31st January 2024

Management

Refeeding

Gradual refeeding can be commenced in the community or a psychiatric unit in a patient with a low risk of refeeding syndrome. There is a careful balance required to feed gently enough to avoid refeeding syndrome but also to avoid underfeeding the patient. Therefore, decisions on how to feed are usually informed by a dietitian, though manuals, meal plans, and more intricate guidance exist. In medical inpatient settings, refeeding and meal plans are often advised by dietitians, especially when needing to use NG tubes. Food is usually commenced at 20calories/kg/day, increasing gradually over 14 days to aim for a weight gain of 500g/week. Lower rate feeds are used where risk of refeeding syndrome is greater. In addition, supplements are often required, usually as Forceval once daily and Pabrinex (1 pair daily) or Vitamin B Co-strong 1-2 tablets TDS, Thiamine (50mg QDS), and in inpatient environments, phosphate supplements (500mg BD) often as a prophylaxis for refeeding syndromes. Although refeeding is necessary to save the patient’s life, it will also treat some of the psychological symptoms, as a starved brain exacerbates a negative body image, increases obsession with food, and produces a depression-like syndrome to reduce activity and conserve energy. Daily bloods (in those with red flags) to twice weekly or once weekly bloods for at least 2 weeks are needed to monitor for improvement and refeeding syndrome. 

Assessing risk of refeeding syndrome is complex, and little research exists to create a good risk stratification. Indeed, doctors can be falsely reassured as physical signs, including blood tests of significant malnutrition, do not appear until just before the patient collapses. Definitions of refeeding syndrome are also varied and complex; however, the MEED guidelines provide a definition of :

• Phosphate <0.32mmol/L
• Potassium <2.5mmol/L 
• Magnesium <0.5mmol/L
•  Oedema and/or organ dysfunction, i.e. cardiac failure, respiratory failure, pulmonary oedema or significantly raised transanimases. 

Legal aspects

A person with an eating disorder can and often will consent to refeeding, as insight is often intact. Sympathy, negotiation and avoiding arguments are key to finding a treatment plan that allows a patient to regain a healthy weight without resorting to restrictive measures. A key part of negotiation is finding food that is initially acceptable to the patient (though returning to these foods later is a key part of treatment) and addressing the person’s life goals and how treatment allows them to achieve goals (whereas continuation of the eating disorder could stop them) could help with motivation with treatment plan adherence. However, for some who lack insight or are overwhelmed by the compulsion to not eat or to purge, then feeding against their will is necessary to save their lives. There may also be need for other restrictions on liberties, including admission to hospital against their will, to restrict exercise, advising to be on complete bed rest, use of a wheelchair for mobilising to the bathroom, and supervision of toilet and bathroom use (to avoid purging) and constant nursing observation to help the patient from sabotaging their treatment, including by doing disguised exercise such as muscle clenching.

The tools available to legally deprive someone of their liberties would be the Mental Capacity Act or Mental Health Act. Whilst it can be argued a patient’s inability to weigh up a decision is influenced by the presence of the eating disorder, usually the Mental Health Act is used, as there are provisions for force-feeding as a treatment. Indeed, this is the only time the Mental Health Act can be used to treat a physical illness or physical manifestations of a mental illness. That is because feeding, even against the patient’s wishes, can improve the patient’s anorexic cognitions. Often, a medical SHO will be tasked with placing a patient on a section 5(2) of the Mental Health Act as the hospital’s ‘nominated deputy’. This allows them to keep the patient admitted to an inpatient ward (i.e. not A&E or outpatient clinic) against the patient’s consent for 72 hours. This does not allow for treatment against the person’s wishes; it will trigger a full Mental Health Act assessment, and the resulting section the patient moves to – either section 2 or section 3 – allows force-feeding, and only if all other methods (referred to in the act as least restrictive options) have been exhausted, i.e. negotiation and adaptation. Only when compliance with treatment plans ends and negotiation and discussion are exhausted, are the skills of mental health nurses required, who are trained in restraint. Often, psychiatric medications, including benzodiazepines and the antipsychotic medication Olanzapine, are helpful for anxiety around refeeding. 

 A patient with an eating disorder does not require a medical bed for the entirety of their refeeding. Decision to transfer to a psychiatric unit is often made based on what facilities are available within the psychiatric unit. This usually means that if a patient requires daily or two daily blood tests, frequent monitoring of physical observations, IV fluids and electrolytes, this is beyond the capacity of most psychiatric inpatient units, although available in some eating disorder specialist units. Care needs to be given with IV fluids, as overhydration is common, and use of 5% dextrose can trigger refeeding syndrome. 

Psychiatric

The initial treatment is psychoeducation and setting regular weekly, then fortnightly appointments for monitoring of weight, as well as assessment of height to determine the patient’s ‘healthy’ weight, determined by BMI. In adults, the main treatment is a modified form of cognitive behavioural therapy (CBT) where thoughts, emotions, physical sensations and actions are linked to understand how the eating disorder behaviour is linked and perpetuated and understand how to break the cycle. In children and adolescents, the main treatment is family therapy. 

Assessing and addressing emotional needs is very important too, as this population has the highest rate of suicide of all mental disorders.

References

• World Health Organization (2019). International Statistical Classification of Diseases and Related Health Problems, Chapter 6: Feeding or eating disorders (11th ed.). https://icd.who.int/
• National Institute for Health and Care Excellence (2017). Eating disorders: recognition and treatment. (NICE Guideline number 69). https://www.nice.org.uk/guidance/ng69
• Royal College of Psychiatrists (2022). MEED. Medical Emergencies in Eating Disorders. RCPsych Guideline CR 233