrow- gelatinous transformation of bone marrow. J Community Hosp Intern Med Perspect. 2014;4(4).

Hariz A, Hamdi MS, Boukhris I, et al. Gelatinous transformation of bone marrow in a patient with anorexia nervosa: an uncommon but reversible etiology. Am J Case Rep. December 2018;19:1449-52.

Hütter G, Ganepola S, Hofmann WK. The hematology of anorexia nervosa. Int J Eat Disord. 2009;42(4):293-300.

Polli N, Scacchi M, Giraldi FP, et al. Low insulin-like growth factor 1 and leukopenia in anorexia nervosa. Int J Eat Disord. 2008;41(4):355-59.

Corbetta F, Tremolizzo L, Conti E, et al. Paradoxical increase of plasma b12 and folates with disease severity in anorexia nervosa. Int J Eat Disord. 2015;48(3):317-22.

Sabel AL, Gaudiani JL, Statland B, Mehler PS. Hematological abnormalities in severe anorexia nervosa. Ann Hematol. 2013;92(5):605-13.

Mehler PS, Blalock DV, Walden K, et al. Medical findings in 1,026 consecutive adult inpatient-residential eating disordered patients. Int J Eat Disord. 2018;51(4):305-13.

Paszthy B, Svec P, Vasarhelyi B, et al. Investigation of regulatory t cells in anorexia nervosa. Eur J Clin Nutr. 2007;61(11):1245-9.

Brown RF, Bartrop R, Beumont P, Birmingham CL. Bacterial infections in anorexia nervosa: delayed recognition increases complications. Int J Eat Disord. 2005;37(3):261-5.

Murciano D, Rigaud D, Pingleton S, et al. Diaphragmatic function in severely malnourished patients with anorexia nervosa. Am J Respir Crit Care Med. 1994;150(6 Pt. 1):1569-74.

Kerem NC, Riskin A, Averin e, Srugo I, Kugelman A. Respiratory acidosis in adolescents with anorexia nervosa hospitalized for medical stabilization: a retrospective study. Int J Eat Disord. 2012;45(1):125-30.

Kerem NC, Averin E, Riskin A, et al. Respiratory functions in adolescents hospitalized for anorexia nervosa: a prospective study. Int J Eat Disord. 2012;45(3):415-22.

Gonzalez-Moro JMR, de Miguel-Diez J, Paz-Gonzalez L, et al. Abnormalities of the respiratory function and control of ventilation in patients with anorexia nervosa. Respiration. 2003;70(5):490-5.

Ziora K, Ziora D, Oswiecimska J, et al. Spirometric parameters in malnourished girls with anorexia nervosa. J Physiol Pharmacol. 2008;59 Suppl 6:801-7.

Winick, Myron. Hunger Disease: Studies by the Jewish Physicians in the Warsaw Ghetto. Edited by Myron Winick; Translated from the Polish by Martha Osnos. Wiley, 1979.

Coxson HO, Chan IH, Mayo JR, et al. Early emphysema in patients with anorexia nervosa. Am J Respir Crit Care Med. 2004;170(7):748-52.

Ryan FC, Whittaker SK, Road JD. Ventilatory dysfunction in severe anorexia nervosa. Chest. 1992;102(4):1286-8.

Sahebjami H, Domino M. Effects of starvation and refeeding on elastase-induced emphysema. J Appl Physiol. 1989;66(6):2611-6.

Jensen VM, Støving RK, Andersen PE. Anorexia nervosa with massive pulmonary air leak and extraordinary propagation. Int J Eat Disord. 2017;50(4):451-3.

Murayama S, Gibo S. Spontaneous pneumomediastinum and macklin effect: overview and appearance on computed tomography. World J Radiol. 2014;6(11):850-4.

Biffl WL, Narayanan V, Gaudiani JL, Mehler PS. The management of pneumothorax in patients with anorexia nervosa: a case report and review of the literature. Patient Saf Surg. 2010;4(1):1.

Holmes SR, Sabel AL, Gaudiani JL. Prevalence and management of oropharyngeal dysphagia in patients with severe anorexia nervosa: a large retrospective review. Int J Eat Disord. 2016;49(2):159-66.

Holmes SR, Gudridge TA, Gaudiani JL, Mehler PS. Dysphagia in severe anorexia nervosa and potential therapeutic intervention: a case series. Ann Otol Rhinol Laryngol. 2012;121(7):449-56.

Titova O, Hjorth OC, Schioth HB, Brooks SJ. Anorexia nervosa is linked to reduced brain structure in reward and sorratosensory regions: a meta-analysis of VBM studies. BMC Psychiatry. April 2013;13:110-6.

Frank GKW, Shott ME, Hagman JO, Yang TT. Localized brain volume and white matter integrity alterations in adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatry. 2013;52(10):1066-75.

King JA, Frank GKW, Thompson PM, Ehrlich S. Structural neuroimaging of anorexia nervosa: future directions in the quest for mechanisms underlying dynamic alterations. Biol Psychiatry. 2018;83(3):224-34.

Miles AE, Voineskos AN, French L, Kaplan AS. Subcortical volume and cortical surface architecture in women with acute and remitted anorexia nervosa: An exploratory neuroimaging study. J Psychiatr Res. July 2018;102:179-85.

Bang L, Rø Ø, Endestad T. Normal white matter microstructure in women long-term recovered from anorexia nervosa: a diffusion tensor imaging study. Int J Eat Disord. 2018;51(1):46-52.

Hestad KA, Weider S, Wilsen KB, Indredavik MS, Sand T. Increased frontal electroencephalogram theta amplitude in patients with anorexia nervosa compared to healthy controls. Neuropsychiatri Dis Treat. September 2016;12:2419-23.

Gelaye B, Sacco S, Brown WJ, Nitchie HL, Ornello R, Peterlin BL. Body composition status and the risk of migraine: A meta-analysis. Neurology. 2017;88(19):1795-804.



  • There are currently no refbacks.
Copyright 2016. All rights reserved.