Clinical Progress Note: Management of Adult Restrictive Eating Disorders in General Medical Units

Introduction

Adult eating disorder (ED) related hospital admissions increased by 79% in recent years.¹ Anorexia nervosa (AN) accounted for most admissions. Individuals with AN restrict energy intake relative to requirements leading to low body weight and exhibit either fear of gaining weight or denial of the seriousness of low body weight.² AN affects 1–3% of the population, and carries a mortality risk up to 16-times higher than same-age peers.³ Malnutrition or refeeding complications constitute over 50% of deaths.

Medical complications due to restriction in atypical anorexia nervosa (AAN) and avoidant restrictive food intake disorder (ARFID) can be just as severe as in classical AN, and the prevalence of these EDs is rising.^4,5 AAN shares all the criteria for AN except that despite significant weight loss, weight is in the normal or above normal range.² In contrast to AN and AAN, dietary restriction in ARFID is not motivated by weight or shape concerns but rather based on sensory sensitivity to food, low appetite, or fear of aversive consequences of food intake.²

Although all EDs are defined by disturbances in eating and/or body perception, these are not the causes. The exact etiology is unknown, but they are believed to arise from the interaction of biological, psychological, and socioenvironmental factors. Eating and weight-related behaviors are maladaptive coping skills that serve a purpose that goes beyond weight loss, attention, or control. EDs are not conscious choices but deeply rooted illnesses.

This article summarizes the current literature regarding inpatient medical management of adult restrictive EDs. Following a Pubmed database search in February 2023 that included permutations of terms “eating disorder”, “anorexia nervosa”, “adult”, “inpatient”, “medical stabilization”, and “medical complications”, studies were selected for inclusion based on applicability. A recent article reviewed the inpatient management of children and adolescents with EDs.⁶ Evidence base is less substantial for adult EDs, but the following recommendations are from the best available research findings, expert opinion, and international guidelines.

Clinical Presentation and Assessment

Patients present with a myriad of symptoms as no organ system is immune to the sequelae of an ED.^4,5,8,9 Fear, shame, and ambivalence often preclude disclosure of ED behaviors. Providers must therefore maintain heightened vigilance for ED related signs and symptoms in every patient as EDs occur across all ages, genders, races, and socioeconomic classes.^3,7 Complications impacting the cardiovascular, gastrointestinal, and musculoskeletal systems are common along with renal and electrolyte imbalances when purging behaviors are present.⁷

When an ED is suspected, family members and caregivers may supply valuable supplemental history. Guidelines recommend assessing orthostatic vital signs, temperature, height, weight, and calculation of body mass index (BMI).⁷ Information regarding weight trends is important as admission weight may be falsely elevated and medical complications are predicted by magnitude and rapidity of weight loss.⁴ A thorough physical exam may show signs of malnutrition (e.g., delayed capillary refill, dry skin, lanugo hair) or purging behaviors (e.g., dental erosions, parotid enlargement, callused knuckles). Recommended laboratory assessments include a complete metabolic panel, magnesium, phosphorus, thyroid function tests, and full blood panel with differential. An electrocardiogram is suggested to evaluate rhythm, rate, and QTc interval. Factors that suggest significant medical instability, which may require hospitalization for acute medical stabilization, are listed in Table 1. Admission decisions must be individualized, as no list can comprehensively cover all parameters.

Table 1.

One or More Factors Indicating Medical Instability

Low Weight	Weight <70% ideal body weight* or BMI <15 kg/m2§
Unstable Vital Signs	Temperature <96.8° F Heart rate <50 beats/minute Systolic blood pressure <90 mmHg associated with syncope, cyanosis, altered mental status, or renal insufficiency Orthostatic increase in heart rate (>30 beats/minute) or decrease in systolic blood pressure (>20 mmHg)
Biochemical Abnormalities	Potassium <3.0 mmol/L Sodium <130 mmol/L Phosphorous <2 mg/dL Glucose <60 mg/dL
Cardiac Dysrhythmia	QTc >500ms Any rhythm other than normal sinus rhythm or sinus bradycardia
Life-threatening Medical Complications (examples only)	Seizure, pancreatitis, marked peripheral edema, pleural effusion, aspiration pneumonia, diabetic ketoacidosis, gastrointestinal bleeding, upper gastrointestinal perforation, hepatic failure

^*Ideal body weight can be calculated using the Hamwi method.¹⁵

^§Diagnostic and Statistical Manual of Mental Disorders-5 categorizes individuals with AN into mild (≥17.0 kg/m²), moderate (16–16.99 kg/m²), severe (15–15.99 kg/m²), and extreme (<15 kg/m²) severity groups using BMI.²

Medical complications in ED patients are a harbinger of future morbidity and mortality. Orthostatic hypotension, syncope, and pre-syncopal symptoms portend cardiovascular instability and sudden cardiac death.^7,10 Bradycardia secondary to restriction improves with adequate nutritional intake. Atropine, other cardioaccelerants, and pacemaker insertion are advised against. Rapid intravenous correction of electrolyte abnormalities or hypoglycemia is often only a temporizing measure and can have detrimental consequences as described below. Values will almost certainly relapse given the overall depleted stores and persistence of ED behaviors without close monitoring. It is impossible to ascertain when these abnormalities will be fatal.

Team Approach

Inpatient hospitalization goals are to reduce behaviors sufficiently to correct physical sequelae and restore medical stability.⁷ Nutritional therapy is initiated to halt weight loss and increase BMI to a safer level. ED complexity necessitates a consistent, multidisciplinary care team. In addition to the hospitalist, the team should include a psychiatrist, psychologist or social worker, and dietitian. Inclusion of nursing and direct care staff is highly recommended, and when feasible, ED-informed occupational and physical therapists. Team meetings 1–2 times per week allow formation of a collective vision and minimize splitting. They also provide a venue for staff feelings to be expressed in a safe and supportive environment as patients can elicit intense countertransference and negative reactions.

Hospitalized ED patients are to be regarded as being under irresistible compulsion and incapable of altering their eating and weight control behaviors. Any unsupervised time can be used for purging or exercising. A one-to-one sitter and fall precautions are strongly advised. Secondary sarcopenia begets functional weakness and balance impairments. Falls in conjunction with low bone density, a practically ubiquitous aftermath of restrictive EDs, can have catastrophic consequences.⁸ Behavioral management recommendations for general medical wards are summarized in Table 2.

Table 2.

Behavioral Management Recommendations

Weight	Weight is monitored daily, preferably before breakfast, after urinating and in a hospital gown. Blind weighing is encouraged during the early stages of recovery where immediate weight restoration is essential (exposure to weight and shape can be incorporated later as an outpatient). Weight approach decisions are made by the clinical team in collaboration with the patient and clearly outlined in the treatment plan to avoid confusion and splitting. Documentation is kept away from the bedside (e.g., screen monitors turned away, scales removed from the room, papers disposed of outside of the room). Whenever possible, weight data should be omitted from documentation accessed via patient portals.
Physical Activity	Rules regarding physical activity are established from time of admission as it is harder to enforce as admission progresses. Staff are instructed to redirect patients when they witness inappropriate behaviors (e.g., prolonged standing, pacing, micro-exercising in bed). If the patient is permitted to leave the ward, supervision and restriction to wheelchair is favored to reduce activity and risk of injury. Supervision is compulsory during bathroom and shower use to limit opportunities for exercise and purging behaviors.
Enteral Nutrition	1:1 supervision is strongly advised to avert sabotaging of tube feeding. A lockable pump is preferred to prevent patients from switching off the device or altering the settings. Tubing is inspected daily and must remain visible to nursing staff, not covered by clothing or bed linen to prevent kinking or holes being put into the tube. Access to bathroom/sinks is limited to prevent syphoning off feeds down drains.
Meals	Only food prescribed by the dietician and on the meal plan is permitted. No unauthorized food can be brought in from outside. Diet foods and chewing gum are prohibited as these can be used to diminish appetite. Patients are never left alone with food. Meal plan, with feeding method, is clearly written and copies are available for staff and patient. Time allowed to complete meals and snacks (e.g., 30 minutes for meals) is determined by the care team, enforced by supervising staff, and documented clearly. All food eaten (type and portion) is recorded by staff or by the patient and verified by staff. Staff are encouraged to use distraction methods, gentle encouragement, and distress tolerance techniques to mitigate meal-related anxiety (more structured psychotherapeutic interventions can be incorporated after medical stabilization). Staff are instructed to verbally acknowledge ED behaviors, such as diverting food, and redirect patients in the moment.

The therapeutic relationship between ED patients and their healthcare team is of central importance. Initiation of nutritional therapy is very frightening for severely ill patients. Anxieties are to be addressed in a calm, compassionate, and nonjudgmental manner. Clear communication of the daily schedule, expectations, and contingencies diminishes fear, provides structure, and establishes firm boundaries. Treatment compliance is strongly influenced by patients’ ability to trust professionals enough to overcome their own ambivalence and reservations.¹¹ Collaborative goal setting may improve patient engagement. Objectives focused on physical stability, function, and meaningful quality of life increase the likelihood patients with severe and persistent illness continue with treatment. Refusal of all modes of nutrition by a severely malnourished patient obligates consideration of involuntary treatment. The extent to which this can be applied will vary based on state laws.¹²

Nutritional Management

Nutritional rehabilitation entails balancing the risk of refeeding syndrome (RS) against the risk of underfeeding. RS refers to the adverse metabolic effects and clinical complications caused by rapid initiation of nutrition after a period of undernutrition. Insulin secretion in response to carbohydrate provision causes an intracellular shift in glucose and electrolytes, which can be life-threatening in the setting of total body depletion. Risk correlates with degree of malnutrition.¹³ Hypophosphatemia is the hallmark of RS. Other potential features include hypokalemia, hypomagnesaemia, and fluid retention.¹³ Guidelines recommend supplementation with thiamine 100mg prior to initiation of feeding and continuation daily for 5–7 days along with multivitamin once daily for 10 days or greater based on clinical status.¹³ Daily laboratory monitoring is usually sufficient during the first week when risk is highest but more frequent monitoring may be required if electrolytes drop. Caloric advancement should be held until electrolytes are stabilized. Ongoing intermittent monitoring is encouraged until goal energy intake reached. Moderate hypophosphatemia is repleted with oral supplements at 1 mmol/kg/day of elemental phosphorus in 3–4 divided doses. More severe cases (<1.5 mg/dL) require IV phosphorus repletion at a dose of 0.25–0.5 mmol/kg/day. Glucose monitoring is recommended in the morning and 1–2 hours after meals. Hypoglycemia, when detected, is an ominous sign, as it forebodes hepatic failure and an inability to generate glucose via gluconeogenesis and glycogenolysis.⁸ Dextrose solutions may contribute to refeeding syndrome and avoidance is urged.¹⁰

IV fluid administration warrants caution. AN is associated with reduced cardiac output and left ventricular mass.¹⁰ During refeeding, the abrupt increase in preload, metabolic requirements, and electrolyte abnormalities can precipitate the onset of new cardiac complications. Smaller aliquots (e.g.,10ml/kg IV) administered in stages are safer. Purging (vomiting, laxatives, or diuretics) behaviors are affiliated with salt and water retention due to elevated aldosterone levels, a physiologic adaptation to chronic dehydration. Metabolic alkalosis and low urine chloride (< 10mmol/L) are consistent with hypovolemia.⁹ Slow infusion rates of saline (50ml/hr) and titration of spironolactone (initial dose 50–100mg) can attenuate edema formation.

Evidence to guide refeeding rates in adults with restrictive EDs is less robust than in adolescents. Consensus exists that patients shouldn’t receive fewer calories than they were consuming prior to admission. Recommendations from the American Society for Parenteral and Enteral Nutrition are to start at 10–20kcal/kg for the first 24 hours and advance by 33% of goal every 1 to 2 days.¹³ The limited data suggest faster rates of feeding are safe in adults without medical comorbidities and BMI>13 kg/m². Many adolescent and young adult programs are adopting higher initial caloric prescriptions (e.g.,1800–2000 kcal/day) and accelerated titrations.¹⁴ Regardless of rate, intake amount is escalated until weight restoration of 2–4lbs/week is achieved.⁷ Typically this stipulates patients consume 3000–4000 kcal/day.¹³

Oral food is preferred option for refeeding; however, on general medical units, nasogastric tube (NGT) feeding is often the safest route to ensure consistent reintroduction of nutrition. If severe gastroparesis or superior mesenteric artery syndrome is a comorbidity, nasojejunal tube (NJT) feeding may be required for management.⁸ Most patients will accept an NGT or NJT when it is explained to them it is an intervention intended to prevent serious complications, not a punishment. Nutrition is a medication, and in their case continuous administration is necessary. Patients can be incentivized to reach oral intake goal with the reward that tube feeds will be reduced, first to nocturnal only, and then stopped entirely. Selection of meals in advance, preferably for several days at a time, with the assistance of the dietician minimizes anxiety over food choices. Maintaining an accurate record of all food, drinks, supplements, and tube feeds is crucial.

There is limited evidence medications are beneficial during acute nutritional rehabilitation.⁷ Atypical antipsychotics, such as olanzapine, may attenuate ruminating thoughts and augment weight gain. If benzodiazepines are used, recommendations are at low doses and for a limited duration given the risk of physical complications and addiction. Gastrointestinal-related distress is common during refeeding and expectant management can prevent nocuous sequelae, such as underfeeding. ED patients, especially those with ARFID, may manifest intense fears regarding gastrointestinal disturbances and benefit from additional education and reassurance.⁵ Delayed gastric and intestinal motility arises from inadequate food and fluid intake. Symptoms often improve with nutritional rehabilitation. Scheduled bulk-forming laxatives are preferred for constipation management as stimulant laxatives have abuse potential. Pro-kinetics, such as metoclopramide, may mitigate discomfort but counseling regarding potential side effects is advised.

Discharge Planning

Inpatient medical admission is only the beginning of a long treatment journey, which can span months. From the onset, it is important to establish realistic expectations regarding outcomes and the likelihood of readmission without continued intensive treatment. With few if any exceptions, patients will meet criteria for inpatient or residential levels of care following physiologic stabilization.⁷ The search for a specialized ED treatment facility should begin immediately following admission. If complicated or prolonged medical admission is anticipated and patient is eligible, then consideration should be given to transferring the patient to a dedicated ED hospital unit such as in Colorado (ACUTE Center for Eating Disorders & Severe Malnutrition). When specialized ED care is unavailable due to geographic or insurance reasons, or patients are unwilling to transfer, discharge to the community requires attentive planning. Brain atrophy and cognitive impairment associated with significantly low BMI (≤16 kg/m²) or rapid weight loss can impede outpatient psychological interventions. Achievement of goal nutritional intake and sufficient reduction in ED behaviors for ongoing weight restoration decreases the chances of readmission. Care plans (follow-up appointments, meal plan, and behavioral goals) are to be clearly written, agreed upon, and distributed to the patient, carers, and outpatient providers.

Conclusion

The rise in adult ED hospital admissions underscores the demand for enhanced medical knowledge in non-specialized settings and adult medical disciplines. Severe EDs pose numerous challenges for healthcare providers, patients, and families alike. Careful orchestration of nutritional rehabilitation is paramount and often entails a collaborative, multidisciplinary care approach. There is a paucity of literature regarding effective management methods on adult general medical floors in the U.S. A cultural shift is imperative as EDs cannot continue to be viewed as the sole responsibility of specialist workforces. Lack of training pertaining to medical emergencies has fatal consequences. EDs are treatable illnesses and full recovery is possible.