The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) divides eating disorders into the following key categories:

Assessing for medical complications based on behaviors rather than diagnosis allows providers to approach patients across the DSM-5 categories and age and gender spectrum, without regard to a patient’s presenting weight. This method also allows providers to look at combinations of behaviors and identify all associated medical complications.

The disordered eating behaviors to focus on are:

• Restrictive Eating, as seen in anorexia nervosa, atypical anorexia nervosa, anorexia nervosa binge-purge type, and possibly ARFID
  • Medical complications are the direct result of the intensity, duration, and frequency of restriction
• Purging, as seen in bulimia nervosa and anorexia nervosa binge-purge type
  • Medical complications result from the intensity, duration, frequency, and method of purging
• Binge Eating, as seen in binge eating disorder, bulimia nervosa, and anorexia nervosa binge-purge type
  • Medical complications are a result of the intensity, duration, and frequency of binge eating episodes
• Selective Eating, as seen in ARFID, anorexia nervosa, and atypical anorexia nervosa (but can be seen in any eating disorder patient showing limited food variety)
  • Medical complications result from the intensity and duration of selective eating, resulting in insufficient variety and possibly total food volume

It’s important to note that individuals with any diagnosis can engage in more than one behavior.

Restriction in some form — that is, reducing energy, nutrient, and/or fluid intake relative to one’s daily estimated needs — is an essential criterion present in some eating disorder classifications. It can occur in eating disorder patients of any age, gender, and diagnosis.

Observed restriction behaviors may include:

• Limiting calories
• Eliminating entire food groups
• Rigid food rules
• Use of diet products
• Skipping meals/snacks
• Going long periods without eating
• Fluid loading
• Excessive fiber intake
• Avoiding a feeling of fullness

Restrictive behaviors may lead to weight suppression and malnutrition, affecting every organ system.

Common medical restriction symptoms and complications include:

• Neurological complications: decline in concentration, memory, cognitive flexibility and function, as well as brain atrophy (a loss of brain mass due to severe malnutrition)
• Musculoskeletal complications: increased risk of bone health issues, including decreased bone mineral density, putting patients at risk for developing osteopenia, osteoporosis, and fractures. Children and adolescents are at risk for chronic pain from bone fractures, reduced strength and mobility, and slowed growth, resulting in a shorter stature.
• Gastrointestinal complications: constipation, bloating, nausea, abdominal pain, difficulty swallowing, and gastroparesis (delayed stomach emptying)
• Cardiovascular complications: bradycardia (low heart rate, which can result in fainting, chest pain, heart failure, and even death), hypotension (low blood pressure, which can result in hypertension, dizziness, nausea, fatigue, blurred vision, cold, clammy skin, confusion, shallow breathing, and even death)
• Endocrine dysfunction: low blood glucose levels, cortisol dysregulation, abnormal thyroid function tests, decreased reproductive hormones (which can result in loss of periods, infertility, and decreased libido), slowed puberty for children and adolescents
• Dermatological signs: xerosis (dry skin), pruritus (itchy skin), hair loss, lanugo (the growth of fine white hair all over the body), acrocyanosis (cold, blue extremities), brittle nails, slowed wound healing

Purging refers to compensatory behaviors that people use to influence body weight or “make up” for calories consumed. People who engage in purging may practice multiple forms, and may be in bodies of all sizes

Frequently observed purging behaviors include:

• Self-induced vomiting
• Laxative abuse
• Misuse of diuretics
• Abuse of other medications/substances (e.g., insulin, diet pills, stimulants, synthetic thyroid hormone, caffeine, etc.)
• Fasting (intentionally going a long period of time without eating)
• Chewing and spitting
• Compulsive/excessive physical activity

Medical complications will directly relate to the intensity, duration, frequency, and method of purging. Complications can increase mortality rates and affect nearly all vital organs and bodily systems:

• Digestive complications: constipation, bloody stools, hemorrhoids, gastrointestinal reflux (GERD), odynophagia (pain with swallowing), esophagitis (irritation/inflammation of the esophagus), and potential stomach and esophageal rupture
• Dental complications: worn down tooth enamel (caused by stomach acid via vomiting), tooth pain or temperature sensitivity, increased cavity risk, mouth ulcers or abrasions, sialadenitis (salivary gland swelling), gum disease, and dry mouth
• Throat complications: dysphasia (difficulty swallowing), globus sensation (sensation of having a lump or something stuck in the throat), chronic coughing, hoarseness and sore throat, indigestion, and even esophageal cancer
• Cardiovascular complications: electrolyte imbalances leading to irregular heartbeat, a weakened heart muscle and potential heart failure, as well as low blood pressure, a weak pulse and anemia. Additionally, there is risk for arrhythmias (abnormal heart rhythms).
• Reproductive complications: hormonal imbalances, irregular menstrual cycles, and infertility
• Dermatological effects: Russell’s sign (callouses on the back of the hand), alopecia (sudden hair loss), hypertrichosis lanuginosa (excessive growth of fine hair on the skin), cheilosis (inflammation at the corners of the mouth, and dry, brittle nails

Binge eating is defined as eating a considerably larger portion of food in a “discrete” amount of time. It can be characterized by:

• Rapid-paced eating while feeling out of control
• Eating beyond fullness or until uncomfortably full
• Consuming food in excess of nutritional needs
• Compulsively eating in the absence of physical hunger
• Exhibiting a binge/fast cycle
• Eating large quantities of specific foods

The presentation of medical complications may be affected by age, gender, and pre-binge eating weight. Medical complications are a result of the intensity, duration, and frequency of binge eating episodes. Binge eating can affect many organ systems:

• Digestive complications: constipation, bloating, abdominal pain, cramping, heartburn (acid reflux), diarrhea, and an increased risk of developing irritable bowel syndrome (IBS) or cholecystitis (gallbladder disease). Repeated consumption of large amounts of food may cause long-term effects, including gastric dilation and gastric perforation (stomach rupture). Additionally, binge eating overloads a person’s system, which may result in low energy, sleepiness, snoring (sleep apnea), and sluggishness.
• Dermatological effects: acanthosis nigricans (darkening skin), brittle hair, dry skin, and facial acne
• Cardiovascular complications: electrolyte imbalances, hypertension (high blood pressure), heart palpitations, and even heart disease.
• Endocrine dysfunction: hormonal imbalances, liver disease, irregular menstrual cycles

Far more severe than simply being a “picky eater,” someone who experiences selective eating may:

• Have a phobia of certain foods
• Follow an extremely limited diet
• Have sensory aversions to specific tastes, textures, or smells
• Rely on supplements or fluids (e.g., Gatorade, Ensure, Boost)
• Have difficulty eating food prepared by others
• Have resistance to trying new foods
• Have a lack of interest in eating
• Have disgust with food/eating
• Have an unwillingness or an inability to eat identified foods

Medical complications of selective eating result from the intensity and duration of selective eating, resulting in insufficient variety and possibly volume. Selectivity can lead directly to macronutrient deficiencies (carbohydrates, fats, and proteins) and micronutrient deficiencies (e.g., anemia, scurvy, vision loss). Selectivity can lead indirectly to chronic issues with volume resulting in restriction (i.e., growth and bone density) and acute issues with volume resulting in restriction (e.g., abnormal labs and vital signs).

Few studies have comprehensively evaluated the medical complications of selective eating. The limited literature available suggests complications associated with selective eating may closely mirror those seen in restriction. Some of the more common medical symptoms of selective eating include:

• Growth stunting (due to loss of bone mineral density)
• Delayed puberty
• Bradycardia
• Amenorrhea (loss of menses)
• Elevated liver function tests
• GI symptoms
  • Abdominal pain
  • Nausea
  • Urgency
• Low energy
• Less common and specific to nutritional deficiencies:
  • Pale pallor
  • Bleeding gums
  • Vision changes