Eating disorders are mental illnesses, but they pose significant risks to a patient’s physical health. They affect nearly every part of the body — from the nervous system to the brain to the heart to the digestive tract — and these effects can be quite serious. In fact, eating disorders have the second highest mortality rate of all mental illnesses, behind only opioid addiction.
Because of these effects on physical health, eating disorder patients sometimes need medical stabilization in a hospital before they can begin to address the psychological, emotional, and behavioral aspects of their illness through outpatient eating disorder treatment. In general, outpatient treatment should be the first line of defense for an eating disorder, as it causes the least disruption to a person’s life and research shows that it’s just as effective as more intensive forms of treatment.
Though Equip is a fully virtual program, our treatment is appropriate for patients needing all levels of care, including higher levels of care like PHP or residential programs — in fact, 75% of Equip patients meet criteria for residential treatment. The one exception is when a patient is medically unstable, in which case inpatient hospitalization is the safest choice. Once a patient is medically stabilized, they can step down to Equip.
But deciding whether or not a patient needs to be admitted for medical stabilization can be a tough call for healthcare providers to make. To help providers navigate this important decision, Michele Zucker, MD, Medical Director at Equip, answered some of the common questions providers have about hospitalization for eating disorder patients.
Why might a patient with an eating disorder need hospitalization?
Serious physical health risks of eating disorders are often the result of a lack of adequate nutrition (also known as Low Energy Availability or LEA) and the associated weight loss. Some of the potential physical consequences of LEA are:
- Abnormal heart rhythms, including very low heart rates (bradycardia) that can lead to death if not managed properly
- Kidney damage or failure
- Liver dysfunction or failure
- Pancreatic dysfunction and pancreatitis
- Slowing of movement of food through the gastrointestinal system that leads to vomiting and inability to keep in food
- Low blood pressure, which can lead to dizziness on standing and fainting
- A weakened heart, and potentially even heart failure.
- Severe malnutrition may also cause a condition called pericardial effusion, where fluid accumulates in the sac surrounding the heart. If this fluid collection becomes large enough, the heart is unable to beat properly to keep blood moving throughout the body.
Other dangerous eating disorder behaviors can also lead to serious medical complications:
- Vomiting to get rid of food may result in bleeding from the esophagus, which can cause a significant amount of blood loss. Excessive vomiting can also lead to potentially dangerous changes in the body’s acid/base status, as well as low potassium.
- Overuse of laxatives can cause low levels of potassium, sodium, magnesium, and phosphorus, which can affect nearly every organ system.
- Excessive exercise contributes to low heart rates.
- Water loading (drinking excessive amounts of water or other fluids) can cause dilution of electrolytes including potassium and sodium. Very low sodium levels can cause seizures.
- Avoidance of drinking adequate fluids or overuse of diuretics can lead to dehydration, which can contribute to kidney dysfunction or failure, dizziness, and fainting.
Studies have found that the faster the rate of weight loss and the larger the degree of weight loss, the more likely someone is to experience a complication called refeeding syndrome. Refeeding syndrome is a condition that can occur when someone starts eating again after a period of very low nutrition, and it can result in shifts in fluids and electrolytes (most commonly phosphorus, potassium, and magnesium). These fluid and electrolyte shifts may affect many organ systems, and can lead to serious complications, including body swelling, double vision, confusion and disorientation, nausea and vomiting, muscle weakness, trouble breathing, abnormal heart rhythms, and even death if not properly managed.
What criteria should I use to determine if a patient needs hospitalization?
At Equip, we follow the American Psychiatric Association Practice Guidelines and the Society for Adolescent Health and Medicine factors to support hospitalization to determine if a patient may need to be hospitalized for medical stabilization before beginning or resuming Equip treatment.
- Very low weight (<75% of the 50th percentile BMI for age and sex)
- Electrolyte disturbance (low potassium, sodium, phosphorus)
- Physiologic instability
- Severely low heart rate (<50 beats/minute daytime; <45 beats/minute sleeping)
- Abnormally low blood pressure
- Low body temperature (<95 degrees F, <35.6 degrees C)
- Orthostatic changes in pulse or heart rate
- Failure to thrive/arrested growth and development
- Uncontrollable binging and purging
- Medical complications of malnutrition (for example fainting, seizures, heart failure, kidney failure, liver failure, pancreatitis, etc.)
- Concurrent medical or psychiatric conditions that limit appropriate outpatient treatment (like type I diabetes, obsessive compulsive disorder, or a suicide attempt)
When a patient is admitted for their eating disorder, what sort of treatment do they receive while at the hospital?
During medical stabilization, patients are often cared for by medical providers, dietitians, and nurses. Many inpatient units also have therapists, psychiatrists, social workers, or occupational therapists on their treatment teams.
When being stabilized, patients’ heart rate and rhythm, blood pressure, and weight are closely monitored. Blood is usually drawn at least once daily for up to seven days to monitor for electrolyte changes that can occur with early refeeding, and any abnormal electrolyte levels are corrected through supplementation. Blood draws also look for other underlying conditions that could be causing or contributing to weight loss or preventing weight gain.
Patients are expected to remain restful in order to ensure the body is using as much of their nutrition as possible to grow and repair instead of for physical activity. A staff member or caregiver may also supervise meals and snacks, as well as the period afterwards in order to prevent purging behaviors. If a patient doesn’t eat all of their prescribed food, then a nasogastric (NG) tube may be placed and a liquid feed given directly into the stomach to ensure optimal caloric intake.
How long does inpatient hospitalization for an eating disorder generally last? What happens after discharge?
The goal of the inpatient hospitalization is to monitor for and treat any electrolyte changes, halt weight loss, normalize vital signs, treat any other medical complications of the eating disorder, and address any additional medical or psychiatric problems. Given these goals, a patient may remain hospitalized from several days to several weeks, depending on the severity of their symptoms and how quickly they’re able to make progress. Their length of stay may also depend on additional medical or psychiatric issues, support systems, and insurance coverage.
After discharge from the hospital, patients may step down to any level of care, including outpatient, intensive outpatient, partial hospitalization, or residential eating disorder treatment. Typically, the inpatient team collaborates with the patient and their family to determine the best next step, and then initiates referrals for that treatment. Equip treatment is an appropriate step down from inpatient care, and many of our patients begin treatment with us immediately after medical stabilization in a hospital.
Before any patient begins treatment at Equip, they’re medically cleared by a medical professional. If a patient needs stabilization at any point before or during treatment, they’re transferred to an inpatient level of care to be stabilized before beginning or resuming Equip treatment.
- Edakubo, S., Fushimi, K. Mortality and risk assessment for anorexia nervosa in acute-care hospitals: a nationwide administrative database analysis. BMC Psychiatry 20, 19 (2020). https://doi.org/10.1186/s12888-020-2433-8
- Society for Adolescent Health and Medicine; Golden NH, Katzman DK, et al. Position Paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2015 Jan;56(1):121-5. doi: 10.1016/j.jadohealth.2014.10.259. PMID: 25530605.
- Peebles R, et al. Outcomes of an inpatient medical nutritional rehabilitation protocol in children and adolescents with eating disorders. J Eat Disord. 2017 Mar 1;5:7. doi: 10.1186/s40337-017-0134-6. PMID: 28265411; PMCID: PMC5331684.
- Frostad, Stein, and Mette Bentz. “Anorexia nervosa: Outpatient treatment and medical management.” World journal of psychiatry vol. 12,4 558-579. 19 Apr. 2022, doi:10.5498/wjp.v12.i4.558