Please note: Eating disorders develop in men, women, girls, and boys. For ease in reading, we have used "she" and "her" in the text below.
IS THE INDIVIDUAL MEDICALLY UNSTABLE? This is a core question addressed by the primary care physician in developing a treatment plan for a patient with an eating disorder. Early detection of the illness often makes outpatient treatment feasible, allowing the individual to hold a job or attend school.
For the patient who is not in urgent need of medical attention but requires 24 hour supervision to curb her abnormal eating habits, the primary care physician is likely to recommend
residential treatment. When a patient’s unhealthy eating habits are placing her cardiovascular or neurological status at risk, admission to an
acute care hospital is indicated. In addition to providing treatment and monitoring for medical complications, hospitalization is an opportunity for the individual to begin to modify her abnormal eating behaviors, such as starving, binge eating, and purging.
For the patient hospitalized with anorexia nervosa, nutritional rehabilitation is a team effort involving the medical doctor, the psychiatrist and the nutritionist.
Daily food and beverage intake is increased gradually in order to prevent the gastrointestinal symptoms and additional emotional distress that might accompany a rapid step-up in calories.
A paced, steady approach to nutritional replenishment also reduces the risk of a rare but dangerous refeeding syndrome, which can strike early in the rehabilitation process, manifesting as edema (swelling), shortness of breath, weakness, paresthesias (abnormal nerve sensations such as tingling, prickling, numbness), mental status changes and weight gain that is greater than expected (due to retained fluid). Fluid imbalance, abnormal glucose metabolism, and low levels of phosphorus, potassium and magnesium are also observed. Some patients need supplementary potassium phosphate or sodium phosphate. If left untreated, refeeding syndrome has the potential to affect cardiac, pulmonary and renal function.
Once nutritional restoration is underway, the low blood pressure and slow resting pulse that are characteristic of anorexia nervosa typically go back to normal. Lightheadedness and
orthostatic changes in pulse, on the other hand, may take up to several weeks to resolve. To alleviate constipation, a common symptom of anorexia nervosa, a stool softener can be prescribed. Malnutrition sets the stage for delayed gastric emptying (the individual’s stomach takes longer than normal to transmit its contents to the small intestine), which results in a feeling of fullness after ingesting only a small amount and can interfere with a patient’s ability or willingness to take in adequate nutrition. Motility in the stomach generally improves after a few weeks of healthy eating; meanwhile, small frequent meals or liquid supplements can help prevent discomfort. Prior to discharge, the primary physician—in collaboration with the patient, the family and the other professionals on the team—sets up continued care, either in a residential facility or on an outpatient basis.
All treatment settings address the overwhelming drive to exercise that is often associated with eating disorders. As the disease gains momentum, healthy involvement in physical activity can grow excessive as individuals enslave themselves to grueling workouts, even trying to exercise when they are injured or ill. Those who participate in team sports tend to supplement games and group
practice sessions by training in private, and it is this solitary exertion that generally constitutes the excess.
Perceived pressure to exercise can reach a point where the eating disordered individual can’t slow down without help. For the patient at risk of medical complications, doctors generally recommend a temporary period of restricted exercise in order to conserve her energy and reduce her risk of injury.
Although the individual typically protests the exercise limits, she may also sense that her activity level has soared beyond her grasp and therefore experience some relief that the doctor has intervened.
Even when an individual with anorexia nervosa is extremely underweight, she is unlikely to see herself as having a problem and may refuse to engage in treatment. Sometimes the “time out” from athletics helps her realize that she is indeed ill and needs to play an active role in her recovery. The prospects of returning to physical activity can serve as an incentive to get well. The primary care physician lends support to parents as they gently – but firmly – approach their child’s situation from a positive perspective, empathizing with her angst and reminding her that the fastest route back to sports is to feed her body. Throughout treatment, the doctor emphasizes that recommendations are intended not as disciplinary measures but rather as medically necessary ones and advises moms and dads to focus on health, not weight, when discussing body image issues with their children.
Practice guideline for the treatment of patients with eating disorders
American Psychiatric Association (APA). Practice guideline for the treatment of patients with eating disorders. 3rd ed. Washington (DC): American Psychiatric Association ; 2006 Jun. 128 p. [765 references].
Behavioral management for anorexia nervosa
Attia, E., Walsh, B.T. Behavioral management for anorexia nervosa. New England Journal of Medicine. 2009; 360: 500-6.
Becker, A.E., Grinspoon, S.K., Klibanski, A., Herzog, D.B. Eating disorders. New England Journal of Medicine. 1999; 340: 1092-8.
Goldstein, M.A., Dechant, E.J., Beresin, E.V. Eating disorders
Pediatrics in Review. 2011; 32: 508-21.
Case records of the Massachusetts General Hospital. Case 29-2008. A 19-year-old man with weight loss and abdominal pain
Goldstein, M.A., Herzog, D.B., Misra, M., Sagar, P. Case records of the Massachusetts General Hospital. Case 29-2008. A 19-year-old man with weight loss and abdominal pain. New England Journal of Medicine. 2008; 359: 1272-83.
Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa
Grinspoon, S., Thomas, E., Pitts, S., Gross, E., Mickley, D., Miller, K., Herzog, D., Klibanski, A.
Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Annals of Internal Medicine. 2000. 133: 790-4.
The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa
Klibanski, A., Biller, B.M., Schoenfeld, D.A., Herzog, D.B., Saxe, V.C. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa Journal of Clinical Endocrinology and Metabolism . 1995; 80: 898-904.
Early identification and treatment of eating disorders: prodrome to syndrome
Le Grange, D., Loeb, K.L. Early identification and treatment of eating disorders: prodrome to syndrome. Early Intervention in Psychiatry. 2007; 1: 27-39.
Medical complications of bulimia nervosa and their treatments
Mehler, P.S. Medical complications of bulimia nervosa and their treatments. International Journal of Eating Disorders. 2011; 44: 95-104.
Medical findings in outpatients with anorexia nervosa
Miller, K.K. Grinspoon, S.K., Ciampa, J., Hier, J., Herzog, D., Klibanski, A. Medical findings in outpatients with anorexia nervosa. Archives of Internal Medicine. 2005; 165: 561-6.
Physiologic estrogen replacement increases bone density in adolescent girls with
Misra, M., Katzman, D., Miller, K.K., Mendes, N., Snelgrove, D., Russell, M., Goldstein, M.A.,
Ebrahimi, S., Clauss, L., Weigel, T., Mickley, D., Schoenfeld, D.A., Herzog, D.B., Klibanski, A.
Physiologic estrogen replacement increases bone density in adolescent girls with
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Excessive exercise in eating disorder patients and in healthy women
Mond, J.M., Calogero, R.M. Excessive exercise in eating disorder patients and in healthy women. Australian and New Zealand Journal of Psychiatry. 2009; 43: 277-34.
Managing anorexia nervosa
Nicholls, D., Hudson, L., Mahomed, F. Managing anorexia nervosa. Archives of Disease in Childhood. 2011; 96: 977-82.
Course and outcome of eating disorders in a primary care-based cohort
van Son, G.E., van Hoeken, D., van Furth, E.F., Donker, G.A., Hoek, H.W. Course and outcome of eating disorders in a primary care-based cohort. International Journal of Eating Disorders. 2010; 43: 130-8.
Minimizing and treating chronicity in the eating disorders: A clinical overview
Wonderlich, S., Mitchell, J.E., Crosby, R.D., Myers, T.C., Kadlec, K., Lahaise, K., Swan-Kremeier, L., Dokken, J., Lange, M., Dinkel, J., Jorgensen, M., Schander, L. Minimizing and treating chronicity in the eating disorders: A clinical overview. International Journal of Eating Disorders. (In press).
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Canberra Hospital Walk-in centre staff at work
Health fair at Hanover Presbyterian Church
This page was last updated on February 25, 2012.