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These vitamin deficiencies can have serious consequences, particularly in patients with eating disorders. In otherwise healthy individuals, deficiencies in vitamin A can lead to poor growth, night blindness, dry eye syndrome, dry skin, and impaired immunity. Vitamin D deficiency can lead to rickets in children, osteomalacia or “soft bones” in adults, and osteoporosis. Low levels of circulating vitamin K are associated with clotting problems and low bone-mineral density. Vitamin E is an antioxidant and one of the body's primary defenders against oxidative damage caused by free radicals. Scientists have implicated oxidative stress in the development of cancer, arthritis, cataracts, heart disease, and in the process of aging itself.
In patients with eating disorders, many of these medical consequences may become even more serious. Patients with anorexia already have an increased incidence of osteoporosis. A reduction in the absorption of vitamins D and K resulting from orlistat abuse may place them at even greater risk of bone fractures. Patients with eating disorders, particularly anorexia nervosa, already are immunocompromised and have decreased resistance to infections. Vitamin A deficiency resulting from orlistat abuse may leave them further susceptible to infectious diseases. Vitamin A deficiency also may exacerbate growth stunting in children with anorexia, some of whom will never reach full adult stature.
Orlistat's side effects of nausea or actual emesis may further promote self-induced vomiting in eating disorder patients. Patients with anorexia who purge are at much greater risk of developing serious medical complications. Purging may lead to excess alkalinity of the blood, potassium deficiency leading to atrial and ventricular arrhythmias and sudden cardiac death, aggravated hypotension with orthostatic blood pressure changes, gastric distention and even rupture, esophagitis and esophageal tears, loss of dental enamel and tooth breakage, aspiration of gastric contents leading to aspiration pneumonia and choking death, and chronic exposure of the esophagus to gastric acid leading to Barrett's esophagus and possible esophageal cancer.
Orlistat also has been linked to menstrual problems, which are endemic to eating disorders. Increased menstrual problems due to orlistat abuse may entail greater hormonal abnormalities with incumbent risks of osteoporosis and infertility.
In addition, orlistat's side effects of anxiety and low energy, although rare, may aggravate these common conditions of eating disorders, making the eating disorder even more difficult to treat because of a patient's heightened anxiety surrounding food and insufficient energy to meaningfully engage in psychotherapy.
In sum, based on what is known about eating disorder patients' propensity to abuse OTC weight and appetite control medications, as well as laxatives, it is highly likely that some eating disorder patients will abuse Alli. Given Alli's FDA approval and the expected marketing activity to accompany its release, the possibility of abuse would appear even greater than for other lesser-known products. Beginning this summer, clinicians would do well to screen for possible Alli abuse in known eating disorder patients and others at risk for eating disorder behaviors.
In the end, cost might end up being the primary deterrent to Alli abuse among eating disorder patients. Although initial product pricing was not available as of this writing, we expect that a typical monthly supply may cost as much as $60. Those who abuse Alli may purchase two to three times as much, spending several hundred dollars per month. Although many OTC diet-related products are not costly and therefore may be preferred by eating disorder patients, even costly OTC diet products—such as imported herbal combinations—are abused by some eating disorder sufferers. With the additional attraction of FDA approval, Alli may indeed interest many eating disorder patients despite the cost factor.
