Acute eating disorders

There’s much more to eating disorder (ED) treatment than simply ‘eating’. Affecting the mind as well as the body, EDs are complex conditions that require the input of a strong multidisciplinary team for optimal recovery.

EDs have the highest mortality rates among any other psychiatric illness,1 emphasising the importance of early detection and commencement of treatment. It is estimated that between 1.25 and 3.4 million people in the UK are affected by an ED, with anorexia nervosa (AN) and bulimia nervosa (BN) accounting for 8% and almost 20% respectively.2 Interestingly, there is a greater incidence of EDs amongst athletes and people with Type 1 diabetes.3 Table 1 looks at the long-term risks of EDs.

Potentially attributable to the world we live in now where diet culture is such a strong influence and where ‘bikini’ or ‘ripped’ bodies circulate social media, EDs can go unnoticed and can be easily disguised by trends that we now consider ‘normal’ such as: • labelling lifestyles or dietary choices – i.e. veganism could be a way to restrict food groups and control intake; • consistent dieting or overexercising – which could be excused by being involved in competitive sports; • celebrity endorsed ‘skinny teas’ and shakes – although a marketing ploy, these can encourage the concept of skipping meals; • diet trends such as fasting, keto, juicing – which promote the avoidance of foods and food groups.

ACUTE MANAGEMENT OF EDS EDs go miles deeper than simply weight and food. However, both of these factors majorly influence the acuity of one’s illness and are vital considerations when it comes to beginning treatment, which is why the input of a specialist dietitian remains important. The weight and BMI upon admission can indicate the severity of the patient’s condition and this, combined with the recent food intake, can highlight the risk of refeeding syndrome, which the patient may be at.

As patients with AN or BN may falsely report their intake in order to please, hide their illness or appear healthier, electrolyte levels should be assessed in conjunction with these

Elle Kelly RD

Elle is a Specialist Eating Disorder Dietitian. She currently works with young people with eating disorders and is completing her Master’s degree in Applied Sports Nutrition.

ellekellynutrition

REFERENCES Please visit: nhdmag.com/ references.html

Cardiovascular system

Gastrointestinal system

Neurological

Endocrine system

Other physical health consequences

Pulse rate decreases. Blood pressure drops. Increased risk of heart failure. Electrolyte imbalances caused by purging or drinking excessive amounts of fluids can lead to irregular heartbeats which can lead to heart failure. Feeling full after small amounts of food. Gastroparesis (slow gastric emptying). Stomach pain and bloating. Nausea and vomiting. Constipation. Laxative abuse can damage the GI tract and cause dependency on laxatives for a bowel movement. Binge eating can cause severe stomach issues. Starvation can lead to obsession about food and often patients with anorexia or bulimia express interest in food-related activities such as baking or cooking for other people, watching cooking programmes, reading recipe books, etc. Poor productivity and ability to concentrate due to insufficient energy intake. Numbness and tingling in hands and feet due to deterioration of protective layer of nerves as a result of low intake of fatty acids. Severe dehydration and electrolyte imbalances can potentially cause seizures and muscle cramps. Inadequate energy intake can lead to fainting, weakness and dizzy spells. Decreased metabolic rate. Decreased core temperature. Sex and thyroid hormone levels drop due to insufficient caloric and fat intake. Loss of menstrual cycle and affected fertility. Decreased bone density, which can lead to osteopenia and osteoporosis, as well as increased risk of fractures. Starvation can cause high cholesterol levels, but this should NOT be treated with medication or restriction of dietary lipids and/or cholesterol. Dry and pale skin, as well as wrinkles and excess skin from extreme weight loss. Brittle hair and hair loss. Lanugo (growth of downy hair on body to conserve heat). Delayed wound healing. Anaemia, causing fatigue, weakness and shortness of breath.

factors. Whether a patient is admitted to a general hospital or a specialist ED unit (SEDU), patients with AN can arrive incredibly unwell, unstable and can deteriorate very quickly. Therefore, prompt assessment is vital in order to begin treatment. It is recommended that adults suffering from anorexia nervosa should be treated on a SEDU4 to ensure that specialist services can be provided, such as nasogastric tube insertion and feeding, regular biochemical testing and prevention of symptomatic behaviour such as purging and exercising, etc.

Refeeding is the initial process of treatment of a patient with AN, which involves gradually increasing nutrient intake at a steady rate in order to prevent refeeding syndrome from developing. Refeeding syndrome occurs as a result of sudden shifts in electrolyte levels, particularly phosphate, potassium and magnesium, and this can be fatal.5 The current literature proves that there is substantial variation in opinion regarding the rate at which refeeding should begin at.

Some research suggests starting at 5kcal/ kg/day for a patient with a BMI below 14, as suggested by NICE (2006), and then increasing at a steady rate each day if electrolyte levels have been closely monitored and are within

Risk of refeeding syndrome should be assessed.

Bloods should be checked daily for the first few days following admission. Regular monitoring of other parameters is also vital, i.e. blood pressure checks, fluid balance, temperature, physical checks. Slow gradual increase in caloric intake. The aim is that a patient should be eating sufficient calories for weight gain within two weeks in order to prevent underfeeding syndrome.

Initially restricting carbohydrate calories.

Increasing dietary phosphate.

range. However, this is often argued as being too low, with some studies suggesting that patients should be started on around 1200kcal, depending on their severity of malnutrition.6 Starting at the higher end of calories than the lower is preferable, as it is considered important for facilitating the correction of low blood glucose levels and to prevent underfeeding. However, patients with a high-risk factor for refeeding syndrome, typically very low BMI, plus electrolyte or renal abnormalities and other medical complications, should begin refeeding more conservatively at about 5-10kcal/kg/day. Ideally, patients should be safely refed within the first 7-10 days and so it is encouraged to step up a patient’s calorie intake as soon as it is considered safe to do so.

With careful reintroduction of food and supplementation to treat nutrient deficiencies, refeeding syndrome can be avoided (see Table 2). However, there are other features of refeeding that may occur throughout the refeeding process, which can affect a patient, both physically and mentally. During the refeeding process, patients may experience the usual symptoms of mechanical eating but to an increased degree, such as gastrointestinal discomfort, increased satiation, body fluid fluctuations and re-established hunger cues. These physical complications can prove uncomfortable for patients, both physically and mentally, which is why additional support should be offered.

Patients with AN have an extreme compulsion to pursue thinness and simply feeling bloated can cause significant anxiety and stress and can potentially be accompanied by the urge to purge or exercise. In SEDUs, there is often supervision following mealtimes in order to offer support to patients who may be experiencing troubling thoughts following a meal and to prevent compensatory and other ED behaviours from taking place, such as vomiting, laxative use, bingeing, or over-exercising.

Due to the complex relationship between a patient and food, it is important that mealtimes are seen as a valuable part of the treatment process and as important as prescribed medications. SEDUs encourage patients to have set mealtimes, which allows for additional staff to be available to support patients during this anxiety-provoking time. Additionally, this promotes routine and consistency, allowing patients to understand that eating meals is a normal part of everyday life and instilling the belief that eating meals is not dependent on their emotions that day, whether they have ‘earned’ or feel that they ‘deserve’ the meal or not.

A food-first approach is crucial in order to help promote normal eating and a normal relationship with food, and nasogastric tube feeding should be considered a last resort. Patients should be encouraged to finish their meal on their own, offered alternatives if necessary, or given the option to have that meal at a later time, or given an oral nutritional supplement on occasions.

CONCLUSION Acute EDs are complex and there is no ‘one size fits all’ or ‘blanket’ approach that we dietitians can use, as the illness is so highly individual. Working within a team of skilled doctors, nurses and psychologists to stabilise a patient is of upmost importance in order to allow a patient to begin their journey to recovery, whatever that may be for them.