Can eating disorders cause anemia?

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Anemia is a condition that occurs when there aren’t enough healthy red blood cells in the body. The red blood cells transport oxygen to the entire body, but if there aren’t enough of them to do this job, then the person with anemia can feel a big difference in their energy and endurance levels. 

Anemia is diagnosed through a blood test called a hematocrit test which measures the proportion of red blood cells in the blood. A hematocrit reading of less than 37% indicates anemia. Another way to test for anemia is by measuring hemoglobin levels, because hemoglobin is a protein in red blood cells which contains iron. Additional tests may be used to determine what is causing the anemia. 

In one study of 921 patients with eating disorders, 36.6% of those with anorexia nervosa (AN) had anemia and 11.2% of those with bulimia nervosa (BN) had anemia. (10)

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Signs of anemia

There are a variety of physical symptoms associated with anemia, some of which are listed below. 

  • Shortness of breath
  • Lack of endurance
  • Feelings of weakness
  • Difficulty paying attention
  • School/work performance is poor
  • Pale skin
  • Fatigue
  • Chest pain
  • Abdominal pain
  • Cold hands and feet
  • Irregular heartbeats
  • Dizziness
  • Headaches

Malnutrition and anemia

Anorexia nervosa can cause anemia due to malnutrition. Some of the deficiencies that cause anemia include vitamin B12, folate, vitamin C, (9) copper, and iron deficiencies.

In one study of over 300 patients with anorexia nervosa, 17% of them had anemia. (5) In a Harvard University study of 214 college women who lived in the community and had AN, 39% of them had anemia. (7) When studying populations with extremely severe anorexia nervosa, rates of anemia are even higher, with one study diagnosing anemia in 79% of 339 patients. (6)

Red blood cells are produced in the bone marrow, and malnutrition due to AN can cause changes in bone marrow. There are multiple types of anemia that affect bone marrow. Malnutrition can cause bone marrow to change and become more fatty than usual, and this is what is usually seen in patients with anorexia nervosa and anemia. 

Both conditions interfere with the production of new blood cells. A type of anemia called pancytopenia occurs when all types of blood cells, including white blood cells, red blood cells, and platelets, are lower than they should be. In patients who have anorexia nervosa and develop pancytopenia, nutritional therapy can help increase blood cell production. 

Anorexia nervosa has one of the highest mortality rates of any psychiatric disorder and the development or co-occurrence of anemia with AN is one of the most significant predictors of mortality in people struggling with the disorder, (8)

The good news is that anemia caused by AN often resolves with nutritional rehabilitation. (3)

Anorexia nervosa and anemia


Anemia can become severe in people with AN and may result in the heart not getting enough oxygen due to insufficient levels of red blood cells. (2) To compensate, the blood pumps faster which can increase risk of heart attack. (11)

The anemia that can occur due to AN is classified as normocytic and normochromic anemia. (3) This is because the problem is that the number of blood cells is too low, in contrast to other types of anemia which can result from blood cells being the wrong size or having the wrong amount of hemoglobin in each cell.

Bulimia nervosa and anemia

Bulimia nervosa and anemia may also occur together. Both BN and anemia are often characterized by vitamin and mineral deficiencies. Purging and compensatory behaviors can result in vitamin and mineral deficiencies, and people with bulimia may also be malnourished.

Why do eating disorders increase the risk of anemia?

Eating disorders can increase the risk of anemia both because of overall malnutrition and specific vitamin and mineral deficiencies. People with eating disorders may also avoid iron rich foods, further increasing the likelihood of becoming anemic.

Treatment

Treatment for anemia is different depending on the cause and severity of the anemia. For severe iron deficiency anemia, blood transfusions may be necessary. 

Diet often plays an important role in rehabilitation for anemia. Eating enough food and including adequate sources of dietary iron is an important part of recovering from both eating disorders and anemia. Some people may also benefit from taking iron pills. 

It’s always a good idea to work with a dietitian and health care team to create an individualized protocol based on your needs and symptoms. 
Through nutritional rehabilitation and restoration of adequate iron levels, it is possible to recover from both eating disorders and anemia.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Rodriguez Vielba P, Lorenzo CM, Pablos EG. Pneumatosis intestinalis in anorexia nervosa. Rev Esp Enferm Dig. 2021 Nov; 113(11):797. https://pubmed.ncbi.nlm.nih.gov/34154369/
  2. Lemille J, Le Bras M, Fauconnier M, Grall-Bronnec M. Anorexia nervosa: Abnormalities in hematological and biochemical parameters. Rev Med Interne. 2021 Aug; 42(8): 558-565. https://pubmed.ncbi.nlm.nih.gov/33461787/
  3. Cleary BS, Gaudiani JL, Mehler PS. Interpreting the complete blood count in anorexia nervosa. Eat Disord. Mar-Apr 2010; 18(2): 132-9. https://pubmed.ncbi.nlm.nih.gov/20390616/
  4. Takeshima M, Ishikawa H, Kitadate A, Sasaki R, Kobayashi T, Nanjyo H, Kanbayashi T, Shimizu T. Anorexia nervosa-associated pancytopenia mimicking idiopathic aplastic anemia: a case report. BMC Psychiatry. 2018 May 25; 18(1):150. https://pubmed.ncbi.nlm.nih.gov/29801443/
  5. De Filippo E, Marra M, Alfinito F, Di Guglielmo ML, Majorano P, Cerciello G, De Caprio C, Contaldo F, Pasanisi F. Hematological complications in anorexia nervosa. Eur J clin Nutr. 2016 Nov; 70(11):1305-1308. https://pubmed.ncbi.nlm.nih.gov/27436150/
  6. Guinhut M, Melchior JC, Godart N, Hanachi M. Extremely severe anorexia nervosa: Hospital course of 354 adult patients in a clinical nutrition-eating disorders unit. Clin Nutr. 2021 Apr; 40(4): 1954-1965. https://pubmed.ncbi.nlm.nih.gov/33023762/
  7. Miller KK, Grinspoon SK, Ciampa J, Hier J, Herzog D, Kilbanski A. Medical findings in outpatients with anorexia nervosa. Arch Intern Med. 2005 Mar 14; 165(5):561-6. https://pubmed.ncbi.nlm.nih.gov/15767533/
  8. Gainhut M, Godart N, Benadjaoud MA, Melchior JC, Hanachi M. Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit. Acta Psychiatr Scand. 2021 Feb; 143(2):130-140. https://pubmed.ncbi.nlm.nih.gov/33247947/ 
  9. Green R, Datta Mitra A. Megaloblastic anemias: nutritional and other causes. Med Clin North A. 2017 Mar; 101(2):297-317. https://pubmed.ncbi.nlm.nih.gov/28189172/
  10. Walsh K, Blalock DV, Mehler PS. Hematological findings in a large sample of patients with anorexia nervosa and bulimia nervosa. Amer J Hematol. 2020 Jan 15. https://onlinelibrary.wiley.com/doi/10.1002/ajh.25732
  11. Kaiafa, G., Kanellos, I., Savopoulos, C., Kakaletsis, N., Giannakoulas, G., & Hatzitolios, A. I. (2015). Is anemia a new cardiovascular risk factor?. International journal of cardiology, 186, 117–124. https://doi.org/10.1016/j.ijcard.2015.03.159

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