Refeeding and Nutrition

Managing meals and eating behaviors during an inpatient medical admission presents many challenges. Unlike specialized units, general medical or psychiatric units often do not have an established treatment program for patients with eating disorders. To complicate matters further, patients admitted for medical complications of their malnutrition may be at significant risk for refeeding syndrome (Katzman 2005).

To effectively minimize such risks, staff need to closely monitor the patient's fluids and electrolytes. A dietician should provide input on the meal content and structure, which are usually divided into three meals and two or three snacks each day. Although the patient's regular food preferences should be considered, meals should be well balanced and varied. Liquid nutritional supplements such as Boost or Ensure can be used if the risk of refeeding syndrome is high. However, because the goal is for the patient to return to normal eating, regular food is preferred. Patients are expected to eat all pre

Table 10-4. Screening laboratory studies for patients with eating disorders

Amylase

Fatty acid ratio

Blood chemistry panel

Luteinizing hormone, follicle-stimulating hormone,

Bilirubin, aspartate aminotransferase:alanine

prolactin, estradiol

aminotransferase ratio, alkaline phosphatase,

Thyroid-stimulating hormone, free thyroxine (T4),

gamma-glutamyl transpeptidase, lactate

total triiodothyronine (T3)

dehydrogenase

Urinalysis

Calcium, magnesium, phosphate

Urine pregnancy test

Complete blood count with differential

Urine toxicity screen

Erythrocyte sedimentation rate

Vitamin D

scribed food portions, although liquid nutrition may be substituted if portions are refused. Patients should be supervised during all meals to ensure that food is consumed and for 1-2 hours after meals if purging is suspected. Families can be used to supervise meals if they understand the above guidelines. Staff and families need to be empathetic with the patient's anxiety around food while being firm and consistent about the need to eat (Honig and Shar-man 2000).

Nasogastric (NG) tube feeding can be used for patients who are unable to take in the required minimum amount of nutrition. NG tube feeding should be a last resort, not only because it may be traumatic for patients but also because it does not allow patients to practice confronting the anxiety associated with eating. In addition, some patients become de pendent on NG tube feeding. In such cases, the weight gain achieved with NG feeding is generally quickly lost following discharge from the hospital. Total parenteral nutrition is not usually required in the treatment of an eating disorder unless the patient has an accompanying general medical condition requiring treatment (American Psychiatric Association 2006).

Malnutrition can cause delayed gastrointestinal transit, leading patients to experience abdominal pain, bloating, and constipation during the refeed-ing process. A warm pack to the abdomen can be helpful, as can relaxation techniques such as deep breathing, guided imagery, biofeedback, or hypnosis. If necessary, stool softeners, promotility agents, and/or mild laxatives can also be used (American Psychiatric Association 2006).

Medical hospitalization

Psychiatric hospitalization

Failure of outpatient treatment

Uncontrollable bingeing and purging

Acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis) Comorbid diagnosis interfering with the treatment of the eating disorder

Severe malnutrition (i.e., weight < 75% average body weight for age, sex, and height) Dehydration

Electrolyte disturbance (e.g., hypokalemia, hyponatremia, hypophosphatemia) Cardiac dysrhythmia Acute food refusal Vital sign instability:

Heart rate < 50 bpm daytime; < 45 bpm at night Hypotension < 80/50 mm Hg Hypothermia < 96°F

Orthostatic change in pulse > 20 bpm or blood pressure > 10 mm Hg Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis)

Source. Reprinted from Golden NH, Katzman DK, Kreipe RE, et al: "Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine." Journal of Adolescent Health 33:496-503, 2003. Copyright 2003, The Society for Adolescent Medicine. Used with permission.

Table 10-5. Suggested indications for medical and psychiatric hospitalization

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