Claudia Douglas, MD
Yolanda Evans, MD, MPH, FAAP
The COVID-19 pandemic has led to a significant increase in disordered eating in the United States. The rise in eating disorders is thought to be related to social isolation, increased anxiety and uncertainty, and decreased access to healthcare providers and mental health specialist. As a result, the National Eating Disorder Association has reported an almost 80% increase in the number of calls and online chats compared to a year ago. Amongst adolescent medicine subspecialty clinics, we are also seeing a significant increase among outpatient clinic referrals and patients who are admitted for medical stabilization due to complications of malnutrition from an eating disorder. The purpose of this bulletin is to provide guidance on managing patients with disordered eating in the primary care setting. The following is a general overview of frequently asked questions among referring providers.
- What are general nutrition recommendations for patients with an eating disorder?
- In general, 3 meals and 3 snacks a day are recommended for everyone. Less focus on calories with more emphasis on the consistency of eating balanced meals on at regular times throughout the day.
- What is the parent’s role?
- Parents/caregivers should prepare, serve, and monitor all meals/snacks. This means the teen is not involved in shopping or cooking and that parents take over this role temporarily (until the teen has restored weight or been engaged with a therapist to work on eating behaviors). Additionally, when possible, we recommend teens and caregivers eat together.
- How are eating disorders treated?
- The treatment of eating disorders is not just about getting to a set expected treatment goal weight. Restoration of weight (returning to historical BMI & weight trends on a growth curve) without appropriate mental health therapy is often ineffective at leading to recovery from disordered eating. Therefore, the most important part of the management of eating disorders is therapy. Family based therapy (FBT) has been shown to be the most effective for adolescents; cognitive based therapy (CBT), dialectical based therapy (DBT), and other types of therapy may be beneficial as well. The outpatient treatment of eating disorders often requires a multidisciplinary team that consists of a medical provider, dietitian, and the therapist. The role of the medical provider is to monitor weight trends, vital signs, and comorbidities associated with malnutrition. The dietitian’s role is to provide support around meal planning (including portions and content) and to determine the treatment goal weight. The role of the therapist is to help provide the diagnosis, including the type, or an eating disorder, explore other mental health comorbidities such as OCD, anxiety, or depression, and to explore the biopsychosocial factors that may have contributed to the eating disorder.
- When should I refer a patient to specialty care?
- Ideally, if a provider had concerns about a patient with disordered eating, they would place a referral to the adolescent medicine clinic and the patient would be seen within 2 weeks. During the initial visit, the patient and family would meet with a medical provider, social workers who provide mental health resources, and nurses who provide community resources such as caregiver meal support classes. If the patient did not already have a referral for a dietitian, a referral would also be placed during the initial medical visit. Due to the significant increase in referrals for evaluation of eating disorders in adolescent medicine, waitlists for initial intakes can be 1-2 months. Additionally, many mental health providers and higher level of care facilities may either be closed to new patients or also have 1-2 month waits because of the increased demand. Because of this, many providers are tasked with being the provider, dietitian, and mental health provider. Given the current high demand for services, providers should act early on referring to specialty services and empower families to contact specialty services as soon as concerns arise.
- What is the focus of the medical visit? How often should patients be seen?
- It is recommended patients come in for medical appointments frequently if their provider is concerned about a decline in medical stability (such as rapid weight loss, more rigid eating behaviors, over exercising, low heart rate). This can be as often as weekly or every 2 weeks. Vital signs, including resting heart rate, blood pressure, height, and weight should be obtained at every visit. We encourage a ‘blind weight.’ That is, the patient voids, disrobes and puts on a gown, then steps on the scale backwards so they do not see their weight. For heart rate and blood pressure, patient should be seated and calm (usually sitting for 3-5 minutes after entering the room) before values are obtained. In the outpatient setting, adequate weight gain for restoration is approximately 1-2lbs per week.
- When does a patient need emergency care? What are the criteria for medical admission?
- It is important to note that every hospital may have different admission criteria. If you, as a primary care provider, recommend a patient proceed to the local emergency department for evaluation, let the family know that admission will depend on the recommendations of the providers who evaluate the patient. Admission criteria in our institution have recently been modified in effort to decrease the spread of Covid-19. If there is a concern that a patient is medically unstable, direct the patient to the nearest emergency department or call 911. Current admission criteria at our institution include:
- HR <45bpm during the day
- EKG abnormalities (for example, prolonged QT)
- Electrolyte abnormalities
- Medical complications of malnutrition including syncope, heart failure, pancreatitis, seizures, etc.
- Relative indications for admission include weight less than 75% of the expected treatment goal weight, dehydration, hypotension, symptomatic orthostatic tachycardia. The presence of these relative indications does not guarantee medical admission but are very concerning. Ultimately, admission is at the discretion of the providers in the admitting institution.
- What can my patient expect if they are admitted for medical stabilization?
- Length of hospital stay is usually 10-14 days but can be longer. The patient will be on a heart monitor 24 hours a day. Labs will be collected daily for the first 5 days to monitor for refeeding syndrome. There will be several teams involved in the patient’s care, including the general medicine team who will be the primary team taking care of the patient. Consulting teams include adolescent medicine, psychiatry, and registered dietitian. There may also be a case manager to help with discharge planning and outpatient referrals. It is important to note that an admission for medical stabilization is truly for that reason. Treatment of the eating disorder, distorted thoughts that accompany it, and rigid behaviors are not the focus of medical admission. The patient will not receive therapy while inpatient on the medical floor; the goal of the psychiatry team during a medical admission is to access for other mental health comorbidities and in some instances to provide a diagnosis. Discharge is based on medical stability (i.e., HR >45 for 24 hours, correction of electrolyte abnormalities). Once patient is discharged, they should follow up with their medical provider weekly until they are able to establish care in adolescent medicine clinic or into a higher level of care. They should also follow up regularly with their therapist and outpatient dietitian.
- How do I manage exercise?
- If a patient is losing weight and exercising, it is recommended they stop all physical activity until they are safe to re-engage. Exercise is then introduced gradually when a patient is gaining weight appropriately (i.e., yoga or walking for 30 minutes /day, 2 days per week and advancing as tolerated). Signs that a patient is not ready to reintroduce exercise include lack of weight restoration/gain, bradycardia, significant dizziness/pre-syncope, unwillingness to change behavior associated with eating disorder, and obsession around exercising/losing weight.
- In a patient who has reached menarche, loss of menstrual period in combination with an eating disorder is an indicator of inadequate energy intake. Adding exercise will use additional energy and likely lead to prolonged amenorrhea. Addition of energy use (exercise) should be added with caution and nutritional guidance should be provided by a dietitian with expertise in this area to ensure appropriate balance of food. DEXA scan to assess bone mineral density is recommended after 6-12 months of amenorrhea. Supplementation with estrogen (such as through combined oral contraceptive pills) is not recommended in a patient with amenorrhea due to malnutrition. Increased food intake is recommended. Patients who have a restrictive eating disorder, secondary amenorrhea, and decreased bone mineral density may be at risk for injury including compression fracture.
- What is a higher level of care and should my patient be referred to one of these programs? What are my options for local facilities that offer higher level of care?
- Treatment can include outpatient (with PCP or adolescent medicine clinic), intensive outpatient, partial hospitalization, and residential programs. There are facilities in Washington as well as in other states that offer expertise in eating disorder care. All are different and have different approaches to working with families. Like most services, these programs are becoming increasingly difficult to get into and wait times are often 1-2 months. If you have a suspicion that a patient may need a higher level of care, strongly recommend the family call the program to set up an intake sooner rather than later. The individual program will determine the appropriate level of care for the patient based on their admission criteria. Each individual program will also work with the family on insurance authorization. Note that for families with Medicaid insurance, coverage can be challenging and may require additional steps (such as single case agreement). Due to the COVID-19 pandemic, many places are offering virtual options, however if families pursue care outside of Washington, there may be challenges with insurance coverage for telemedicine outside of the state.
Eating disorders are serious and potentially life-threatening conditions that require prompt intervention to prevent mortality and morbidity. Always review growth charts in medial encounters for concerning trends; when appropriate, inquire about the menstrual history, and reinforce the importance of consistent eating patterns when seeing an adolescent or young adult. Eating disorders are challenging for patients, families, and caregivers. However, it is important to remember that adolescents who receive timely treatment for an eating disorder often go on to lead healthy lives. Below are additional resources for the primary care provider who is treating someone with an eating disorder.
Treatment references for providers:
- Medical Care Standards for Eating Disorder Care:
- Guidebook for Nutrition Care for Eating Disorders:
- Evidence-Based Psychological Treatments for Eating Disorders Overview:
Resource for providers and parents:
- The National Eating Disorders Association: https://www.nationaleatingdisorders.org/
Print resources for parents:
- Your Child’s Weight: Helping without Harming by Ellyn Satter, 2005
Mental health referral line number for assistance with identifying community resources:
- Families or providers can call: 1-833-303-5437
Community programs offering services for the management of disordered eating:
- Seattle Children’s Adolescent Medicine
- The Emily Program
- Center for Discovery
- Eating Recovery Center
- The Evidence Based Treatment Centers of Seattle
- Opal (for patients over age 18 years)
- Thira Health (offering services for mood disorders)
- Sunrise Nutrition
- Mind/Body Nutrition
- The Veritas Collaborative
- Roger’s Memorial