What are the warning signs of physical distress in individuals with anorexia?

Warning Signs of Physical Distress in Anorexia Nervosa

The most critical warning signs of physical distress in anorexia nervosa include hypothermia, bradycardia (heart rate <40 bpm), hypotension, syncope, and significant electrolyte abnormalities, which require immediate medical attention as they can be life-threatening. 1, 2

Cardiovascular Warning Signs

• Bradycardia (slow heart rate) - particularly concerning when:

  • Heart rate falls below 40 bpm
  • Associated with symptoms like dizziness or syncope
  • Accompanied by QTc prolongation on ECG 2, 3

• Hypotension - blood pressure abnormalities:

  • Systolic BP <90 mmHg
  • Orthostatic changes (drop in BP when standing)
  • Accompanied by dizziness or lightheadedness 1, 4

• Arrhythmias and conduction abnormalities:

  • Prolonged QTc interval
  • Junctional rhythm
  • T-wave inversions 3

Metabolic and Nutritional Warning Signs

• Electrolyte abnormalities:

  • Hypokalemia (low potassium)
  • Hyponatremia (low sodium)
  • Hypophosphatemia (especially during refeeding)
  • Metabolic alkalosis (in purging behaviors) 1, 4

• Severe malnutrition indicators:

  • Rapid weight loss (>10% of body weight)
  • BMI significantly below expected for age/sex
  • Muscle wasting and loss of subcutaneous fat
  • Hair loss and lanugo (fine body hair) 1, 5

• Temperature dysregulation:

  • Hypothermia (body temperature <36°C/96.8°F)
  • Cold extremities with poor circulation
  • Inability to maintain body temperature 1

Neurological and Cognitive Warning Signs

• Cognitive impairment:

  • Poor concentration
  • Memory deficits
  • Prolonged sleeping
  • Confusion or altered mental status 1

• Neurological symptoms:

  • Syncope (fainting)
  • Seizures
  • Muscle weakness
  • Peripheral neuropathy 5

Gastrointestinal Warning Signs

• Digestive system abnormalities:
  • Severe constipation
  • Abdominal pain
  • Delayed gastric emptying
  • Signs of superior mesenteric artery syndrome (postprandial pain, vomiting) 1

Laboratory Abnormalities Requiring Urgent Attention

• Critical lab values:
  • Severe hypokalemia (<3.0 mEq/L)
  • Hypomagnesemia
  • Elevated liver enzymes
  • Leukopenia (low white blood cell count)
  • Anemia 1, 5

High-Risk Scenarios Requiring Immediate Intervention

1. Cardiac red flags:

   • Heart rate <40 bpm
   • QTc >500 ms
   • Any syncope or pre-syncope
   • Chest pain with exertion 2, 3

2. Refeeding syndrome risk:

   • Severely low BMI (<16)
   • Rapid weight loss
   • Little or no nutritional intake for >10 days
   • Low initial phosphorus, potassium, or magnesium 2

3. Severe dehydration:

   • Decreased skin turgor
   • Dry mucous membranes
   • Orthostatic hypotension
   • Reduced urine output 4

Monitoring Recommendations

• Regular vital sign monitoring (heart rate, blood pressure, temperature)
• Weekly weight measurements (more frequently during refeeding)
• ECG monitoring for patients with severe bradycardia or electrolyte abnormalities
• Regular laboratory testing including comprehensive metabolic panel and complete blood count 1

Important Caveats

• Bradycardia in anorexia nervosa is often an adaptive response to starvation and may not require specific cardiac interventions beyond careful refeeding 2
• Overly aggressive refeeding can precipitate dangerous fluid shifts and electrolyte abnormalities (refeeding syndrome) 2
• Most cardiovascular abnormalities are reversible with proper nutritional rehabilitation, but some complications like bone loss may be permanent 4, 5
• The presence of multiple warning signs significantly increases the risk of medical instability and need for hospitalization 1

Early recognition of these warning signs and prompt medical intervention are essential to prevent potentially fatal complications in individuals with anorexia nervosa.