What is anorexia nervosa

Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by a low weight, fear of gaining weight, a strong desire to be thin and food restriction ¹. Many people with anorexia nervosa see themselves as overweight, even when they are clearly underweight. Eating, food and weight control become obsessions. Many people with anorexia restrict their food intake by dieting, fasting, or excessive exercise. They hardly eat at all — and the small amount of food they do eat becomes an obsession in terms of calorie counting or trying to eat as little as possible.

Some people with anorexia also may engage in binge eating and purging — eating a lot of food and then trying to get rid of the calories by making themselves throw up, using some type of medication or laxatives, diuretics, or enemas or exercising excessively, or some combination of these.

There are two subtypes of anorexia nervosa ²:

1. In the restricting subtype, people maintain their low body weight by restricting food intake and, sometimes, by exercise.
2. Individuals with the binge-eating/purging type also restrict their food intake, but regularly engage in binge-eating and/or purging behaviors such as self-induced vomiting or the misuse of laxatives, diuretics or enemas.

Many people move back and forth between subtypes during the course of their illness.

Anorexia nervosa affects mainly adolescent girls and young women and is up to ten times more common in women than in men ³, ⁴. The estimated prevalence of anorexia nervosa among young females is 0.3% ⁵ and it affects up to 4% of females and 0.2% of males during their lifetime ⁶.

The most common age of onset is 15-25 years ⁷. The age of onset appears to be decreasing ⁸. The incidence is low in children aged 4-11 years, but it increases significantly with age above 11 years ⁹. The restricting subtype of anorexia nervosa is associated with earlier onset and greater likelihood of crossover to the binge-eating/purging subtype ¹⁰. Onset after the age of 30 years is rare ¹¹.

The global incidence of anorexia nervosa appears to be increasing, particularly in Asia and the Middle East ¹². However, the incidence of anorexia nervosa remains low in Africa and among African American females in the USA, in Latin America, and among Hispanics/Latinos in the USA ¹³. These observations may reflect both genetic and cultural etiological factors. A large-scale national health survey in South Africa revealed that despite a high mean BMI of 29 kg/m², more black African females were happy with their current weight and fewer attempted to lose weight, compared with females of other ethnicities ¹⁴. A study involving the Caribbean Island of Curacao found no cases of anorexia nervosa among the mainly black population, while the incidence in the white population was similar to that in the United States and the Netherlands ¹⁵. That study was performed when the cultural influence of North America and Europe was increasing with the development of an affluent minority and relatively poor majority ¹⁶. Studies involving Hispanics/Latinos in the United States found that they had fewer concerns about weight gain than did their non-Hispanic white peers, leading to fewer cases of anorexia nervosa ¹⁷. This seems to be related to a body ideal of a “curvier” shape and higher body weight compared with the ideals in Western countries ¹⁸. Case series of males with anorexia nervosa in Western societies indicate that they display many of the same characteristics and clinical course as females with anorexia nervosa ¹⁹. Anorexia nervosa in males has been reported in non-Western societies, but few cross-cultural data are available on the incidence and prevalence of anorexia nervosa among males ²⁰.

Researchers are not sure exactly what causes anorexia and other eating disorders. Researchers are finding a complex combination of genetic, biological, behavioral, psychological, and social factors may be the cause. This combination includes having specific genes, a person’s biology, body image and self-esteem, social experiences, family health history, and sometimes other mental health illnesses.

Researchers are also studying unusual activity in the brain, such as changing levels of serotonin or other chemicals, to see how it may affect eating. They’re investigating how the structure and function of specific brain regions may contribute to anorexia ²¹.

The difference between dieting and anorexia
Healthy Dieting	Anorexia
Healthy dieting is an attempt to control weight.	Anorexia is an attempt to control your life and emotions.
Your self-esteem is based on more than just weight and body image.	Your self-esteem is based entirely on how much you weigh and how thin you are.
You view weight loss as a way to improve your health and appearance.	You view weight loss as a way to achieve happiness.
Your goal is to lose weight in a healthy way.	Becoming thin is all that matters; health is not a concern.

Anorexia is not really about weight or food. The food and weight-related issues are in fact symptoms of a deeper issue: depression, anxiety, loneliness, insecurity, pressure to be perfect, or feeling out of control. Problems that no amount of dieting or weight loss can cure.

In order to overcome anorexia, you first need to understand that it meets a need in your life. For example, maybe you feel powerless in many parts of your life, but you can control what you eat. Saying “no” to food, getting the best of hunger, and controlling the number on the scale may make you feel strong and successful—at least for a short while. You may even come to enjoy your hunger pangs as reminders of a “special talent” that most people don’t possess.

Anorexia may also be a way of distracting yourself from difficult emotions. When you spend most of your time thinking about food, dieting, and weight loss, you don’t have to face other problems in your life or deal with complicated emotions. Restricting food may provide an emotional numbness, anesthetizing you from feelings of anxiety, sadness, or anger, perhaps even replacing those emotions with a sense of calm or safety.

Unfortunately, any boost you get from starving yourself or shedding pounds is extremely short-lived—and at some point, it will stop working for you at all. Dieting and weight loss can’t repair the negative self-image at the heart of anorexia. The only way to do that is to identify the emotional need that self-starvation fulfills and find other ways to meet it.

The physical signs and symptoms of anorexia nervosa are related to starvation. Anorexia also includes emotional and behavioral issues involving an unrealistic perception of body weight and an extremely strong fear of gaining weight or becoming fat.

It may be difficult to notice signs and symptoms because what is considered a low body weight is different for each person, and some individuals may not appear extremely thin. Also, people with anorexia often disguise their thinness, eating habits or physical problems.

People with anorexia nervosa typically:

• Fear of weight gain by weighing themselves repeatedly
• Portion food carefully
• Eat very small quantities of only certain foods
• Body image becomes the predominant measure of self-worth, with concomitant denial of the seriousness of the illness
• Refuse to maintain weight within the normal range for height and age.
• Have a body image disturbance
• Absence of menstrual cycles or amenorrhoea in women (and loss of sexual interest in men).

The major weight loss strategies observed in individuals with anorexia nervosa include:

1. Food restriction,
2. Binge-purge behaviors and
3. Excessive exercise.

Some who have anorexia nervosa recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic, or long-lasting, form of anorexia nervosa, in which their health declines as they battle the illness.

Anorexia nervosa has significant physical consequences. Affected individuals can experience nutritional and hormonal problems that negatively impact bone density. Low body weight in females can cause the body to stop producing estrogen, resulting in a condition known as amenorrhea or absent menstrual periods. Low estrogen levels contribute to significant losses in bone density.

In addition, individuals with anorexia often produce excessive amounts of the adrenal hormone cortisol, which is known to trigger bone loss. Other problems, such as a decrease in the production of growth hormone and other growth factors, low body weight (apart from the estrogen loss it causes), calcium deficiency, and malnutrition, may contribute to bone loss in girls and women with anorexia. Weight loss, restricted dietary intake, and testosterone deficiency may be responsible for the low bone density found in males with the disorder.

Studies suggest that low bone mass is common in people with anorexia and that it occurs early in the course of the disease. Girls with anorexia may be less likely to reach their peak bone density and therefore may be at increased risk for osteoporosis and fracture throughout life.

Treatment for anorexia is generally done using a team approach, which includes doctors, mental health professionals, nutritionists, and dietitians, all with experience in eating disorders. If you live with family members they may be invited to participate in some of your treatment.

Your treatment plans may include one or more of the following:

• Nutrition therapy. Doctors, nurses, and counselors will help you eat healthy to reach and maintain a healthy weight. Some girls or women may need to be hospitalized or participate in a residential treatment program (live temporarily at a medical facility) to make sure they eat enough to recover. Hospitalization may also be required to monitor any heart problems in people with anorexia. Reaching a healthy weight is a key part of the recovery process so that your body’s biology, including thoughts and feelings in your brain, work correctly.
• Psychotherapy. Sometimes called “talk therapy,” psychotherapy is counseling to help you change any harmful thoughts or behaviors. This therapy may focus on the importance of talking about your feelings and how they affect what you do. You may work one-on-one with a therapist or in a group with others who have anorexia. For girls with anorexia, counseling may involve the whole family.
• Support groups can be helpful for some people with anorexia when added to other treatment. In support groups, girls or women and sometimes their families meet and share their stories.
• Medicine. Studies suggest that medicines like antidepressants can help some girls and women with anorexia by improving the depression and anxiety symptoms that often go along with anorexia.

Most girls and women do get better with treatment and are able to eat and exercise in healthy ways again ²². Some may get better after the first treatment. Others get well but may relapse and need treatment again. Ongoing therapy and nutrition education are highly important to continued recovery.

Unfortunately, one of the biggest challenges in treating anorexia is that many people with anorexia don’t want treatment, at least initially ²³. Their desire to remain thin overrides concerns about their health. If you have a loved one you’re worried about, urge her or him to talk to a doctor.

Barriers to treatment may include:

• Thinking you don’t need treatment
• Fearing weight gain
• Not seeing anorexia as an illness but rather a lifestyle choice

If you’re experiencing any of the problems listed above, or if you think you may have an eating disorder, get help. If you’re hiding your anorexia from loved ones, try to find a person you trust to talk to about what’s going on.

People with anorexia can recover. However, they’re at increased risk of relapse during periods of high stress or during triggering situations. Ongoing therapy or periodic appointments during times of stress may help you stay healthy.

Anorexia nervosa statistics

Eating disorders affect millions of people from all walks of life, currently the Centers for Disease Control and Prevention has no statistics, but according to the Harvard School of Public Health, eating disorder affects somewhere close to 4% of the U.S. population ²⁴. They affect men and women, people of all gender identities, all race and ethnicity groups, all income groups, and people across the country.

The point prevalence for strictly defined anorexia nervosa is around 0.9% in young females and around 0.3% in adult females ²⁵. Prevalence rates in males have not been well studied, but research indicates that for every 10 to 12 females diagnosed with the disorder, there is at least one male ²⁶.

According to the Harvard School of Public Health around 30 million Americans will be affected by eating disorders in their lifetime and probably double or triple that are affected by what might be called sub-clinical eating disorders, which doesn’t mean they’re not potentially just as harmful, but they just may not reach all the criteria to get a psychiatric diagnosis ²⁴.

Eating disorders are more than just going on a diet to lose weight or trying to exercise every day. They represent extremes in eating behavior and ways of thinking about eating — the diet that never ends and gradually gets more restrictive, for example. Or the person who can’t go out with friends because he or she thinks it’s more important to go running to work off a snack eaten earlier.

The most common eating disorders are anorexia nervosa and bulimia nervosa (usually called simply “anorexia” and “bulimia”). But other food-related disorders, like avoidant/restrictive food intake disorder, binge eating, body image disorders, and food phobias, are becoming more and more commonly identified.

What is the difference between anorexia and other eating disorders?

Women with eating disorders, such as anorexia, bulimia, and binge eating disorder, have a mental health condition that affects how they eat, and sometimes how they exercise. These eating disorders threaten their health.

Unlike women with bulimia and binge eating disorder, girls and women with anorexia do not eat enough to sustain basic bodily functions. Women with bulimia and binge eating disorder usually binge, or eat too much while feeling out of control.

It is possible to have more than one eating disorder in your lifetime. Regardless of what type of eating disorder you may have, you can get better with treatment.

How does anorexia affect a woman’s health?

With anorexia, your body doesn’t get the energy that it needs from food, so it slows down and stops working normally. Over time, anorexia can affect your body in the following ways ²⁷:

• Heart problems, including low blood pressure, a slower heart rate, irregular heartbeat, heart attack, and sudden death from heart problems ²⁸
• Anemia (when your red blood cells do not carry enough oxygen to your body) and other blood problems
• Thinning of the bones (osteopenia or osteoporosis)
• Kidney stones or kidney failure
• Lack of periods, which can cause problems getting pregnant
• During pregnancy, a higher risk for miscarriage, cesarean delivery, or having a baby with low birth weight

Anorexia is a serious illness that can also lead to death. Among women and girls, anorexia is second only to opioid abuse as a leading cause of death due to a serious mental health problem ²⁹. Many people with anorexia also have other mental health problems such as depression or anxiety ³⁰, ³¹.

Long-term studies of 20 years or more show that women who had an eating disorder in the past usually reach and maintain a healthy weight after treatment ³².

Who is at risk for anorexia?

Anorexia is more common among girls and women than boys and men ³³.

Anorexia is also more common among girls and younger women than older women. On average, girls develop anorexia at 16 or 17 ³⁴. Teen girls between 13 and 19 and young women in their early 20s are most at risk. But eating disorders are happening more often in older women. In one recent study, 13% of American Teen girls between 13 and 19 and young women in their early 20s are most at risk. But women in mid-life and beyond also experience eating disorders. In one study, 13% of American women over 50 had signs of an eating disorder ³⁵.

How does anorexia affect pregnancy?

Anorexia can cause problems getting pregnant and during pregnancy.

Extreme weight loss can cause missed menstrual periods because you may not ovulate, or release an egg from the ovary. When you do not weigh enough to ovulate, it is difficult to get pregnant. However, if you do not want to have children right now and you have sex, you should use birth control.

Anorexia can also cause problems during pregnancy. Anorexia raises your risk for:

• Miscarriage (pregnancy loss)
• Premature birth (also called preterm birth), or childbirth before 37 weeks of pregnancy
• Delivery by cesarean section (C-section)
• Having a low birth weight baby (less than five pounds, eight ounces at birth)
• Depression after the baby is born (postpartum depression)

If I had an eating disorder in the past, can I still get pregnant?

Yes. Women who have recovered from anorexia, are at a healthy weight, and have normal menstrual cycles have a better chance of getting pregnant and having a safe and healthy pregnancy.

If you had an eating disorder in the past, it may take you a little longer to get pregnant (about six months to a year) compared to women who never had an eating disorder ³⁶.

Tell your doctor if you had an eating disorder in the past and are trying to become pregnant.

Types of anorexia

Anorexia nervosa may be divided into 2 subtypes ²:

1. In the Restricting type, individuals lose weight through fasting or excessive exercise.
2. In the Binge eating/purging type, individuals binge on large amounts of food and purge after that. They purge by self-induced vomiting, laxative/diuretic usage.

Atypical anorexia nervosa

Atypical anorexia nervosa also called atypical anorexia, was added to the Diagnostic and Statistical Manual, fifth edition (DSM-5) under the category of Other Specified Feeding and Eating Disorder (OSFED) ³⁷. Those with atypical anorexia nervosa have all the features of anorexia nervosa such as restricting energy intake, intense fear of gaining weight, disturbance in one’s experience of body weight or shape, and a persistent lack of recognition of the seriousness of one’s current body weight ³⁸. What distinguishes atypical anorexia nervosa from anorexia nervosa is that despite meeting all the criteria for anorexia nervosa and losing a significant amount of weight, the individual’s weight is within or above the ‘normal’ weight range ³⁹. However, like individuals with anorexia nervosa, those with atypical anorexia nervosa present with weight loss and may be severely malnourished with medical and psychiatric instability. This presents a challenge for health care providers to recognize and treat atypical anorexia nervosa appropriately as most providers have been trained to rely on low weight as a primary indicator of malnourishment and diagnosis of anorexia nervosa.

One study found that youth with atypical anorexia nervosa who were previously overweight or obese experienced an increased rate and greater percentage of weight loss when compared to premorbid normal weighted adolescents with anorexia nervosa ⁴⁰. In addition, over the last ten years, clinicians have documented an increase of youth with atypical anorexia nervosa admitted to inpatient units ⁴¹, ⁴². These patients exhibited the same behaviors and cognitions as those with anorexia nervosa and similarly experienced acute medical complications. Medical instability appears to be just as severe if not worse in patients with atypical anorexia nervosa ⁴³, ⁴⁴, ⁴⁵ and in one study those with atypical anorexia nervosa experienced more severe disordered eating behaviors and higher body image distress when compared to those with anorexia nervosa ⁴⁴.

Anorexia nervosa causes

The exact causes of anorexia are not known. While a number of personality, interpersonal, psychological and biological factors have been associated with anorexia nervosa ⁴⁶, to date the exact causes of anorexia are not known and likely to be multi-factorial ⁴⁷, ⁴⁸. Many factors may be involved. Genes and hormones may play a role. Social attitudes that promote very thin body types may also be involved. Living in a society in which a high value is placed on thinness, including occupations that require a lean physique and perfectionism (e.g., sports and modelling), seems to be associated with an increased risk of anorexia nervosa ², ⁴⁹, ⁵⁰.

• Biological factors. Although it’s not yet clear which genes are involved, there may be genetic changes that make some people at higher risk of developing anorexia. Some people may have a genetic tendency toward perfectionism, sensitivity and perseverance — all traits associated with anorexia.
• Psychological factors. Some people with anorexia may have obsessive-compulsive personality traits that make it easier to stick to strict diets and forgo food despite being hungry. They may have an extreme drive for perfectionism, which causes them to think they’re never thin enough. And they may have high levels of anxiety and engage in restrictive eating to reduce it.
• Environmental factors. Modern Western culture emphasizes thinness. Success and worth are often equated with being thin. Peer pressure may help fuel the desire to be thin, particularly among young girls.

Studies demonstrate biological factors play a role in the development of anorexia nervosa in addition to environmental factors. Patients with anorexia nervosa have altered brain function and structure, where there are deficits in neurotransmitters dopamine (eating behavior and reward) and serotonin (impulse control and neuroticism), differential activation of the corticolimbic system (appetite and fear), and diminished activity among the frontostriatal circuits (habitual behaviors). Patients have co-morbid psychiatric disorders such as major depressive disorder and generalized anxiety disorder ⁵¹.

Most anorexia nervosa patients report that they started losing weight by voluntary dieting, but in some patients the weight loss is caused by depression, trauma, excessive exercise, a gastrointestinal disorder or protracted infection ¹⁵. If the initial weight loss is voluntary, the patient usually has a positive experience during the first month. However, over time they will find it increasingly difficult to eat normally, and a normal meal can induce discomfort, anxiety or even panic reactions. The person with anorexia nervosa gradually becomes preoccupied with body weight and body shape. Negative experiences from trying to eat normally lead patients to eating too little. Food intake is further decreased in times of stress, and even everyday stressful experiences may induce a further reduction in food intake. Thus, patients enter a vicious cycle of reduced food intake with increasing overvaluation of shape and weight, and further reduction of food intake. Treatment becomes more difficult when these psychological maintaining mechanisms are established. The vicious cycle appears to include both psychological and somatic factors that are closely related to nutritional status ¹⁵.

Risk factors for developing anorexia

Anorexia is more common in girls and women. However, boys and men have increasingly developed eating disorders, possibly related to growing social pressures.

Anorexia is also more common among teenagers. Anorexia often begins during the pre-teen or teen years or young adulthood ⁴⁷. It is more common in females, but may also be seen in males. Still, people of any age can develop this eating disorder, though it’s rare in those over 40. Teens may be more at risk because of all the changes their bodies go through during puberty. They may also face increased peer pressure and be more sensitive to criticism or even casual comments about weight or body shape.

Risk factors for anorexia include:

• Being more worried about, or paying more attention to, weight and shape
• Having an anxiety disorder as a child
• Having a negative self-image
• Having eating problems during infancy or early childhood
• Having certain social or cultural ideas about health and beauty
• Trying to be perfect or overly focused on rules
• Dieting and starvation. Dieting is a risk factor for developing an eating disorder. There is strong evidence that many of the symptoms of anorexia are actually symptoms of starvation. Starvation affects the brain and influences mood changes, rigidity in thinking, anxiety and reduction in appetite. Starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.

Both psychiatric and somatic comorbidities are common in anorexia nervosa. The most common psychiatric comorbidities are mood and anxiety disorders, obsessive-compulsive disorders, personality disorders, substance-use disorders and neurodevelopmental disorders such as autism spectrum disorder or attention-deficit hyperactivity disorder ²³. Comorbid disorders tend to worsen the prognosis of anorexia nervosa because they interfere with treatment response ⁵². Suicidal behaviors and ideation are markedly increased in patients with eating disorder ⁵³. Type 1 diabetes is sometimes a challenging comorbidity, since the omission of insulin in order to lose weight can induce severe complications, including recurring ketoacidosis and rapid development of neurological, retinal and renal complications, and is associated with a significantly increased mortality rate compared with anorexia nervosa without type 1 diabetes ⁵³.

Anorexia nervosa symptoms

Symptoms of anorexia nervosa include:

• Extremely low body weight or not making expected developmental weight gains.
• Severe food restriction.
• Relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight.
• Refuses to keep weight at what is considered normal for their age and height (15% or more below the normal weight).
• Intense fear of gaining weight or becoming fat, even when underweight.
• Distorted body image and self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight
• Lack of menstruation among girls and women.

People with anorexia may severely limit the amount of food they eat. Or they eat and then make themselves throw up. Other behaviors include:

• Cutting food into small pieces or moving them around the plate instead of eating
• Exercising all the time, even when the weather is bad, they are hurt, or their schedule is busy
• Going to the bathroom right after meals
• Refusing to eat around other people
• Using pills to make themselves urinate (water pills, or diuretics), have a bowel movement (enemas and laxatives), or decrease their appetite (diet pills)

Other symptoms and medical complications may develop over time, including:

• Thinning of the bones (osteopenia or osteoporosis)
• Brittle hair and nails
• Dry and yellowish skin
• Growth of fine hair all over the body (lanugo)
• Mild anemia, muscle wasting, and weakness
• Severe constipation
• Low blood pressure, or slowed breathing and pulse
• Damage to the structure and function of the heart
• Brain damage
• Multi-organ failure
• Drop in internal body temperature, causing a person to feel cold all the time
• Lethargy, sluggishness, or feeling tired all the time
• Infertility.
• Depression
• Dry mouth
• Extreme sensitivity to cold (wearing several layers of clothing to stay warm)
• Wasting away of muscle and loss of body fat

Physical signs and symptoms of anorexia

Physical signs and symptoms of anorexia may include:

• Extreme weight loss or not making expected developmental weight gains
• Thin appearance
• Abnormal blood counts
• Fatigue
• Insomnia
• Dizziness or fainting
• Bluish discoloration of the fingers
• Hair that thins, breaks or falls out
• Soft, downy hair covering the body
• Absence of menstruation
• Constipation and abdominal pain
• Dry or yellowish skin
• Intolerance of cold
• Irregular heart rhythms
• Low blood pressure
• Dehydration
• Swelling of arms or legs
• Eroded teeth and calluses on the knuckles from induced vomiting

Some people who have anorexia binge and purge, similar to individuals who have bulimia. But people with anorexia generally struggle with an abnormally low body weight, while individuals with bulimia typically are normal to above normal weight.

Emotional and behavioral symptoms

Behavioral symptoms of anorexia may include attempts to lose weight by:

• Severely restricting food intake through dieting or fasting
• Exercising excessively
• Bingeing and self-induced vomiting to get rid of food, which may include the use of laxatives, enemas, diet aids or herbal products

Emotional and behavioral signs and symptoms may include:

• Preoccupation with food, which sometimes includes cooking elaborate meals for others but not eating them
• Frequently skipping meals or refusing to eat
• Denial of hunger or making excuses for not eating
• Eating only a few certain “safe” foods, usually those low in fat and calories
• Adopting rigid meal or eating rituals, such as spitting food out after chewing
• Not wanting to eat in public
• Lying about how much food has been eaten
• Fear of gaining weight that may include repeated weighing or measuring the body
• Frequent checking in the mirror for perceived flaws
• Complaining about being fat or having parts of the body that are fat
• Covering up in layers of clothing
• Flat mood (lack of emotion)
• Social withdrawal
• Irritability
• Insomnia
• Reduced interest in sex

Anorexia nervosa complications

Anorexia can have numerous complications. Most complications of anorexia nervosa are secondary effects from starvation. At its most severe, it can be fatal. Death may occur suddenly — even when someone is not severely underweight. This may result from abnormal heart rhythms (arrhythmias) or an imbalance of electrolytes — minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body.

Malnutrition subsequent to self-starvation leads to protein deficiency and disruption of multiple organ systems, including the cardiovascular, renal, gastrointestinal, neurologic, endocrine, integumentary, hematologic, and reproductive systems. Endocrine and metabolic disturbances, for example, result in the following ⁵⁴:

• Delayed puberty
• Amenorrhea
• Anovulation
• Low estrogen states
• Increased growth hormone
• Decreased antidiuretic hormone
• Hypercarotenemia
• Hypothermia
• Hypokalemia
• Hyponatremia
• Hypoglycemia
• Euthyroid sick syndrome
• Hypercortisolism
• Arrested growth
• Osteoporosis

Other complications of anorexia include:

• Anemia
• Heart problems, such as mitral valve prolapse, abnormal heart rhythms or heart failure
• Bone loss (osteoporosis), increasing the risk of fractures
• Loss of muscle
• In females, absence of a period
• In males, decreased testosterone
• Gastrointestinal problems, such as constipation, bloating or nausea
• Electrolyte abnormalities, such as low blood potassium, sodium and chloride
• Kidney problems
• Social impairment. In the Swanson study, 97.1% of adolescents with anorexia nervosa reporting suffering from some form of impairment (most commonly, social impairment) in the previous 12 months, with 24.2% reporting severe impairment; 11.6% reported a complete inability to carry out normal activities for at least 1 day ⁵⁵.

If a person with anorexia becomes severely malnourished, every organ in the body can be damaged, including the brain, heart and kidneys. This damage may not be fully reversible, even when the anorexia is under control.

Cardiovascular effects of anorexia nervosa include the following ⁵⁶, ⁵⁷:

• Cardiomyopathy
• Mitral valve prolapse
• Supraventricular and ventricular dysrhythmias
• Long QT syndrome
• Bradycardia
• Orthostatic hypotension
• Shock due to congestive heart failure

Renal disturbances include the following:

• Decreased glomerular filtration rate (GFR)
• Elevated BUN
• Edema
• Acidosis with dehydration
• Hypokalemia
• Hypochloremic alkalosis with vomiting
• Hyperaldosteronism
• Renal calculi

Gastrointestinal findings in anorexia nervosa include the following:

• Constipation
• Decreased intestinal mobility
• Delayed gastric emptying
• Gastric dilation and rupture: From binge eating and purging; gastric rupture can lead to pneumothorax and pneumoperitoneum ⁵⁸

Neurologic disturbances include the following:

• Peripheral neuropathy
• Ventricular enlargement

Integumentary findings include the following:

• Dry skin and hair
• Hair loss
• Lanugo body hair

Hematologic findings include the following:

• Anemia
• Leukopenia
• Thrombocytopenia

Reproductive disturbances include the following:

• Infertility
• Low ̶ birth-weight infant

Patients who induce vomiting develop dental enamel erosion, palatal trauma, enlarged parotids, esophagitis, Mallory-Weiss lesions, elevated transaminase levels, and, in extreme cases, seizures (due to electrolyte disturbances). Cases of superior mesenteric artery syndrome from loss of intraperitoneal fat in anorexia nervosa have been reported ⁵⁹.

In addition to the host of physical complications, people with anorexia also commonly have other mental health disorders as well. They may include:

• Depression, anxiety and other mood disorders
• Personality disorders
• Obsessive-compulsive disorders
• Alcohol and substance misuse
• Self-injury, suicidal thoughts or suicide attempts

Anorexia prevention

There’s no guaranteed way to prevent anorexia nervosa. Primary care physicians (pediatricians, family physicians and internists) may be in a good position to identify early indicators of anorexia and prevent the development of full-blown illness. For instance, they can ask questions about eating habits and satisfaction with appearance during routine medical appointments.

If you notice that a family member or friend has low self-esteem, severe dieting habits and dissatisfaction with appearance, consider talking to him or her about these issues. Although you may not be able to prevent an eating disorder from developing, you can talk about healthier behavior or treatment options.

Anorexia diagnosis

Your doctor will ask you questions about your symptoms and medical history. It may be difficult to talk to a doctor or nurse about secret eating or exercise behaviors. But doctors and nurses want to help you be healthy. Being honest about your eating and exercise behaviors with a doctor or nurse is a good way to ask for help.

If your doctor suspects that you have anorexia nervosa, he or she will typically do blood and urine tests and exams to help pinpoint a diagnosis, rule out medical causes for the weight loss, and check for any related complications. Your doctor may also do other tests, such as kidney function tests, bone density tests, or an electrocardiogram (ECG or EKG), to see if or how severe weight loss has affected your health.

These exams and tests generally include:

• Physical exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; checking your skin and nails for problems; listening to your heart and lungs; and examining your abdomen.
• Lab tests. These may include a complete blood count (CBC) and more-specialized blood tests to check electrolytes and protein as well as functioning of your liver, kidney and thyroid. A urinalysis also may be done.
• Psychological evaluation. A doctor or mental health professional will likely ask about your thoughts, feelings and eating habits. You may also be asked to complete psychological self-assessment questionnaires.
• Other studies. X-rays may be taken to check your bone density, check for stress fractures or broken bones, or check for pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities.

Your mental health professional also may use the diagnostic criteria for anorexia in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Anorexia DSM 5 diagnostic criteria

Anorexia nervosa DSM 5 diagnostic criteria ³⁷:

• Criterion A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
• Criterion B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
• Criterion C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specify whether:

• Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
• Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Specify if:

• In partial remission: After full criteria for anorexia nervosa were previously met. Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met.
• In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time.

Specify current severity:

The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.

• Mild: BMI ≥ 17kg/m²
• Moderate: BMI 16-16.99 kg/m²
• Severe: BMI 15-15.99 kg/m²
• Extreme: BMI < 15 kg/m²

There are three essential features of anorexia nervosa:

• persistent energy intake restriction;
• intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain;
• and a disturbance in self-perceived weight or shape.

The individual maintains a body weight that is below a minimally normal level for age, sex, developmental trajectory, and physical health (Criterion A). Individuals’ body weights frequently meet this criterion following a significant weight loss, but among children and adolescents, there may alternatively be failure to make expected weight gain or to maintain a normal developmental
trajectory (i.e., while growing in height) instead of weight loss.

Criterion A requires that the individual’s weight be significantly low (i.e., less than minimally normal or, for children and adolescents, less than that minimally expected). Weight assessment can be challenging because normal weight range differs among individuals, and different thresholds have been published defining thinness or underweight status. Body mass index (BMI; calculated as weight in kilograms/height in meters squared) is a useful measure to assess body weight for height. For adults, a BMI of 18.5 kg/m² has been employed by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) as the lower limit of normal body weight. Therefore, most adults with a BMI greater than or equal to 18.5 kg/m² would not be considered to have a significantly low body weight. On the other hand, a BMI of lower than 17.0 kg/m² has been considered by the WHO to indicate moderate or severe thinness; therefore, an individual with a BMI less than 17.0 kg/m² would likely be considered to have a significantly low weight. An adult with a BMI between 17.0 and 18.5 kg/m², or even above 18.5 kg/m², might be considered to have a significantly low weight if clinical history or other physiological information supports this judgment.

For children and adolescents, determining a BMI-for-age percentile is useful (see, e.g., the CDC BMI percentile calculator for children and teenagers [https://www.cdc.gov/healthyweight/bmi/calculator.html]). As for adults, it is not possible to provide definitive standards for judging whether a child’s or an adolescent’s weight is significantly low, and variations in developmental trajectories among youth limit the utility of simple numerical guidelines. The CDC has used a BMI-for-age below the 5th percentile as suggesting underweight; however, children and adolescents with a BMI above this benchmark may be judged to be significantly underweight in light of failure to maintain their expected growth trajectory. In summary, in determining whether Criterion A is met, the clinician should consider available numerical guidelines, as well as the individual’s body build, weight history, and any physiological disturbances.

Individuals with this disorder typically display an intense fear of gaining weight or of becoming fat (Criterion B). This intense fear of becoming fat is usually not alleviated by weight loss. In fact, concern about weight gain may increase even as weight falls. Younger individuals with anorexia nervosa, as well as some adults, may not recognize or acknowledge a fear of weight gain. In the absence of another explanation for the significantly low weight, clinician inference drawn from collateral history, observational data, physical and laboratory findings, or longitudinal course either indicating a fear of weight gain or supporting persistent behaviors that prevent it may be used to establish Criterion B.

The experience and significance of body weight and shape are distorted in these individuals (Criterion C). Some individuals feel globally overweight. Others realize that they are thin but are still concerned that certain body parts, particularly the abdomen, buttocks, and thighs, are “too fat.” They may employ a variety of techniques to evaluate their body size or weight, including frequent weighing, obsessive measuring of body parts, and persistent use of a mirror to check for perceived areas of “fat.” The self-esteem of individuals with anorexia nervosa is highly dependent on their perceptions of body shape and weight. Weight loss is often viewed as an impressive achievement and a sign of extraordinary self discipline, whereas weight gain is perceived as an unacceptable failure of self-control. Although some individuals with this disorder may acknowledge being thin, they often do not recognize the serious medical implications of their malnourished state.

Often, the individual is brought to professional attention by family members after marked weight loss (or failure to make expected weight gains) has occurred. If individuals seek help on their own, it is usually because of distress over the somatic and psychological consequences of starvation. It is rare for an individual with anorexia nervosa to complain of weight loss per se. In fact, individuals with anorexia nervosa frequently either lack insight into or deny the problem. It is therefore often important to obtain information from family members or other sources to evaluate the history of weight loss and other features of the illness.

Anorexia nervosa treatment

The biggest challenge in treating anorexia nervosa is helping the person recognize that they have an illness. Most people with anorexia deny that they have an eating disorder. They often seek treatment only when their condition is serious.

Goals of treatment are to restore normal body weight and eating habits. A weight gain of 1 to 3 pounds (lb) or 0.5 to 1.5 kilograms (kg) per week is considered a safe goal.

Different programs have been designed to treat anorexia. These may include any of the following measures:

• Increasing social activity
• Reducing the amount of physical activity
• Using schedules for eating

To start, a short hospital stay may be recommended. This is followed by a day treatment program.

No medications are approved to treat anorexia because none has been found to work very well. However, antidepressants or other psychiatric medications can help treat other mental health disorders you may also have, such as depression or anxiety.

A longer hospital stay may be needed if:

• The person has lost a lot of weight (being below 70% of their ideal body weight for their age and height). For severe and life-threatening malnutrition, the person may need to be fed through a vein or stomach tube.
• Weight loss continues, even with treatment
• Medical complications, such as heart problems, confusion, or low potassium levels develop
• The person has severe depression or thinks about committing suicide

Care providers who are usually involved in these programs include:

• Nurse practitioners
• Physicians
• Physician assistants
• Dietitians
• Mental health care providers

Treatment is often very difficult. People and their families must work hard. Many therapies may be tried until the disorder is under control.

People may drop out of programs if they have unrealistic hopes of being “cured” with therapy alone.

Different kinds of talk therapy are used to treat people with anorexia:

• Cognitive behavioral therapy (a type of talk therapy), group therapy, and family therapy have all been successful.
• Goal of therapy is to change person’s thoughts or behavior to encourage them to eat in a healthier way. This kind of therapy is more useful for treating younger people who have not had anorexia for a long time.
• If the person is young, therapy may involve the whole family. The family is seen as a part of the solution, instead of the cause of the eating disorder.
• Support groups may also be a part of treatment. In support groups, patients and families meet and share what they have been through.

Medicines such as antidepressants, antipsychotics, and mood stabilizers may help some people when given as part of a complete treatment program. These medicines can help treat depression or anxiety. Although medicines may help, none has been proven to decrease the desire to lose weight.

Hospitalization

If your life is in immediate danger, you may need treatment in a hospital emergency room for such issues as a heart rhythm disturbance, dehydration, electrolyte imbalances or a psychiatric emergency. Hospitalization may be required for medical complications, severe psychiatric problems, severe malnutrition or continued refusal to eat.

Some clinics specialize in treating people with eating disorders. They may offer day programs or residential programs rather than full hospitalization. Specialized eating disorder programs may offer more-intensive treatment over longer periods of time.

Medical care

Because of the host of complications anorexia causes, you may need frequent monitoring of vital signs, hydration level and electrolytes, as well as related physical conditions. In severe cases, people with anorexia may initially require feeding through a tube that’s placed in their nose and goes to the stomach (nasogastric tube).

Care is usually coordinated by a primary care doctor or a mental health professional, with other professionals involved.

Restoring a healthy weight

The first goal of treatment is getting back to a healthy weight. You can’t recover from anorexia without returning to a healthy weight and learning proper nutrition. Those involved in this process may include:

• Your primary care doctor, who can provide medical care and supervise your calorie needs and weight gain
• A psychologist or other mental health professional, who can work with you to develop behavioral strategies to help you return to a healthy weight
• A dietitian, who can offer guidance getting back to regular patterns of eating, including providing specific meal plans and calorie requirements that help you meet your weight goals
• Your family, who will likely be involved in helping you maintain normal eating habits

Psychotherapy

These types of therapy may be beneficial for anorexia:

• Family-based therapy. This is the only evidence-based treatment for teenagers with anorexia. Because the teenager with anorexia is unable to make good choices about eating and health while in the grips of this serious condition, this therapy mobilizes parents to help their child with re-feeding and weight restoration until the child can make good choices about health.
• Individual therapy. For adults, cognitive behavioral therapy — specifically enhanced cognitive behavioral therapy — has been shown to help. The main goal is to normalize eating patterns and behaviors to support weight gain. The second goal is to help change distorted beliefs and thoughts that maintain restrictive eating.

Family therapy

The focus of structural family therapy ⁶⁰ centers on individual physiological vulnerability, dysfunctional transactional styles and the role the sick child plays in facilitating conflict avoidance. A second approach, derived from structural therapy, is systems therapy, including Milan and Post-Milan family therapy. This approach attempts to elicit changes in the family dynamic by presenting information that encourages family members to reflect on their own behaviour within the family dynamic ⁶¹. In these approaches the family is not included in the therapy process until after weight restoration has been achieved ⁶¹.

Rather than considering the impact of the family dynamic on the onset of the illness, strategic family therapy acknowledges the effect of the illness on all family members and focuses on inducing change in the eating disorder symptoms. This is often achieved through highlighting paradoxical intentions of family members ⁶². Like strategic family therapy, the Maudsley model, termed family based therapy, disregards the notion that the family dynamic is a direct causative agent in the pathogenesis of the disorder ⁶³. It emphasises behavioural recovery, rather than insight or understanding, and empowers family members to support the recovery of their child in the home setting. Families are helped to manage the eating behaviours of their child by providing education about anorexia nervosa, encouraging parents to generate strategies for increasing food intake and limiting physical activity. Emphasis is also placed on applying these strategies consistently and calmly ⁶⁴. There are three principal phases to the treatment process. In the first phase, the principal focus is on refeeding and weight gain. This is achieved by placing responsibility for the child’s eating patterns in the hands of the parents and emphasising the adolescent’s inability to control his or her eating patterns due to the effects of starvation. The second phase focuses on problem-solving regarding family and psychological issues that interfere with refeeding. The final phase centers around more general family and psychological issues, particularly those related to increasing autonomy for the adolescent and family boundaries. This is generally achieved through working with the adolescent and family members in joint family therapy sessions. More recent studies have investigated the efficacy of implementing this therapy in sessions where the patient is seen separately from their parents (termed separated family based therapy) ⁶⁵. When implemented with adult patients, parents are not encouraged to take control of the patients’ eating behaviour in the same way as when working with younger patients.

A further therapy described in the literature, behavioral family systems therapy, has a number of similarities with the family based therapy described above. Behavioral family systems therapy also has three stages to treatment, which are highly similar in nature to those utilized in family based therapy ⁶⁶. The major principles of this therapy include the acknowledgment that the adolescent lacks control over their weight and eating habits, work to address cognitive distortions and problems with the family structure, as well as work to overcome cognitive distortions of the patient, and in later stages, to promote autonomy ⁶⁷.

In addition to these formally described family therapy interventions, families are involved in other treatment approaches that support the recovery of the affected family member. This involvement may take various forms, and while not necessarily having such a well described theoretical underpinning, may also have an important influence on recovery.

Relapse prevention

Relapse prevention forms part of most psychotherapies, both inpatient and outpatient treatments. But relapse after the end of treatment remains a significant challenge. The usual strategy adopted for addressing relapse after inpatient treatment has been to provide some type of post-hospitalization treatment. Preliminary evidence, which remains to be validated, suggests that cognitive behavior therapy (CBT) is beneficial for patients with anorexia nervosa as relapse prevention ⁶⁸. One large trial tested Internet-based CBT added to treatment as usual vs treatment as usual alone in the post-hospitalization treatment phase in 258 females ⁶⁹. Cognitive behavior therapy (CBT) completers had greater improvements in BMI compared with those who received treatment as usual only. These findings indicate that the relapse-prevention effect of CBT can be delivered via the Internet.

Lifestyle and home remedies

When you have anorexia, it can be difficult to take care of yourself properly. In addition to professional treatment, follow these steps:

• Stick to your treatment plan. Don’t skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
• Talk to your doctor about appropriate vitamin and mineral supplements. If you’re not eating well, chances are your body isn’t getting all of the nutrients it needs, such as Vitamin D or iron. However, getting most of your vitamins and minerals from food is typically recommended.
• Don’t isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart.
• Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.

New ways to find emotional fulfillment

Once you understand the link between your emotions and your disordered eating patterns—and can identify your triggers—you still need to find alternatives to dieting that you can turn to for emotional fulfillment. For example:

• If you’re depressed or lonely, call someone who always makes you feel better, schedule time with family or friends, watch a comedy show, or play with a dog or cat.
• If you’re anxious, expend your nervous energy by dancing to your favorite music, squeezing a stress ball, or taking a brisk walk or bike ride.
• If you’re exhausted, treat yourself with a hot cup of tea, go for a walk, take a bath, or light some scented candles.
• If you’re bored, read a good book, explore the outdoors, visit a museum, or turn to a hobby you enjoy (playing the guitar, knitting, shooting hoops, scrapbooking, etc.).

Using mindfulness to cope with difficult emotions

When you start to feel overwhelmed by negativity, discomfort, or the urge to restrict food, take a moment to stop whatever you’re doing and investigate what’s going on inside.

• Identify the emotion you’re feeling. Is it guilt? Shame? Helplessness? Loneliness? Anxiety? Disappointment? Fear? Insecurity?
• Accept the experience you’re having. Avoidance and resistance only make negative emotions stronger. Instead, try to accept what you’re feeling without judging yourself.
• Dig deeper. Where do you feel the emotion in your body? What kinds of thoughts are going through your head?
• Distance yourself. Realize that you are NOT your feelings. Emotions are passing events, like clouds moving across the sky. They don’t define who you are.

Once you learn how to accept and tolerate your feelings, they’ll no longer seem so scary. You’ll realize that you’re still in control and that negative emotions are only temporary. Once you stop fighting them, they’ll quickly pass.

Challenge damaging mindsets

People with anorexia are often perfectionists and overachievers. They’re the “good” daughters and sons who do what they’re told, try to excel in everything they do, and focus on pleasing others. But while they may appear to have it all together, inside they feel helpless, inadequate, and worthless.

If that sounds familiar to you, here’s the good news: these feelings don’t reflect reality. They’re fueled by irrational, self-sabotaging ways of thinking that you can learn to overcome.

Damaging mindsets that fuel anorexia

• All-or-nothing thinking. Through this harshly critical lens, if you’re not perfect, you’re a total failure. You have a hard time seeing shades of gray, at least when it comes to yourself.
• Emotional reasoning. You believe if you feel a certain way, it must be true. “I feel fat” means “I am fat.” “I feel hopeless” means you’ll never get better.
• Musts, must-nots, and have-tos. You hold yourself to a rigid set of rules (“I must not eat more than x number of calories,“ “I have to get straight A’s,” “I must always be in control.” etc.) and beat yourself up if you break them.
• Labeling. You call yourself names based on mistakes and perceived shortcomings. “I’m unhappy with how I look” becomes “I’m disgusting.” Slipping up becomes “I’m a “failure.”
• Catastrophizing. You jump to the worst-case scenario. If you backslide in recovery, for example, you assume that there’s no hope you’ll ever get better.

Once you identify the destructive thoughts patterns that you default to, you can start to challenge them with questions such as:

• “What’s the evidence that this thought is true? Not true?”
• “What would I tell a friend who had this thought?”
• “Is there another way of looking at the situation or an alternate explanation?”
• “How might I look at this situation if I didn’t have anorexia?”

As you cross-examine your negative thoughts, you may be surprised at how quickly they crumble. In the process, you’ll develop a more balanced perspective.

Develop a healthier relationship with food

Even though anorexia isn’t fundamentally about food, over time you’ve developed harmful food habits that can be tough to break. Developing a healthier relationship with food entails:

• Getting back to a healthy weight
• Starting to eat more food
• Changing how you think about yourself and food

Getting past your fear of gaining weight. Getting back to a normal weight is no easy task. The thought of gaining weight is probably extremely frightening, and you may be tempted to resist. But this fear is a symptom of your anorexia. Reading about anorexia or talking to other people who have lived with it can help. It also helps to be honest about your feelings and fears. The better your family and treatment team understand what you’re going through, the better support you’ll receive.

Let go of rigid food rules. While following rigid rules may help you feel in control, it’s a temporary illusion. The truth is that these rules are controlling you, not the other way around. In order to get better, you’ll need to let go. This is a big change that will feel scary at first, but day by day, it will get easier.

Get back in touch with your body. If you have anorexia, you’ve learned to ignore your body’s hunger and fullness signals. You may not even recognize them anymore. The goal is to get back in touch with these internal cues, so you can eat based on your physiological needs.

Allow yourself to eat all foods. Instead of putting certain food off limits, eat whatever you want, but pay attention to how you feel physically after eating different foods. Ideally, what you eat should leave you feeling satisfied and energized.

Get rid of your scale. Instead of focusing on weight as a measurement of self-worth, focus on how you feel. Make health and vitality your goal, not a number on the scale.

Develop a healthy meal plan. If you need to gain weight, a nutritionist or dietician can help you develop a healthy meal plan that includes enough calories to get you back to a normal weight. While you can do this on your own, you’re probably out of touch with what a normal meal or serving size looks like.

Alternative medicine

Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with anorexia. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications. These products do not go through a rigorous review process and may have ingredients that are not posted on the bottle.

Keep in mind that natural doesn’t always mean safe. If you use dietary supplements or herbs, discuss the potential risks with your doctor.

Anxiety-reducing approaches that complement anorexia treatment may increase the sense of well-being and promote relaxation. Examples of these approaches include massage, yoga and meditation.

Coping and support

You may find it difficult to cope with anorexia when you’re hit with mixed messages by the media, culture, and perhaps your own family or friends. You may even have heard people joke that they wish they could have anorexia for a while so that they could lose weight.

Whether you have anorexia or your loved one has anorexia, ask your doctor or mental health professional for advice on coping strategies and emotional support. Learning effective coping strategies and getting the support you need from family and friends are vital to successful treatment.

Support Groups

The stress of illness can be eased by joining a support group. Sharing with others who have common experiences and problems can help you not feel alone.

• In the U.S.: National Eating Disorders Association (https://www.nationaleatingdisorders.org/help-support) or call 1-800-931-2237 (National Eating Disorders Association)
• UK: Beat Eating Disorders (https://helpfinder.beateatingdisorders.org.uk/) or call 0345 643 1414 (Helpfinder)
• Australia: Butterfly Foundation for Eating Disorders (https://butterfly.org.au/Get%20Support/Helpline/) or call 1800 33 4673 (National Eating Disorders Collaboration)
• Canada: Service Provider Directory (https://nedic.ca/find-a-provider/) or call 1-866-633-4220 (NEDIC)

Anorexia nervosa prognosis

Anorexia is a serious condition that can be life threatening. Treatment programs can help people with the condition return to a normal weight. But it is common for the disease to return.

Women who develop this eating disorder at an early age have a better chance of recovering completely. Most people with anorexia will continue to prefer a lower body weight and be very focused on food and calories.

Weight management may be hard. Long-term treatment may be needed to stay at a healthy weight.

Rates of recovery from anorexia nervosa at 1- to 2-year follow-ups with the best available treatments lie in the range of 13-50% across age groups ⁷⁰. Among the patients who complete psychotherapy the relapse rates are ranging from 9% to 52%, with most studies finding rates higher than 25% ⁷¹. The average duration of illness with anorexia nervosa is about 6 years ⁷. The long-term course is heterogeneous, with 20-year longitudinal studies finding that 30%-60% of patients will experience full remission, while 20% will have enduring illness and the remainder will have residual symptoms ⁷¹.

In a meta-analysis of 36 studies published between 1966 and 2010, the standardized mortality ratio for patients with anorexia nervosa (the percentage of observed deaths among patients with anorexia nervosa divided by the percentage of expected deaths in the population of origin) was 5.9 ²⁹. One in five individuals with anorexia nervosa who died had committed suicide ²⁹. However, these data were often derived from patients admitted to hospitals, and early intervention and active engagement might have reduced the prevalence, need for hospitalization and mortality ²³. No mortality was observed in a cohort of 51 patients with anorexia nervosa recruited from all individuals born in 1985 in Gothenburg, Sweden who were followed for 30 years ⁷². Although these observations were made in a small cohort of young patients, they might indicate that early intervention and structured follow-up are associated with low mortality.

Possible Complications of Anorexia Nervosa

Anorexia can be dangerous. It may lead to serious health problems over time, including:

• Bone weakening or osteoporosis – a condition in which the bones become less dense and more likely to fracture. Fractures from osteoporosis can result in significant pain and disability.
• Decrease in white blood cells, which leads to increased risk of infection
• A low potassium level in the blood, which may cause dangerous heart rhythms
• Severe lack of water and fluids in the body (dehydration)
• Lack of protein, vitamins, minerals, and other important nutrients in the body (malnutrition)
• Seizures due to fluid or sodium loss from repeated diarrhea or vomiting
• Thyroid gland problems
• Tooth decay.

Severe and enduring anorexia nervosa

A substantial subgroup of patients with anorexia nervosa develop severe and enduring anorexia nervosa ⁷³. This is currently a rather ill-defined patient population ¹⁵. Severe and enduring anorexia nervosa is characterized by ⁷⁴, ⁷⁵:

1. A persistent state of dietary restriction, underweight and overvaluation of weight/shape with functional impairment;
2. Duration longer than 3 years; and
3. Exposure to at least two appropriately delivered evidence-based treatments.

It is difficult to define what an appropriate treatment is, and a duration of longer than 3 years is very common among patients with anorexia nervosa ¹⁵. In addition, the criteria for recovery from anorexia nervosa remain unclear, so this population is potentially very large. In a 22-year follow-up study of 246 patients with anorexia nervosa and bulimia nervosa, the patients were assessed at 9 years and at 22-25 years after inclusion. Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery by the 22-year follow-up ²² These findings argue against the implementation of palliative care for individuals with severe and enduring anorexia nervosa. At present only one formal randomized control trial has been published on the treatment of patients with severe and enduring anorexia nervosa ¹⁵. In that study, 63 patients with an anorexia nervosa duration of at least 7 years were randomized to receive either CBT or Specialist Supportive Clinical Management, both adapted for the treatment of severe and enduring anorexia nervosa and both in an outpatient setting. A very low attrition rate was observed, and small effects on the BMI and quality of life were detected in both treatment groups ⁷⁶. Raykos et al ⁷⁷ compared illness severity and duration with outcome among 134 patients with severe and enduring anorexia nervosa who received cognitive behavior therapy (CBT) with an eating disorder focus in an outpatient setting and found that the illness severity and duration had no effect on outcome. In an inpatient study by Calugi and colleagues ⁶⁸, ⁷⁸, 66 adult patients were divided into groups according to their illness duration: ≤ 7 or > 7 years. All patients received inpatient intensive cognitive behavior therapy (CBT) with an eating disorder focus as described by Dalle Grave ⁷⁹, and the two groups showed similar improvements in BMI and eating-disorder symptoms at the end of treatment and at the 12-months follow-up ⁸⁰. Thus, there appears to be either a weak or no association between anorexia nervosa duration and the effect of treatment among patients with severe and enduring anorexia nervosa ⁸¹. Although the findings of several studies indicate that these patients can benefit from psychotherapy, many with severe and enduring anorexia nervosa are not provided with a treatment program when they seek care ⁷⁵. Their presence in an eating-disorder unit can exert complicated effects on the environment, with a significant proportion of severe and enduring anorexia nervosa patients reporting having experienced coercive efforts to increase their body weight ⁷⁵. The poor understanding and paucity of treatments for severe and enduring anorexia nervosa has been described as a crisis in the field of eating disorders ⁷⁵.

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