Severe eating disorders may be accompanied by life-threatening medical complications that require stabilization before psychiatric treatment.

1. Medical Management of Severe Eating
Disorders
By The Doctor Weighs In

2. Introduction
• Severe eating disorders are the only mental illnesses
regularly accompanied by dangerous, life-threatening
medical complications. Significant medical instability
results from a number of abnormalities, such as
progressive malnutrition, purging behaviors, and blood
chemistry abnormalities.
• In fact, the disorder can compromise virtually all of the
body’s vital organs and systems.
• There are a number of different eating disorders that lead
to excessive weight loss and associated medical
complications.
• Related content:
What You Need to Know About Eating Disorders
Eating Disorders: Risk Factors, Diagnosis, Treatment,
and Outcomes

3. Medical Complications of Severe
Eating Disorders

4. Medical Complications of Eating
Disorders Can Be Treated Effectively
• The good news is that nearly all medical complications of
eating disorders can completely resolve with safe nutritional
rehabilitation and weight restoration. This is true regardless of
how extensive they are.

5. Many Patients with Severe Eating Disorders
will Require a High Level of Care
• More than one-third of individuals suffering from
eating disorders will require treatment at a higher
level of care. This can range from 24-hour
inpatient psychiatric care to comprehensive
daytime behavioral programming.
• Most treatment programs offer some degree of
minimum internal medicine and/or nursing support
to manage medical issues of eating disorders.
However, some patients may be so medically
compromised by their illness that they require
specialized medical, hospital-based stabilization
prior to entering a residential eating disorder
treatment program.

6. Determining The Appropriate Level of Care
Needed
• It is not uncommon for patients, families, and
providers to begin with the least intensive
intervention. However, starting a treatment plan
with the appropriate level of care can have a
significant impact on the patient’s health. It is also
a factor that influences success in recovery and
satisfaction with treatment.
• The American Psychiatric Association (APA) has
outlined five levels of psychiatric care. They are
divided between outpatient and inpatient
treatments.

7. Weight Specific Recommendations to
Levels of Care
• It is important to remember that no guideline is absolute when it comes
to these complex illnesses. The frequency of purging behaviors and
other physical or psychiatric symptoms must be considered alongside
patient weight to ascertain the appropriate level of care that may be
needed.

8. What is Inpatient Medical Stabilization for
Eating Disorders?
• In general, initial medical stabilization in a hospital-
based unit is recommended for eating disorder
patients who are severely low weight, seriously
medically compromised, or at risk for major
complications from refeeding syndrome. The latter
is a dangerous metabolic disturbance that can
occur when nutritional rehabilitation is first initiated.
• Patients with any/all of the following criteria may
require medical treatment from experienced
providers in a specialized medical hospital unit
before entering a behavioral treatment program in
a traditional eating disorder unit.

9. What is The Goal of Medical Stabilization of
Patients with Severe Eating Disorders?
• The goals of medical stabilization are to improve and
normalize the patient’s vital signs, cardiovascular
system, and bowel function as well as restore levels of
key electrolytes including phosphorus, potassium,
magnesium, and calcium in a timely manner. Medical
stabilization also involves nutritional rehabilitation to
support weight restoration.
• Most experts agree that careful caloric initiation is vital
to medical stability and improved cognitive function. It is
hallmarked by the ability to tolerate and complete the
most basic activities of daily living. Inpatient medical
units have the expertise and resources to deliver any
form of nutrition required, including oral, enteral, or
intravenous calories.

10. Understanding The Difference Between
Medical and Psychiatric Treatment
• It is also important that providers, patients, and families
understand the difference between inpatient psychiatric
treatment and inpatient medical stabilization for the most
severe eating disorders.
• While an inpatient psychiatric facility offers round-the-clock
behavioral treatment and likely some degree of medical
support, an inpatient medical stabilization program requires a
hospital-based telemetry unit.
• Its full-time internal medicine physicians, nurses, dietitians,
and skilled rehabilitation providers expertly treat any life-
threatening medical complication of severe eating disorders.
These medical teams collaborate with psychiatrists,
psychologists, and behavioral health technicians to support
behavioral recovery.

11. Avoiding Refeeding Syndrome
• Increasing caloric intake quickly in individuals with
severe anorexia nervosa or ARFID, without
frequent monitoring of blood tests and electrolyte
replenishment, can lead to refeeding syndrome. A
dangerous shift in fluids and electrolytes within the
body are characteristic of the disorder.
• It occurs in a small subset of patients when
calories are introduced quickly, lab tests are not
checked frequently, and resultant abnormalities
are not treated in a timely fashion. The lower the
patient’s BMI, the greater the risk of refeeding
complications.

12. Eating Disorder Patients with Normal
or High BMI
• Assuming that patients with a “normal” or
“higher” BMI are always stable enough to
access lower levels of care may inadvertently
cause harm. Some of these patients may
present with a falsely elevated weight.
• They can also be at risk for dangerous
complications due to excessive purging
behaviors followed by abrupt cessation or
significant and rapid “weight disruption” that is
marked weight loss over a short period of time.

13. The Bottom Line on The Management of
Severe Eating Disorders
• Eating disorders at any stage are complex and can be life-
threatening. Seeking treatment for a severe eating disorder can
be overwhelming.

14. Get in Touch
The Doctor Weighs In
Author: Philip Mehler, MD, FACP, FAED, CEDS
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