Co-occurring Conditions with Eating Disorders: What to Know

By Reva Schlanger MS, RD, LD

Most people know that there are serious medical consequences with eating disorders, however there are some conditions are more rare and harder to look out for (plus less literature on). Lately in our practice we have been seeing some clients struggling with certain conditions that professionals in the field unfortunately may miss. It is important for clinicians and clients alike to learn about all the different possible conditions/diagnoses a person can have as to protect the safety and well-being of the client. As we always say- get curious!  Do your research (from scientific research articles not “dr. google”) and advocate for yourself. Below are 4 diagnoses/conditions that may accompany your eating disorder and are explained in greater detail. If you are concerned about yourself or a loved one having one of these conditions, reach out to your team to discuss it further. It is a great learning opportunity for everyone!

1. Superior Mesenteric Artery Syndrome or SMA Syndrome

What happens in this case is that there is a loss of the fat pad that normally surrounds the SMA, as a direct result of severe weight loss. This narrows the angle between two blood vessels and blocks the duodenum (part of the small intestine). The SMA syndrome symptoms start with upper abdominal pain soon after eating along with early satiety, nausea, and vomiting. Abdominal CT scan or an upper GI series are the tools used to diagnose SMA syndrome which essentially means that food cannot get through the gastrointestinal tract. You would have to go to the ER and advocate to get a scan for your your GI tract as this is not routinely done. People with this rare syndrome will typically require tube feeding to bypass the blocked duodenum and regain weight. Once the person starts to regain weight, the fat pad will come back, and she/he should be able to start eating orally again. Although it is an easy solution, many miss this condition as these symptoms (nausea, vomiting and bloating) are similar to some normal refeeding symptoms. It is important to advocate for yourself if you feel something is wrong. Remember you know your body best and if after several typical remedies it does not stop, mention going to the hospital for a scan. Worst comes to worst you come home ruling out an illness that can have serious consequences. Dr. Philip Mehler has a lot of research on SMA and if curious, I would recommend checking out his book: Eating Disorder: A Guide to Medical Care and Complications.

To learn more about SMA Syndrome, click here: https://www.cureus.com/articles/24415-superior-mesenteric-artery-syndrome-secondary-to-anorexia-nervosa-and-methamphetamine-use

2. Pediatric Auto-immune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS)

No, it is not those cuddly animals you see in the zoo, this is something a lot less common. PANDAS happens because an infection (usually strep) causes a misdirected immune response and causes inflammation in parts of a child’s brain. Usually, this type of anorexia nervosa starts before a child hits puberty. Possible symptoms include restrictive eating habits, fear of weight gain, contamination fears, lack of appetite, anxiety, depression, irritability, and decreased concentration. Restrictive eating and OCD are the two major symptoms in the diagnostic criteria for PANDAS. Although this is rare, cases still come up time to time. Many cases of severe anorexia are reported in children with PANDAS and sometimes it is the primary symptom. In children with PANDAS induced anorexia nervosa, antibiotics often resolve the symptoms. If your child seemed to have an illness followed by a decline in eating habits – weight loss, selective eating, fear of choking/throwing up, difficulty swallowing, contamination issues or ritualistic eating habits call your doctor right away. Sometimes kids are diagnosed with ARFID prior to finding out that they are also diagnosed with PANDAS. Bringing this up to your doctor and suggesting a course of antibiotics will not harm your child and could be a helpful part of treatment.

To learn more about PANDAS, click here: https://aspire.care/families-parents-caregivers/pans-eating-disorder-food-restrictions/

3. Serious GI Complications like Bowel Ischemia

Gastrointestinal (GI) complications are common within those who struggle with eating disorders (especially Anorexia Nervosa patients). During the refeeding process, many will complain of abdominal pain, nausea, bloating or vomiting. This can be due to nonfatal GI complications such as delayed gastric emptying, delayed small bowel transit time and constipation. A lot of times healthcare professionals dismiss these complaints since they are nonfatal and will resolve in the weight restoration process. However, these same symptoms can indicate conditions that are less common but potentially life threatening like spontaneous rupture of the stomach, pancreatitis (inflammation of the pancreas), bowel ischemia (pain and difficulty for intestines to work properly) and necrosis of the bowels (death of the tissue). Always be an advocate of yourself of continue to be honest and open with your team. If you feel something is off, follow your gut – no pun intended. Any report of laxative abuse or serve malnourishment could indicate a serious GI issue and would require going to a hospital and having x-rays. For clinicians, make sure to listen to the client and ask a lot of detailed questions about their history- if you are concerned about something, better be on the safe side and has any serious condition ruled out.

To learn more about GI complications, click here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6950592/

4. Refeeding Syndrome

Refeeding syndrome is a rare but fatal reaction that happens in the body once a starved person starts eating again. It is defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving an increased intake of nourishment. These shifts result from a slew of hormonal and metabolic changes, and can cause serious health complications such as seizures, heart failure, and comas. The hallmark feature of refeeding syndrome is hypophosphatemia (a low level of phosphate in the blood). It may also show abnormal sodium levels, hypokalemia (low potassium levels), and hypomagnesemia (low magnesium). Typically, when a person severely malnourished admits to a facility (residential or inpatient), their potassium, phosphate, magnesium, and calcium levels will be checked. Client will slowly start eating a low-calorie meal plan and will be increased in calories slowly after labs have been checked to assess for any abnormalities. The purpose of this is to make sure the person does not start to abnormal labs or fluid retention. With chronic starvation, the body is so fragile that calories and fluid need to be continuously monitored to make sure the person does not start seizing or go into cardiac arrest. If the person does go into refeeding syndrome, typically the team will not increase calories until the electrolytes are repleted and labs are stable. Only then will calories slowly start to be increased until labs remain stable while this person is eating an appropriate number of calories for weight restoration. Remember to be as honest as possible about your eating habits and weight changes with your team as they will help make sure you are stable and getting the proper care in recovery.

To learn more about refeeding syndrome, click here: https://www.eatingdisorderhope.com/information/anorexia/refeeding-patients-with-anorexia-nervosa-what-does-research-show

References:

1. Sato, Y., Fukudo, S. Gastrointestinal symptoms and disorders in patients with eating disorders. Clin J Gastroenterol8, 255–263 (2015). https://doi.org/10.1007/s12328-015-0611-x
2. Rebecca E. Hommer, Susan E. Swedo; Anorexia and Autoimmunity: Challenging the Etiologic Constructs of Disordered Eating. PediatricsDecember 2017; 140 (6): e20173060. 10.1542/peds.2017-3060
3. Santonicola A, Gagliardi M, Guarino MPL, Siniscalchi M, Ciacci C, Iovino P. Eating Disorders and Gastrointestinal Diseases. Nutrients. 2019;11(12):3038. Published 2019 Dec 12. doi:10.3390/nu11123038
4. Vignaud, M., Constantin, JM., Ruivard, M. et al.Refeeding syndrome influences outcome of anorexia nervosa patients in intensive care unit: an observational study. Crit Care 14, R172 (2010). https://doi.org/10.1186/cc9274