Written By: Sara Scheler, RDN
I attended a lecture at the Colorado Society for Parenteral and Enteral Nutrition (CSPEN) nutrition support symposium in September, where Carrie Schimmelpfenning, RDN at Denver Health’s ACUTE eating disorder center, provided information regarding severely malnourished eating disorder patients. Carrie shared an overview of ACUTE, a review of common eating disorders, and nutrition therapy recommendations for critically ill eating disorder patients. The following is a summary of Carrie’s informative presentation.
ACUTE is an inpatient medical stabilization program for eating disorder patients—the only one if its kind in the country. Admission criteria includes weighing <70% of IBW, having a BMI <15, severe medical complications from an eating disorder, and/or needing to safely detox from laxative or diuretic abuse. ACUTE accepts male and female patients 17 years of age and older. Patients are seen 5 days/week by internal medicine doctors, registered dietitians, psychologists, psychiatrist, occupational therapists, physical therapists and speech therapists. They receive customized, daily meal plans and receive 24/7 observation for their first week. The goals of ACUTE are: to nourish the body with calories (the ultimate goal is a 2-3 pound per week weight gain), correct micronutrient/macronutrient deficiencies, empower clients to choose for themselves, provide nutrition education, and reduce disordered eating behavior.
Anorexia nervosa (AN)affects 0.9% of women and 0.1% of men nationwide. It has the highest mortality rate of any psychiatric disorder. The average recovery from anorexia nervosa is seven years; about 30% of patients never fully recover. Anorexia nervosa occurs when genetic predisposition meets an environmental trigger (abuse, social, trauma, etc.). The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) defines anorexia nervosa as:
- Restriction of energy intake leading to significant low body weight
- Intense fear of gaining weight
- Disturbance in the way a patient’s weight or shape is experienced or denial of the seriousness of their low weight
AN patients are categorized into one of two subtypes. Restricting anorexia nervosa involves severely restricted PO intake; these patients have not binged and purged in the past three months. A patient who has binged and purged in the past three months is characterized as binge-purge subtype. Patients can move back and forth between the two subtypes.
Bulimia Nervosa is characterized by recurrent episodes of binge eating (once per week or more), and recurrent compensatory behavior in order to prevent weight gain (laxatives, vomiting, diuretics and/or exercise). Bulimic patients typically present with a healthy BMI.
ARFID (avoidant-restrictive food intake disorder) is a newer ED diagnosis, in which patients chronically fail to meet appropriate nutritional and/or energy needs. Food avoidance in ARFID can be related to sensory issues (taste/texture avoidance) or a fear-based experience (Carrie shared that one of her patients choked on food when he was young and had a fear of eating related to that incident). ARFID patients typically present with significant weight loss, nutritional deficiencies, dependence on enteral nutrition and/or oral nutrition supplements, and abnormal psychosocial functioning due to their condition.
Carrie highlighted a few medical complications that are common among ED patients in detail:
Patients are at risk for refeeding syndrome if they weigh <70% of their IBW, have been NPO for 7-10 days, and/or experience >10% weight loss in the past 2-3 months. Refeeding syndrome is characterized by a metabolic shift of utilizing fat for energy to utilizing carbohydrates for energy. Hypophosphatemia, hypomagnesemia, hypokalemia and edema are classic signs of refeeding syndrome. Thiamine deficiency is also common, as carbohydrate metabolism requires thiamine.
Cardiac complications are common among eating disorder patients, as a starved body utilizes muscles in the heart for energy. Phosphorous depletion and edema exacerbate cardiac complications in AN patients.
Superior mesenteric artery syndrome occurs when the fat pad surrounding the duodenum disintegrates and compresses, causing nausea, vomiting, abdominal distention, diarrhea and abdominal pain. Nutrition therapy for this condition include an all-liquid diet (milk, ice cream, oral nutrition supplements, pudding, ice cream, etc.) until the patient can tolerate whole foods.
Fifty percent of anorexia nervosa patients have hepatitis, and it is common for AN patients to have AST and ALT values 2-3 times higher than normal. Refeeding hepatitis looks similar to fatty liver, where the liver enlarges. Nutrition therapy for refeeding hepatitis includes reducing carbohydrate intake to <45% of total calories and holding or reducing caloric intake until liver enzymes stabilize.
About 50% of AN patients experience gastroparesis. In this condition, the gastrointestinal tract slows during starvation, in order to absorb nutrients completely. Eating disorder patients may feel their disorder is reinforced by their GI symptoms, as any PO intake causes abdominal pain, bloating and discomfort. Carrie tells her patients “the only way out of this is through it.” A return to proper digestion will come in time, provided the GI tract is utilized. Nutrition therapy for gastroparesis in eating disorder patients involves small, frequent, low-fiber meals. A low-fat diet is typically recommended for gastroparesis, as fat increases gastric emptying time, however, Carrie still recommends 25% of her patients’ calories come from fat, as it is very difficult to meet energy goals with a low-fat diet. A patient would have to consume a high volume of low-fat foods in order to meet energy needs, and it is unrealistic to expect eating disorder patients to consume high-volumes of food.
Some ACUTE patients are on nutrition support, though Carrie explained that TPN is not recommended unless the case is very severe. Patients can manipulate their PICC line and harm themselves; they also need to feel their GI tract being utilized, in order to work toward a full recovery. Carrie recommends a post-pyloric NG tube if enteral nutrition is required. Some of her patients take nocturnal feeds, or are willing to accept a bedtime oral nutrition supplement instead. Hearing the machine pumping at night, Carrie explained, causes a great deal of anxiety for patients, so she is often able to bargain with them to accept a supplement and stay off nutrition support. Carrie recommends starting on a 1.2 kcal/ml formula and transitioning to a 2 kcal/ml formula, to decrease total volume.
“Almost all medical complications associated with eating disorders can be resolved with consistent nutrition and full weight restoration,” Carrie said. This is particularly exciting for dietitians, as our main goal is to provide adequate nutrition to restore patients to their full, healthy capacity.
Carrie discussed the “therapeutic relationship” dietitians have with ED patients: her job is to establish trust, establish autonomy and boundaries, provide acceptance, normalize patients’ experiences, struggles and thoughts, and remain open and curious when patients resist.
ACUTE admission line: 1-844-649-8844