Medical complications of anorexia are primarily those associated with starvation. For a complete review of these complications, the reader is referred to several recent reviews. Major negative effects are seen within the cardiovascular, endocrine, and gastrointestinal systems. Cardiac complications are the most common medical cause of death in patients with anorexia. A screening electrocardiogram (ECG) commonly shows sinus bradycardia, ST -segment depression, T-wave flattening, low-voltage, right-ward QRS axis, and possibly a prolonged QT interval. The latter finding may be a marker of patients at risk for ventricular tachycardia and sudden death, and closer surveillance is warranted. Other potentially serious cardiac findings are a pulse less than 40 beats/min, rhythms other than sinus, systolic blood pressure less than 60 mmHg, or evidence of CHF. The greatest period of risk for cardiac decompensation is during the first 2 weeks of refeeding; the reduced left ventricular mass and contractility may be unable to withstand the increased metabolic demand, particularly in the setting of hypophosphatemia associated with refeeding.

The etiology of amenorrhea, a cardinal manifestation of anorexia, is likely multifactorial including malnutrition, weight loss, and strenuous exercise in the setting of a hypothalamic abnormality. Studies on recovery of menses show variable rates of persistent amenorrhea from 5 to 44 percent.

Bone loss is a serious clinical problem, and 50 percent of women with anorexia have bone mineral density measurements (both cortical and trabecular bone) that are more than 2 SD below normal. Among young women who have not yet achieved their full growth, anorexia can impede maximal skeletal growth and mineralization. Contributing factors include estrogen deficiency, vitamin and micronutrient deficiency, cortisol excess, progesterone deficiency, and the inhibitory effect of malnutrition on bone formation and osteoblast function.

Gastrointestinal difficulties are primarily related to alterations in intestinal motility; prolonged transit time is present in up to 80 percent of patients with anorexia. This can lead to symptoms such as postprandial fullness and discomfort, sometimes prompting induced vomiting in an attempt to relieve the sensation. Chronic constipation is likely due to both starvation and reflex hypofunctioning of the colon; fecal impaction can result.

Other medical complications include cerebral atrophy, generalized muscle weakness, dermatologic changes (e.g., dry skin, brittle nails, and increased lanugo-like hair on the back and extremities), and hematologic changes (anemia, leukopenia, or pancytopenia). Reported effects on the immune system are inconsistent. For women who are able to conceive, pregnancies are often complicated by poor weight gain and the delivery of low birth weight or premature infants.

Psychological complications of starvation include impaired concentration, labile mood, and depressed mood to the point of severe psychomotor retardation with more severe starvation. These side effects are often unrecognized or mistreated as depression without addressing food intake.

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