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.