Presenter: Kate Wimberly, MD
Dr. Wimberly’s PHM 2023 session presented updates to the inpatient management of eating disorders that included indications for hospitalization for medical stabilization, recommendations for nutritional rehabilitation, and the use of FBT, or family-based therapy.
She reviewed the spectrum of eating disorders and the differences between them. With an 8% lifetime prevalence for females and 2% for men, and a doubling of inpatient admissions and emergency department visits during the first year of the pandemic, Dr. Wimberly highlighted how we, as hospitalists, are likely to care for hospitalized patients with eating disorders.
She discussed factors supporting acute medical hospitalization for eating disorders as published in the Society for Adolescent Health and Medicine’s position paper on the management of restrictive eating disorders. The proposed admission criteria include body mass index (BMI) of <75% of the median for age and sex, dehydration, electrolyte abnormalities, electrocardiogram abnormalities, comorbid medical or psychiatric conditions that prohibit appropriate outpatient management, arrested growth and development, failure of outpatient treatment, acute food refusal, uncontrollable binging or purging, medical complications of malnutrition (such as syncope, pancreatitis, cardiac failure, or seizures), and physiological instability (evidenced by heart rate less than 50 bpm during the day or less than 45 bpm at night, blood pressure less than 90/45 mmHg, temperature less than 96 degrees Fahrenheit, or abnormal orthostatic vitals).1
Dr. Wimberly highlighted her institution’s use of a malnutrition severity classification system, using the percentage of body weight lost and percent median BMI to determine an initial calorie goal, calorie advancement schedule, lab frequency, and need for telemetry. Prior recommendations for nutritional rehab advised to “start low and go slow,” but recent studies have shown we can start nutritional rehab at higher calories, and advance calories faster, leading to shortened hospital lengths of stay, without an increase in adverse effects such as refeeding syndrome.
The importance of a multidisciplinary approach to treatment and partnering with the family through the use of family-based therapy was discussed and examples were given as to how family partnerships could be started during the acute hospitalization. Dr. Wimberly also highlighted the instrumental role psychiatry plays in eating disorder diagnoses and management. She ended the presentation by talking about the impact our words can have on a patient’s perception of themselves and their eating disorder. She recommended being mindful of our language and addressing food and body size in a nonjudgmental manner.
- Admissions for eating disorders have dramatically increased in recent years. With this increase in disease, there has also been a growth in research surrounding eating disorders with recent publications discussing risk stratification of malnutrition in patients with eating disorders and proposed inpatient criteria for medical stabilization.
- We no longer need to approach nutritional rehab in a “start low and go slow” manner. Studies have shown benefits, without serious adverse events, to starting nutritional rehab at higher calories and increasing calories quicker.
- Treatment of an eating disorder requires a multidisciplinary approach with family involvement being vital.
Dr. Callahan is a pediatric hospitalist and assistant professor of pediatrics at Norton Children’s Hospital and the University of Louisville in Louisville, Ky.
- Society of Adolescent Health and Medicine. Medical Management of Restrictive Eating Disorders in Adolescents and Young Adults. J Adolesc Health. 2022;71(5):648-54.