Outpatient Medical Considerations for Those with Eating Disorders

Outpatient Medical Considerations for Those with Eating Disorders

By Jennifer L. Gaudiani, MD, CEDS, FAED

As an outpatient internal medicine physician who specializes in eating disorders, I get to work on the front lines with therapists and dietitians, helping promote recovery work within the context of an individual’s everyday life. Some of my patients have never needed to step up to a higher level of care, and others arrive at my clinic having just completed their first, or 10th, full course of residential, partial hospitalization program, and intensive outpatient program care. I take care of adolescents and adults, of all shapes, sizes, and genders, with disordered eating and eating disorders.

There are four key topics that this article will cover. One, I will review guidelines for appropriateness of outpatient care. Two, I will highlight the main considerations medically for those who purely restrict … whether that occurs in the setting of low body weight, so-called normal body weight, or higher body weight. Three, I will discuss the major medical issues in those who purge. Finally, I will consider important weight-stigma-associated mistakes practitioners make and highlight the importance of a Health at Every Size® approach for those with binge eating disorder and patients in general. Of course, a comprehensive review of this set of topics would take a whole book, so I will review each topic briefly.

An outpatient with an eating disorder should have a multidisciplinary team, composed of at least a therapist and a dietitian who have eating disorder expertise. Optimally, a physician with eating disorder knowledge—or a willingness to learn—should join this team so that the therapist and dietitian are not required to step out of scope of practice and advocate for/interpret medical care. This team can certainly be joined by many other practitioners, from a psychiatrist to any number of specialists as needed. The team has the responsibility of communicating regularly with one another, allying always with the recovery process and one another to provide a united front against the pressure of the eating disorder, and should take a non-assumptive, patient-values-oriented approach. That is, when patients identify their top motivations to get better, and the team continually refocuses the recovery struggle around those motivations, patients feel they are being seen as a whole person. The physician can productively demonstrate objective evidence of body suffering from the eating disorder and use that to help patients understand that they are sick enough to progress with the recovery process. Many patients feel, in the throes of the mental illness, that they are “fine” and, therefore, have no reason to make changes in their eating-disordered behaviors.

Just as the team has responsibilities to the patient, the patient has responsibilities to continue to earn the privilege of remaining outpatient, rather than stepping up to a higher level of care. Outpatients should be seeing their multidisciplinary team regularly and need to grant open communicative access among those team members. Patients need to be able to follow, for starters, the fundamental medical rules that the team establishes: consuming (and not purging) a basic, sustaining number of calories each day; purging infrequently enough that blood laboratory values are minimally abnormal; moving physically at a level approved by their medical provider (and no more); and using substances in ways that appear safe in the outpatient setting. There may be other rules that the therapist establishes for safe outpatient care, related to self-harm, suicidality, and severity of comorbid psychiatric conditions. To remain in the outpatient setting over time, patients need to show at least slow progress toward recovery, or be able to maintain goals recently achieved. The rate of progress required will depend to a certain extent upon the patient’s individual presentation. A young teenager, for instance, with new onset anorexia nervosa, should make consistent weight gain progress of at least 1 to 2 pounds per week in the outpatient setting. On the other hand, a middle-aged patient with a lifelong eating disorder might be permitted to maintain a low body weight in the service of a harm reduction model, if that patient feels unable to restore beyond a certain weight without a relapse in behaviors. The power of a united treatment team to set expectations and hold patients accountable to their recovery journey, in a compassionate but firm way, cannot be overestimated. Patients who cannot consistently achieve the above criteria typically belong in a higher level of care, if insurance benefits are available.

The outpatient medical complications of restrictive eating typically center on metabolic slowing, organ dysfunction as a result of malnourishment, and risks that emerge from nutritional rehabilitation. When exposed to a chronic imbalance of energy intake compared with physical exertion, one’s “cave-person brain” or “animal brain” (the part of our brain that runs the day-to-day functions of our bodies) makes dramatic physiologic changes designed to slow the metabolism and spare calories. For athletes, this process is called Relative Energy Deficiency in Sport (RED-S), replacing the older, narrower, and exclusive Female Athlete Triad.[1]

In an attempt to conserve heat, the body temperature drops, lanugo hair is regrown as a “pelt” on the face, fingers and toes become cold as the microcirculation clamps down to spare energy loss, and the individual shivers and seeks warm clothing and fluids. The heart rate slows owing to high vagal/parasympathetic tone, much like a bear’s in winter. Where an athlete’s heart will stay slow at rest and with minimal exertion, such as walking down the hall and back, a starving person’s heart will be slow at rest but may increase by 75 percent or more (say, from 50 to 90) with ambulation, because of overall muscle loss and deconditioning. This is a key distinguisher between an “athletic heart” and a “starving person’s heart,” and will occur even if the patient has continued to overexercise while restricting.

The digestion slows down, causing gastroparesis—early satiety, nausea, and bloating after even small meals—and constipation, as the cave-person brain elects not to spend an extra calorie on a wriggle of the viscera. The hypothalamus of the brain rolls back in time to preadolescence in terms of hormone production, causing low levels of estrogen and testosterone in females and males. We now know that menstrual function varies widely across the spectrum of weight and caloric intake, with some patients continuing normal menstrual cycles despite being significantly underweight, and others failing to resume their periods even after a year of adequate weight restoration. In the setting of low sex hormones and high stress hormones resulting from malnutrition, bone density can fall rapidly. Low bone density is considered one of the few medical complications of anorexia nervosa that may never fully recover.

In addition to the above complications caused by slowed metabolism, some body systems simply begin to fail in response to malnutrition. The hair and skin can become dry and brittle. The bone marrow, which makes the cells of the blood, can stop functioning, causing leukopenia (low white blood cells), anemia (low red blood cells), and thrombocytopenia (low platelets.)[2] The liver can begin to consume itself, with elevations in the AST and ALT blood tests.[3] Perhaps most dangerous, hypoglycemia (low blood sugar) can develop. In the setting of chronic restriction, the body uses up its stores of glycogen in the liver and in muscle and then must rely on muscle breakdown to synthesize glucose. When the need for glucose—the only fuel that the brain can use—outstrips the body’s ability to break down muscle, hypoglycemia ensues.[4] This can cause seizure, coma, brain damage, or cardiac arrest. Hypoglycemia may actually be the cause of cardiac arrest in anorexia nervosa. It’s not that the heart slows to a stop, it’s that it runs out of fuel.

Refeeding syndrome is a third major category of medical complications of restriction. When a malnourished person begins to take in nourishment again, major shifts in electrolytes and fluids can cause serious problems with the heart, blood cells, respiration, and brain. Low blood levels of phosphorus are the most dangerous, while fluid buildup in the feet and ankles that feels triggering and uncomfortable can, rarely, progress to dangerous fluid buildup in the lungs. As long as one monitors patients for low phosphorus levels during refeeding, it is not hard to replace phosphorus with oral solutions. Older strategies of starting calories very low to prevent refeeding hypophosphatemia, however, have been debunked as causing the “underfeeding syndrome,” in which patients continue to lose weight and experience worsening organ function because of initiation of calories at too low a level. Refeeding syndrome is more correlated with very low body mass index than it is with initial caloric intake.[5],[6],[7] Patients in almost any setting can safely be started on 1600 kcal/day and should rarely be started lower, as long as blood tests are drawn appropriately to check for phosphorus levels.

In patients who purge, medical complications arise mostly from the type and degree of purging, as well as from the process of purging cessation itself. Purging by vomiting can cause severe dental erosion, mouth sores, precancerous changes of the esophagus, esophagus or stomach bleeding, volume depletion (the medical term for dehydration), and critical electrolyte abnormalities. Purging by laxative abuse, the second-most-common mode of purging, can cause severe volume depletion, electrolyte abnormalities, acidosis of the blood, and possibly long-term colonic damage from stimulant laxatives. Purging by diuretic abuse can cause kidney damage to the point of needing permanent dialysis, and can also cause volume depletion and electrolyte derangement.

The most common electrolyte abnormalities found in those who purge are low potassium levels (hypokalemia), low sodium levels (hyponatremia), and high bicarbonate levels (hypercarbia). Potassium is lost in the vomit, stool, and urine. Very low levels, such as those below 3 mEq/L, can cause muscle cramps, seizure, and cardiac arrest. Low sodium levels in those who purge usually relate to volume depletion and will normalize when appropriate salt and water have been administered either by mouth or intravenously. Bicarbonate levels above 30 mEq/L (normally 22 to 28) reflect volume depletion, while levels above 40 mEq/L mark a medical emergency that must be managed in a hospital owing to high risk for complications.

The cessation of purging can also prove medically problematic. The chronically dehydrated body overproduces aldosterone, produced in the adrenal glands, in anticipation of future hydration. Aldosterone prevents the kidneys from excreting salt and water. This is because the body wants to hold on to these life-sustaining nutrients and not waste them in the urine. Thus, patients who receive rapid infusions of intravenous fluids can end up severely edematous (retaining salt and water). This shows up visibly and on the scale, which can alienate and frighten patients. In rare situations, it can lead to fluid in the lungs and brain, which is life-threatening. Secondary hyperaldosteronism, or Pseudo-Bartter syndrome, as this physiologic process is called, is appropriately diagnosed in a patient who purges and has a bicarbonate level above 30 mEq/L.[8] Those who abuse laxatives can have a misleadingly low bicarbonate level, so a high degree of clinical suspicion for chronic dehydration is sufficient to make the diagnosis. Pseudo-Bartter syndrome can be managed successfully across care settings. Providers should recommend no more than 2 to 3 liters of daily fluid intake and absolute cessation of purging, as well as use of spironolactone to block the aldosterone until the body adjusts after two or three weeks without purging. Those who abuse laxatives are likely still to note impressive changes in weight when abuse stops, because they are so much more volume-depleted than those who purge by other mechanisms. They tend to need a higher dose of spironolactone and for a longer period of time.

Finally, I believe it vital to address the topic of weight stigma. Weight stigma is a serious issue that has major medical implications across virtually all patients, with eating disorders or without. Physicians are known to be serious perpetrators of weight stigma.[9],[10] Patients with all the torments and behaviors of someone with classic anorexia nervosa, who aren’t formally “underweight,” are all too often invalidated, marginalized, and dangerously missed by the medical system. In fact, these patients do meet the criteria for the DSM-5 diagnosis “atypical anorexia nervosa,” but this often isn’t recognized. Patients in larger bodies who drop weight through dangerous, eating-disordered means are often praised for their weight loss. Patients with binge eating disorder (BED) may not be screened for an eating disorder, as practitioners (who are often size-privileged) assume their higher weight results from “poor choices.” Meanwhile, typical office practices have body mass index charts, color coded green/yellow/red, right in front of the dreaded scale, plus a tendency to bring every conversation back to weight-loss techniques and size disapproval, even when the chief complaint is completely unrelated to weight. These tendencies chill a patient’s willingness even to walk through the clinic door. This is unacceptable, and bad medicine.

Not everyone with BED is in a larger body, and not everyone in a larger body has BED. Our thin-obsessed culture, which flows over into the halls of power of a medical clinic, assumes thin equates with healthy. This assumption neglects the fact that healthy people in larger bodies, with good exercise capacity, may live longer than those in smaller bodies who don’t move much.[11] Furthermore, the act of engaging in regular aerobic exercise and/or resistance training causes life-prolonging changes in a number of cardiovascular risk factors, independent of any change in body weight.[12]

The Health at Every Size (HAES®) philosophy is one I have fully adopted in my outpatient practice. It promotes the acceptance that individuals come in a diversity of shapes and sizes. When patients eat a broad variety of foods, in sufficient quantities to nourish the body’s daily needs and their own enjoyment; move for joy and vitality as able; and attend to their mental-health needs, they will be as healthy, related to their size and nutrition, as they can be. HAES never promotes a weight-loss or dieting culture, because study after study shows that dieting does not work. I want to note that I locate this topic with privilege and social justice considerations because many people don’t have access to good food or safe spaces to move, and their bodies aren’t safe in society. HAES does not mean “everyone in every-size body is healthy.” Instead, it reminds us that we cannot simply look at someone and assume from the body’s appearance something about that person’s health. Nonetheless, this is an activity physicians engage in every day, whether consciously or unconsciously. Medical professionals, myself included, must continually question the ways we were trained to consider the topics of size and weight. We must use compassionate, evidence-based practices and pay attention to the mental-health aspects of medical care.

In this article, I reviewed some key medical topics that apply to the outpatient setting. While there are good primary care practitioners who understand eating disorders, many of them work in higher levels of care. This can leave outpatients (and their families and teams) in the challenging position of having to teach medical providers what to look for, how to evaluate medical findings congruent with the unique physiology of those with eating disorders, and how to communicate that information in a way that is recovery-motivating rather than triggering. Probably the single-best resource patients and families can bring to willing but inexperienced practitioners is the superb Academy for Eating Disorders “Eating Disorders: A Guide to Medical Care,” which is available as a free download.[13]

In sum, careful attention to the medical complications of eating disorders, at all body sizes and shapes, significantly improves the recovery process. A multidisciplinary team, ideally including a medical practitioner with eating disorder expertise or a willingness to learn, serves patients best by seeing them as whole people.

About the author:

Jennifer L. Gaudiani, MD, CEDS, is the Founder and Medical Director of the Gaudiani Clinic. Board Certified in Internal Medicine, she completed her undergraduate degree at Harvard, medical school at Boston University School of Medicine, and her internal medicine residency and chief residency at Yale. From 2008 to 2016, she was one of the leaders of the ACUTE Center for Eating Disorders at Denver Health, the nation’s top medical stabilization center for adults with eating disorders who are too medically compromised to receive care in a mental health setting. She left as its Medical Director to found the Gaudiani Clinic, which provides superb outpatient medical care to patients with eating disorders and disordered eating, of all shapes and sizes. Through a collaborative, communicative, multi-disciplinary approach, the Clinic cares for the whole person, in the context of their values. She has lectured nationally and internationally, is widely published in the scientific literature as well as on blogs, and sits on the board of IAEDP (International Association of Eating Disorder Professionals) as the only internist. Dr. Gaudiani is one of very few outpatient internists in the US who carries the Certified Eating Disorder Specialist designation.

References:

[1] Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R., & Ljungqvist, A. (2014). The IOC consensus statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(7), 491-497.

[2] Sabel, A.L., Gaudiani, J.L., Statland, B., & Mehler, P.S. (2013). Hematologic abnormalities in severe anorexia nervosa. Annals of Hematology, 92(5), 605-613.

[3] Rosen, E., Sabel, A.L., Brinton, J.T., Catanach, B., Gaudiani, J.L., & Mehler, P.S. (2016). Liver dysfunction in patients with severe anorexia nervosa. International Journal of Eating Disorders, 49(2), 151-158.

[4] Gaudiani, J.L., Sabel, A.L., Mascolo, M., & Mehler, P.S. (2012). Severe anorexia nervosa: Outcomes from a medical stabilization unit. International Journal of Eating Disorders, 45(1), 85-92.

[5] Smith, K., Lesser, J., Brandenburg, B., Lesser, A., Cici, J., Juenneman, R., Beadle, A., Eckhardt, S., Lantz, E., Lock, J., & Le Grange, D. (2016). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa and atypical anorexia nervosa at Children’s Hospitals and Clinics of Minnesota. Journal of Eating Disorders, 4,35.

[6] Peebles, R., Lesser, A., Park, C.C., Heckert, K., Timko, C.A., Lantzouni, E., Liebman, R., & Weaver, L. (2017). Outcomes of an inpatient medical nutritional rehabilitation protocol in children and adolescents with eating disorders. Journal of Eating Disorders, 5, 7.

[7] O’Connor, G., Nicholls, D., Hudson, L., & Singhal, A. (2016). Refeeding low weight hospitalized adolescents with anorexia nervosa: A multicenter randomized controlled trial. Nutrition in Clinical Practice, 31(5), 681-689.

[8] Bahia, A., Mascolo, M., Gaudiani, J.L., & Mehler, P.S. (2012). PseudoBartter syndrome in eating disorders. International Journal of Eating Disorders, 45(1), 150-153.

[9] Bombak, A.E., McPhail, D., & Ward, P. (2016). Reproducing stigma: Interpreting “overweight” and “obese” women’s experiences of weight-based discrimination in reproductive healthcare. Social Science & Medicine, 166, 94-101.

[10] Phelan, S.M., Burgess, D.J., Yeazel, M.W., Hellerstedt, W.L., Griffin, J.M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews, 16(4), 319-326.

[11] Lavie, C.J., De Schutter, A., & Milani, R.V. Healthy obese versus unhealthy lean: The obesity paradox. (2015). Nature Reviews Endocrinology, 11(1), 55-62.

[12] Italian Diabetes Exercise Study (IDES) Investigators; Balducci, S., Zanuso, S., Cardelli, P. … Pugliese, G. (2012). Changes in physical fitness predict improvements in modifiable cardiovascular risk factors independently of body weight loss in subjects with type 2 diabetes participating in the Italian Diabetes and Exercise Study (IDES). Diabetes Care, 35(6), 1347-1354.

[13] (https://www.aedweb.org/index.php/education/eating-disorder-information/eating-disorder-information-13)

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