NHS TAYSIDE EATING DISORDERS SERVICE
ADULT EATING DISORDERS MEDICAL RESOURCE PACK
Contact Us
For consultation/advice about this document, or indeed any aspect of eating disorder
management, please do not hesitate to contact the team (Monday to Friday, 9am to
5pm):
NHS Tayside Eating Disorders Service
4 Dudhope Terrace
Dundee DD3 6HG
Tel: 01382 306160
Fax: 01382 306166
E-mail: eatingdisorders.Tayside@nhs.net
Acknowledgements
NHS Tayside Eating Disorders Service would like to thank NHS Lothian’s Anorexia
Nervosa Intensive Treatment Team, NHS Dumfries and Galloway’s Eating Disorders
Service, and the Eating Disorders Network, South East Scotland, for kindly permitting
the use of some of their material for this document.
NHS TAYSIDE EATING DISORDERS SERVICE
ADULT EATING DISORDERS MEDICAL RESOURCE PACK
Sections
1. Introduction
2. The Role of the GP and the Primary Care Team
3. Assessment
4. Examination
5. Investigations
6. The Role of Specialist Services
7. Recommendations for the Frequency of Physical Monitoring in Eating
Disorders
8. Risk Guidelines
9. Management of Long-Term Eating Disorders
10. Bone Health
11. Eden Unit Pathway
12. Guidance for Medical Admissions within NHS Tayside
13. Re-Feeding Syndrome
14. Legislation Relevant to Eating Disorders
15. Eating Disorders and Fitness to Drive
Introduction
Eating disorders are relatively rare conditions, and most GPs see few patients with an
eating disorder in any one year. The first point of contact with health services for the
majority of people with an eating disorder, however, is the primary care team. It is
acknowledged in NHS QIS Eating Disorders in Scotland – Recommendations for
Management and Treatment (2006), that clear guidance is required to help the primary
care team manage people with an eating disorder. Therefore, this resource pack has
been developed to provide guidance to GPs about assessment, diagnosis, local referral
pathways, and how to access information on eating disorders for primary care staff,
patients and carers.
Although eating disorders are often managed within mental health services, there are
important physical manifestations that have to be considered. They may present to a
variety of health professionals, including primary care staff, dentists, diabetes
specialists and midwives.
The Role of the GP and Primary Care Team

Assessment – it is important to look out for significant physical symptoms,
including, dizziness, fainting, loss of consciousness, chest pain, palpitations,
ankle oedema, bowel disturbance, vomiting blood, muscle weakness,
sensitivity to cold, slurred speech, confusion and also dental problems

Examination – a physical examination, tailored to the severity of the illness,
should be routinely performed in patients with eating disorders. Patients with
very low weight (BMI<15), with rapid weight loss (more than 0.5kg per
week), with frequent vomiting (more than once per day) and/or severe laxative
abuse, need frequent physical monitoring

Investigations – baseline investigations are helpful for assessing the severity of
any eating disorder, and are useful when referring to secondary care. These
should include biochemistry, haematology, an ECG and a DEXA scan

Risk assessment – this should be done to assist the primary care team in
identifying those for whom early intervention and referral would be most
useful

All patients with anorexia nervosa should have an alert placed in their
prescribing record regarding the risk of side-effects, particularly cardiac sideeffects

Health care professionals should be aware of the risks of drugs that prolong
the QTc interval

Medication should not be used as the sole or primary treatment for anorexia
nervosa. If any medication is being considered for a person with anorexia
nervosa, the side-effects of drug treatment, particularly cardiac side-effects,
should be carefully considered and discussed

If a person with an eating disorder is unwilling to accept assessment or referral
to secondary care services, the GP can access advice and support from NHS
Tayside Eating Disorders Service. Alternatively, there are a number of
websites, such as that of B-eat, which provide help
Assessment
Any contact with the primary care team should be seen as an opportunity to engage
the person with an eating disorder, and attempts should be made to ensure that they
will return in the future. This is not a simple process, as many people with eating
disorders do not wish to engage with health services. It is recommended by NHS QIS
that primary care teams should include patients with severe chronic eating disorders
on their registers of people with severe and enduring mental illness.
It is important to remember that people with eating disorders will often present to GPs
with indirect symptoms, such as anxiety, depression, gastrointestinal symptoms,
menstrual symptoms, or diabetic patients with poor diabetic control. Opportunistic
questioning should start with questions that are non-threatening, for example, ‘When
your mood alters, does this have any effect on your eating?’, or ‘Have there been
changes to your appetite, eating or weight?’
Further questions can then be asked to clarify whether it is likely that the person has
an eating disorder. The SCOFF questionnaire has been validated for use as a
screening tool in people with an eating disorder over the age of 18 years If the person scores 2 or more positive answers, then an eating disorder is likely:

Do you make yourself Sick because you feel uncomfortably full?

Do you worry that you have lost Control over how much you eat?

Have you recently lost more than One stone in a 3-month period?

Do you believe yourself to be Fat when others say you are too thin?

Would you say that Food dominates your life?
Once it is established that the person has an eating disorder, then further history
taking is required. There should be some exploration of relevant family and personal
factors, and screening for any physical symptoms. The following questions would
suggest that the person was at increased risk from their eating disorder:

Do you make yourself sick every day, or several times some days?

Do you use in excess of 20 laxatives per day?

Are you losing more than 1kg/week in weight?

Have you collapsed or passed out recently?

Have you felt so weak that it was difficult to climb stairs?

Have you had pain in your chest or palpitations?
Throughout the process of evaluating the person’s symptoms, it is important to
maintain a rapport and positive engagement.
Examination
Health care professionals need to be sensitive to the extreme anxiety some people
have regarding their body weight and shape when they approach a physical
examination. If the person is comfortable with this, weight and height should be
measured and body mass index (BMI) calculated.
Calculating Body Mass Index (BMI):

Weight (kg), divided by height (m) squared = BMI

For optimum measurement of weight, the person should be weighed in one
layer of clothing, without shoes. They should be asked to empty pockets. The
same scales should be used for successive weighing

Height should be measured and recorded

BMI can give a rough guide to risk in adults, although rate of weight loss is
also important
Risk
Low-Moderate
Moderate
High
Very High
BMI
17.5-16
16-15
14.9-13
<13
BMI Ranges and Implications:

25-20 – healthy

19.9-18 – underweight

17.9-16 – severely underweight (menstruation may become intermittent or
cease)

15.9-14 – emaciated (physical starvation symptoms are the priority)

13.9-12 – severely emaciated (inpatient treatment may become necessary)

11.9-10 – ‘in extremis’ (death is imminent)
A physical health assessment should be performed for all patients with an eating
disorder. Some key signs to check for include:

Dental erosion

Irregular heart sounds

Low body temperature

Oedema

Parotid/sub-mandibular enlargement

Postural hypotension

Signs of dehydration
Squat Test The patient is asked to squat down on her haunches and is asked to stand up without
using her arms as levers if at all possible.
Investigations
Baseline investigations are helpful for assessing the severity of any eating disorder,
and useful when referring to secondary care. These should include:

Urea and Electrolytes, Ca, Mg, Zinc, Bicarbonate, Amylase, TFTs, LFTs,
GGT, Total Protein, Albumin, Glucose, Creatine Kinase and FBC

An ECG is recommended to monitor the QTc interval, which may become
prolonged. The QTc interval is prolonged if >470ms in females and >440ms in
males. Cardiac arrythmias can also occur

DEXA bone scans are recommended in people with a past or current history of
anorexia nervosa
The Role of Specialist Services
Most people with an eating disorder can be managed on an outpatient basis, with a
psychological component, medical monitoring and dietetic advice provided by a
multidisciplinary team.
There should be regular physical monitoring, both during outpatient and inpatient
weight restoration.
NHS Tayside Eating Disorders Service is not resourced to carry out physical
examination, blood test monitoring or ECG monitoring. We can advise on what
investigations are carried out, how frequently and on further action that may be
required dependent on results.
Recommendations for the Frequency of Physical Monitoring in Eating Disorders
Low-moderate risk:

Physical examination 6-monthly

Bloods 6-monthly

ECG 6-monthly

DEXA scan 2-yearly (if osteopenic on initial scan)
Moderate risk:

Physical examination 6-weekly

Bloods 6-weekly

ECG 6-weekly

DEXA scan 2-yearly
High risk:

Physical examination 2-weekly

Bloods 2-weekly

ECG 2-weekly

DEXA scan 2-yearly
Very high risk:

Physical examination weekly

Bloods weekly (or more often if major abnormalities)

ECG weekly

DEXA scan 2-yearly
Risk Guideline
System
Investigation
Moderate Risk
High Risk
Nutrition
BMI
<14
<12
Weight loss/week
>0.5kg
>1.0kg
Skin breakdown
<0.1cm
>0.2cm
Purpuric rash
Absent
Present
Albumin
<35
<32
Creatinine Kinase
>170
>250
Glucose
<3.5
<2.5
Hb
<11
<9
Acute Hb drop
Absent
Present
Neutrophil count
<1.5
<1.0
Platelets
<130
<110
WCC
<4
<2
Alk phos
>110
>200
ALT
>45
>90
AST
>40
>80
Bilirubin
>20
>40
GGT
>45
>90
K+
<3.5
<3.0
Mg++
0.5-0.7
<0.5
Na+
<135
<130
PO4--
0.5-0.8
<0.5
Urea
>7
>10
Systolic BP
<90
<80
Diastolic BP
<70
<60
Postural drop
>10
>20
Pulse rate
<50
<40
Bone Marrow
Liver
Salt/Water Balance
Differential
CRP, TFT
Diagnosis
Circulation
Musculo-skeletal
Squat Test
Unable
to
rise Unable
without arms for without
balance
Sit Up Test
to
rise
arms
for
leverage
Unable to sit up Unable to sit up at
without arms for all
leverage
Temperature
ECG
<35.0C/98F
<34.5C/97F
Arrythmias
Absent
Present
QTc
<440ms
>440ms
The frequency of physical health monitoring is determined by the level of risk.
Management of Long-Term Eating Disorders
A small, but important, group of eating disorder patients do not respond to active
treatment or fail to engage in treatment. People with chronic eating disorders are
unlikely to make spontaneous contact with treatment services unless an arrangement
is in place to promote this, but they can sometimes receive important or life saving
treatment if they do. The following recommendations are relevant:

There should be a clear and written agreement between the patient, the GP and
secondary care services about the nature and frequency of physical monitoring

The aim of monitoring is to maintain stability in the patient’s physical state
and weight, even if low
Bone Health
General Principles:

The most important way of ensuring bone health in those with eating disorders
is through the promotion of a healthy, balanced diet

Calcium and Vitamin D supplements should be recommended if dietary intake
is insufficient

Smoking is directly toxic to bone health, and the importance of cessation
should be emphasised

Regular weight-bearing exercise (e.g., walking for 30 minutes per day) is
important for bone health, and should be encouraged in those with a BMI >16.
However, excessive exercise and extreme sports are to be avoided in those
with osteoporosis
DEXA Scanning:

A DEXA scan is not required for those with bulimia nervosa

A baseline DEXA scan should be organised for those with a BMI <17.5, or
with a past history of (atypical) anorexia nervosa that resulted in prolonged
amenorrhea

Consequent management will depend on baseline Bone Mineral Density
(BMD)

If two successive BMD measurements are normal, no further measurement is
required

T Score – reflects the amount of bone compared with a young adult of the
same gender with peak bone mass. A score above –1 is considered normal. A
score between –1 and –2.5 is classified as osteopenia (low bone mass). A
score below –2.5 is classified as osteoporosis. The T Score is used to estimate
the risk of developing a fracture

Z Score – reflects the amount of bone compared with other adults of the same
age, gender and size. If this score is unusually high or low, it may indicate a
need for further medical tests
Drug Treatments:

There is little evidence for any treatment to improve bone density in those
with eating disorders

Oral bisphosphonates are the drugs of choice in those who have a very low
BMD or who have sustained a low trauma fracture

There is some concern about very long term use of bisphosphonates. The
recommendation is to treat for five years and then repeat DEXA scanning. If
BMD has improved to above the treatment recommendation level (i.e., >-2.5
for those who have previously sustained a low trauma fracture, and >-3.5 for
those who have not), treatment can be stopped. DEXA scanning should be
repeated two years later, with a view to restarting treatment if BMD has
dropped back to a treatment appropriate level. If ongoing treatment is required,
it should be continued for five years before further DEXA scanning

Bisphosphonates are contraindicated in females of childbearing age in view of
the potential for teratogenicity. They are taken up into the bone directly and
can remain present for many years after stopping. Risedronate is excreted
more rapidly than Alendronate and, therefore, is the drug of choice. Reliable
contraception must be used for the duration of treatment and continued for at
least six months after stopping before planned pregnancy

For those intolerant of Risedronate, the options lie between Alendronate,
monthly oral lbandronate, or three-monthly IV lbandronate; the appropriate
treatment being based on individual patient characteristics

If intolerant of bisphosphonates, or possibly planning pregnancy in the next
few years, it may be appropriate not to treat, as the risks may outweigh the
benefits

There is no evidence that oestrogen replacement by Oral Contraceptive Pill
alone improves bone density
Eden Unit Pathway
NHS Tayside Eating Disorders Service is part of a Managed Clinical Network
covering the North of Scotland.
NHS Tayside, along with NHS Grampian and Highland, has invested in 10 inpatient
beds in a new unit, the Eden Unit, sited within Royal Cornhill Hospital, Aberdeen.
The unit is exclusively for patients with eating disorders, primarily severe anorexia
nervosa.
Referral to the Eden Unit is made by NHS Tayside Eating Disorders Service staff and
the patient will usually already be known to our service. Admission to the Eden Unit
is arranged electively. Patients requiring emergency admission because of physical
risk would require to be admitted to a medical ward in NHS Tayside in the first
instance. Patients requiring emergency admission because of psychiatric risk e.g.
suicide would require to be admitted to the appropriate NHS Tayside general
psychiatry ward.
A small minority of people with eating disorders will at times require hospital care.
Due to a lack of research in this area, there is currently little empirical evidence
regarding the effectiveness of inpatient care for eating disorders. However, there is
some consensus of expert opinion as to when patients should be hospitalised:

Admission for treatment when change is expected to occur

Admission for medical management when there is no expectation of change
People with anorexia nervosa may require hospitalisation for both brief management
and definitive treatment. The following may indicate need for admission:

Severity of weight loss

Severe physical problems such as marked orthostatic hypotension,
bradycardia, and hypokalaemia

People with extreme levels of purging and/or exercise may benefit from a
more structured treatment setting

People with co-morbid medical conditions, such as diabetes mellitus, may
require more intensive medical management
NHS QIS Eating Disorders in Scotland – Recommendations for Management and
Treatment (2006) suggests the following admission criteria:

When the person’s
condition
is
life threatening as
a
result
of
starvation/purging/over-exercise/infection or other physical health problems

When a self-harming overdose is suspected

When treatment is required for the management of a co-morbid condition
The QIS guideline suggests that the person should be admitted to a setting as near to
home as possible, and that the decision to admit should be based on the support
available. Correcting the nutritional deficits in people with eating disorders should
ideally involve input from a Consultant Physician with a special interest in nutrition.
There is no evidence supporting inpatient care for people with bulimia nervosa. While
admission will often achieve improved control in hospital, this rarely translates into
out of hospital improvement. People with bulimia nervosa may require admission for
other problems, however, such as low mood and/or self-harm.
Guidance for Medical Admissions within NHS Tayside
When the physical complications of anorexia nervosa or bulimia nervosa become
extreme, and the person is at risk of serious medical consequences, they can be said to
be ‘in extremis.’ The safest place for a person ‘in extremis’ is in an acute medical
ward. It is important to remember that patients with severe eating disorders may
present with other acute medical emergencies.
In NHS Tayside, patients requiring inpatient medical admission should be referred to
the Gastroenterology department at Ninewells Hospital by contacting switchboard and
asking to be put through to the doctor carrying the GI page. In an acute emergency,
the patient may need to be admitted through the usual emergency medical admissions
process but the GI page should still be informed of the admission and need for
gastroenterology input.
Criteria for Inpatient Medical Management The following criteria are very likely to necessitate inpatient medical management:
1. Clinical abnormalities –

Clinical signs of cardiac failure

Core body temperature <34 degrees C

Pulse <40bpm or systolic BP <80 + or – collapse

Seizures

Severe abdominal distension or pain

Unable to rise from a squat or walk unaided
2. Biochemical abnormalities –

Hypokalaemia <2.8mmol/L with a bicarbonate >38mmol/L

Hypokalaemia with ECG changes

Hyponatraemia <125mmol/L, with confusion or seizures

Hypoproteinaemia with marked oedema

Symptomatic hypoglycaemia <2.8mmol/L

Urea >15mmol/L

Creatinine >120mmol/L with hyperkalaemia >5.0mmol/L

Hypocalcaemia <2.0mmol/L, with alkaline phosphatase >150µL and albumin
>36g/L

Hypocalcaemia <2.0mmol/L with hypomagnesaemia <0.5mmol/L

Hypophosphataemia <0.32mmol/L
3. Haematological abnormalities –

Anaemia Hb <7g/dL

Neutropenia <1.0 x 10(9)/L

Thrombocytopenia, total platelet count <20 x 10(9)/L or <130 x 10(9)/L with
overt bleeding
4. ECG abnormalities –

Arrhythmia on ECG

Prolonged QTc and ischaemic signs

Prolonged QTc, with collapse or palpitations (>470ms in females and >440ms
in males)
MARSIPAN Guidelines Guidelines on the Management of Really Sick Patients with Anorexia Nervosa have
been produced in a joint report by the Royal College of Psychiatrists and the Royal
College of Physicians. These are available on line at www.marsipan.org.uk
Inpatient Medical Management Inpatient medical management will be determined by treating physicians, but will
usually involve re-hydration with IV fluids in the first instance, as some of the ‘in
extremis’ indicators may improve with this alone. However, for many, the
consequences of chronic starvation will require careful naso-gastric re-feeding to
reduce the physical risks. It will be important for any person with an eating disorder
admitted ‘in extremis’ to be monitored for re-feeding syndrome, as they will be at
high risk of developing this condition. If the person is compliant, re-feeding can be
initiated in the first week in the inpatient medical unit, and, where necessary, can be
continued in an inpatient eating disorders unit. If the person is non-compliant, it may
be necessary to use the Mental Health Care and Treatment (Scotland) Act (2003).
Liaison with NHS Tayside Eating Disorders Service Anyone with a severe eating disorder, admitted ‘in extremis’ to a medical ward,
should be referred for psychiatric assessment. The referral should be made, via
Liaison Psychiatry, to the Consultant Psychiatrist attached to NHS Tayside Eating
Disorders Service. An initial assessment, including a risk assessment, will be
completed by the Consultant Psychiatrist or their junior doctor. Follow-up thereafter
will depend on the level of risk, and may include wider involvement of the local
eating disorders service, or transfer to the regional inpatient eating disorders unit. If
the person refuses psychiatric assessment, physicians should discuss this with Liaison
Psychiatry, as consideration may need to be given to detention under the Mental
Health Care and Treatment (Scotland) Act (2003).
Criteria for Discharge from Inpatient Medical Management The following criteria should be met prior to a patient being discharged from medical
care:

Weight loss should be stopped. The presence and degree of oedema should be
noted in the calculation of weight change

Biochemical indices should be within safe limits

ECG should be within safe limits

Haematological indices should be within safe limits

Core body temperature >35 degrees C

The patient can rise from a squat and walk unaided
A decision should be reached jointly between physicians and the patient’s
Responsible Medical Officer regarding discharge arrangements. The views of the
patient, and their carers (if appropriate), should also be sought regarding further
treatment. The discharge plan should be communicated to the patient, carers, and GP,
as soon as possible.
Guidance for Weight Monitoring of a Patient with an Eating Disorder (who has been
Admitted to a Medical Ward):

The patient’s initial (admission) weight should be obtained the morning
following admission to the ward

Thereafter, the patient’s weight should be checked in the morning, on waking,
and before they have any fluids to drink

The patient should be asked to pass urine prior to being weighed

The patient should be weighed wearing the same clothes each time. This will
be a t-shirt and underpants. No heavy jewellery or hair ornaments should be
worn

The same set of scales should be used at each weight check

The patient should be asked to stand on the scales and look straight ahead. Be
mindful of any distress that the patient may feel about being weighed

Weights should be measured and recorded in kilogrammes

Weight checks should be carried out weekly, on the morning of the ward
round

If the patient’s weight drops at any time, the frequency of weighing should be
increased to twice weekly, until weight gain is re-established at a rate of at
least 0.5kg per week and the previously highest weight has been restored

Spot checks should be carried out if there is concern that weight is being
artificially raised
Notes:

Patients may attempt to drink excessive amounts of fluid prior to weight
checks, particularly during the evening and night before

Patients may attempt to withhold bowel movements until after weight checks.
If this seems to be occurring, frequency of bowel movements should be
recorded

Patients may attempt to conceal objects on their bodies, e.g., by hiding weights
in elaborate hairstyles and sanitary products
Guidance on Laxative Reduction in a Patient with an Eating Disorder (who has been
Admitted to a Medical Ward) A laxative is a medication that can be used on a short-term basis to treat constipation
by stimulating emptying of the bowel. Some people with eating disorders take
laxatives in the belief that this will help them to lose weight, or to compensate for
over-eating. Stimulant laxatives leave the body feeling empty, but the resultant weight
loss is the result of dehydration due to large amounts of water being removed from the
large bowel. Laxatives have little effect on body fat or muscle mass, as food is
digested in the small intestine where most nutrients and calories are absorbed.
Laxative abuse can have serious side-effects on health, for example, long-term
dehydration can lead to problems with kidney function, or kidney failure, and
hypokalaemia can trigger cardiac problems. Other side-effects of laxative abuse
include confusion, convulsions, headaches, muscle cramps and weaknesses, rectal
bleeding and urinary tract infections.
General Advice on how to Stop Laxative Abuse If the patient has been taking small amounts of laxatives over a short period of time,
they may be able to stop immediately. If the patient has been taking large amounts
over a long period of time, it is better that they cut down gradually. This can be done
by reducing the amount taken each day, e.g., from 50 down to 45 for 3-4 days, then 45
to 40, and so on. Or they can aim to have one laxative-free day per week, building up
to no longer taking them at all.

Ensure an adequate fluid intake, of 1.5 to 2.0 litres (8-10 glasses) of water or
other drinks, daily

Include plenty of dietary fibre (wholegrain bread and cereals, fruit and
vegetables) in regular meals

Increase daily activity level (as appropriate to body weight)
The patient must be prepared for some discomfort while their body adjusts during the
period of laxative withdrawal. Any concerns they have about abdominal distension or
pain should be discussed. Similarly, the psychological difficulty in ceasing laxative
abuse can be significant for the patient.
According to research, the length of time a person has been abusing laxatives is not an
indicator of how severe their withdrawal symptoms will be. Stopping laxatives
suddenly is likely to cause water retention of up to as much as 4-5 litres. This can lead
to bloating and swelling of the ankles, feet and fingers. This is a temporary state that
can last for 10-14 days, before gradually resolving.
Re-Feeding Syndrome
What is Re-Feeding Syndrome?
Re-feeding syndrome involves potentially fatal shifts in fluids and electrolytes in
malnourished patients undergoing rapid re-feeding. These shifts result from hormonal
and metabolic changes, and may cause serious complications.
The hallmark feature of re-feeding syndrome is hypophosphataemia. However, the
syndrome is complex and may also feature hypokalaemia, hypomagnesaemia,
abnormal fluid and sodium balance, changes in fat, glucose and protein, and thiamine
deficiency.
The true incidence of re-feeding syndrome is unknown.
What are the Risk Factors for Re-Feeding Syndrome?
NICE (2004) –
Either the patient has one of the following:

BMI<16

Unintentional weight loss >15% in the past 3-6 months

Little or no nutritional intake for >10 days

Low levels of magnesium, phosphate or potassium before re-feeding
Or the patient has two of the following:

BMI<18.5

Unintentional weight loss >10% in the past 3-6 months

Little or no nutritional intake for >5 days

History of alcohol or drug misuse (including antacids, chemotherapy, diuretics
or insulin)
Other patients at risk from re-feeding syndrome include elderly patients, patients with
chronic alcohol problems, patients with uncontrolled diabetes, and other patients with
chronic malnutrition.
How does Re-Feeding Syndrome Develop?
Re-feeding syndrome develops due to hormonal and metabolic changes caused by
rapid re-feeding, whether oral, enteral or parenteral.
In early starvation, the body switches from using carbohydrate to fat and protein as
the main source of energy, and the basal metabolic rate drops by 20-25%. During
prolonged fasting, the hormonal and metabolic changes are aimed at preventing
protein and muscle breakdown. Muscles and other tissues decrease their use of ketone
bodies and use fatty acids as their main energy source. This allows the levels of
ketone bodies to rise in the blood and stimulates the brain to switch from glucose to
ketone bodies as its main energy source. During prolonged starvation, several
intracellular minerals become depleted even though serum concentrations of these
minerals may remain normal. They remain normal because they are mainly in the
intracellular compartment that contracts during starvation, in addition to which, there
is a reduction in renal excretion of these minerals in the serum.
During re-feeding, the increase in glucose in the blood leads to increased insulin
secretion. Insulin stimulates fat, glycogen and protein synthesis, and this process
requires minerals such as magnesium and phosphate, and co-factors such as thiamine.
Insulin stimulates the absorption of glucose and potassium into the cells, magnesium
and phosphate are also taken up, and water follows by osmosis. These processes result
in a decrease in the serum levels of magnesium, phosphate and potassium, all of
which are already depleted.
What Symptoms can occur in Re-Feeding Syndrome?
Re-feeding oedema can be marked, occasionally leading to weight gain of up to 1kg
per day. It is important to rule out other causes including cardiac failure,
hypothyroidism and renal failure. Re-feeding oedema can also occur if there has been
a prolonged period of diuretic abuse. Re-feeding oedema will resolve spontaneously
but may take several weeks, and patients may need to be prepared for this. Diuretics
should be used with extreme caution, as they may precipitate further loss of potassium
and cardiac arrest.
Acute gastric dilation is a rare, but potentially lethal, complication of re-feeding. It
presents with vomiting, and abdominal pain and distension. If recognised early, it
responds to nasogastric aspiration and intravenous feeding.
How do you Prevent Re-Feeding Syndrome?
To ensure adequate prevention of re-feeding syndrome, the NICE (2004) guidelines
recommend a thorough nutritional assessment before re-feeding is started. Weight
changes over time, alcohol intake, and psychosocial problems should all be
ascertained.
Plasma glucose, magnesium, phosphate, potassium and sodium should be monitored
at baseline. NICE states that correcting fluid and electrolyte imbalances before refeeding begins is not necessary, and should be undertaken concurrently. Electrolytes
should be monitored once daily for one week, and at least three times the following
week. Oral, enteral or parenteral supplements of magnesium (give 0.2mmol/kg/day iv
or 0.4mmol/kg/day orally), phosphate (give 0.3-0.6mmol/kg/day), and potassium
(give 2-4mmol/kg/day) should be given unless blood levels are high before refeeding.
Vitamin supplementation should be started immediately before re-feeding and
continued for the first 10 days. This should take the form of thiamine 200-300mg
daily orally, Vitamin B high potency 1-2 tablets three times daily, and multivitamin or
trace element supplements once daily.
For patients at high risk of developing re-feeding syndrome, nutritional repletion of
energy should be started slowly and can then be increased to meet needs over 4-7
days. The dietitian will decide on the initial energy requirements of the patient, but
this can vary from 5kcal/kg/24 hours to 20kcal/kg/24 hours.
What are other Complications of Re-Feeding?
Re-feeding syndrome can cause cardiac abnormalities, delirium, respiratory failure,
status epilepticus, and suppression of the haematological system.
Legislation Relevant to Eating Disorders
The Mental Health Care and Treatment (Scotland) Act, 2003 The Mental Health Care and Treatment (Scotland) Act, 2003 is based on a set of
guiding principles and, as a general rule, anyone who performs functions under the
Act should act in accordance with these principles. These include:

The present and past wishes and feelings of the patient

The views of the patient’s Named Person, carer(s), guardian or lawful attorney

The importance of the patient participating as fully as possible

The importance of providing the maximum benefit to the patient

The importance of providing appropriate services to the patient

The needs and circumstances of the patient’s carer(s)
The Act also sets out principles relating to the way in which the function must be
discharged. These require the person discharging the function to do so in a way
which, for example:

Involves the minimum restriction on the freedom of the patient that appears to
be necessary

Encourages equal opportunities

If the patient is a child, best secures their welfare
A patient who is subject to a Short-Term Order, or a Compulsory Treatment Order,
can be given treatment without his or her consent, if it is in accordance with the rules
set out in the Act that deal with medical treatment. In the context of an eating
disorder, treatment is considered to include nutrition by artificial means.
Treatment with Consent Nutrition by artificial means may be included as part of an agreed treatment plan in
collaboration with the patient. In the treatment of an eating disorder, the use of
artificial means may be more acceptable to the patient for a time than making the
constant effort to eat. The Mental Welfare Commission (MWC) expect that this
would be the usual context in which feeding by artificial means would occur.
Where there is consent, the patient must be considered capable of giving valid and
informed consent. This consent must be given in writing. Consent should be reviewed
regularly to ensure continuing valid consent is given.
Treatment without Consent On occasion, it may be necessary to consider providing nutrition by artificial means
without the consent of the patient. Feeding against the will of the patient should be an
intervention of last resort in the care and management of anorexia nervosa and other
eating disorders.
The Mental Health Care and Treatment (Scotland) Act, 2003, section 240, authorises
the giving of nutrition by artificial means where the patient does not consent to the
treatment. The decision to proceed with artificial feeding without the patient’s consent
is ethically complex, and the decision to initiate or withdraw treatment should always
be made on a case-by-case basis, taking into consideration the potential benefits and
disadvantages of imposing treatment. The primary purpose of artificial feeding
without consent should be to save the patient’s life, or to prevent further serious
deterioration of their physical condition.
Urgent Treatment The Act includes provision for urgent medical treatment, which may be given without
consent in order to save life or prevent serious suffering. In some circumstances, this
provision may cover nutrition by artificial means. These circumstances would be
where a decision has been made to provide the treatment, and a Designated Medical
Practitioner’s (DMP) opinion has been requested, but it becomes essential for the
patient’s safety to commence treatment before the DMP has visited. Should this arise,
the circumstances should be reported to the MWC.
Types of Feeding The code of practice which accompanies the Act, states that there is a difference
between forcible feeding and artificial means of feeding someone, for example,
through a nasogastric tube, an intravenous drip or directly into the stomach through a
gastrostomy. These methods of nutrition bypass the patient’s need to swallow food,
but forcible feeding involves using direct force to make an individual swallow food.
Forcible feeding may involve methods such as forcibly pushing food into the
individual’s mouth, or holding his/her mouth open to receive food. This type of
forcible feeding is not authorised by the Act, and the code of practice states it should
never be used.
Hydration by artificial means is not considered part of nutrition in recent guidance by
the MWC. Any nutritional component in intravenous fluid replacement is minimal,
and nutrition is not the purpose of such treatment. However, the law does include
provision for urgent medical treatment for mental disorder where the patient is
detained in hospital under the Act. In this situation, treatment can be given to save life
or prevent serious harm. Hydration may be given under this provision. If it is
necessary to continue this treatment beyond the initial urgency (e.g., for longer than
seven days), and where there is total refusal of both food and fluids, it is likely that
the patient will also require treatment with nutrition. If there is no need for the patient
to receive nutrition, e.g., where fluids alone are resisted as a consequence of the
mental disorder, then treatment can continue if the patient’s Responsible Medical
Officer (RMO) determines that it is in the patient’s best interests.
Safeguards If artificial feeding without consent is being considered for any patient liable to
compulsory treatment under the Act, the provision of safeguards for the patient are
built in. The patient’s RMO is required to arrange, through the MWC, a DMP to
examine the patient and consider whether the treatment should be authorised under
the Act. A DMP is an experienced and independent psychiatrist, who considers and
makes a judgement on the benefit to the patient of the treatment proposed. Where a
patient is aged less than 18 years, then either the RMO or the DMP must be a
specialist in child and adolescent psychiatry. The DMP must certify that the treatment
is in the patient’s best interests, and is required to ‘have regard’ to the reason for
refusal if that is known. The MWC recommend that DMPs authorise treatment for a
maximum period of three months. The DMP may authorise treatment for shorter
periods or attach conditions to the treatment.
Named Persons and Advanced Statements In order to ensure that the views and wishes of a patient with mental disorder are
considered in care and treatment decisions, the Act provides for the appointment of a
‘Named Person.’ In relation to nutrition by artificial means, the Named Person has the
right to be consulted on the issue of detention, to make appeals about detentions, and
to be consulted by the DMP before they make a decision authorising treatment.
Both the patient’s RMO and DMP must have regard to any valid ‘Advanced
Statement’ made by the patient before making a decision about treatment. This is a
written statement by the patient setting out how they would or would not like to be
treated should they be unable to make treatment decisions as a result of mental
disorder. If a decision is made that goes against the Advanced Statement, then the
patient has to be given the reasons for this in writing. A copy should also be given to
the Named Person, any welfare guardian and the MWC.
Adults with Incapacity (Scotland) Act, 2000 The Adults with Incapacity (Scotland) Act, 2000 deals with issues relating to the
personal welfare of an adult (aged over 16 years) as well as medical treatment.
Informal patients, who lack the capacity to make their own decisions about treatment,
may be given treatment for a mental disorder under the Act. The associated code of
practice states, however, that if an adult resists treatment, then consideration should be
given as to whether it would be appropriate that he or she should be formally treated
under the 2003 Act.
The 2000 Act prohibits the use of force or detention unless immediately necessary,
and does not authorise detention in hospital. Therefore, this Act can only authorise
feeding by artificial means if it does not involve the use of force.
Human Rights Act, 1998 Patients have a right, under article 3 of the Human Rights Act, 1998, to be protected
from inhumane or degrading treatment. Whether the treatment was judged inhumane
or degrading would depend on the patient’s circumstances. Any treatment given must
always be clinically justifiable, and a proportionate response to the risk presented.
Issues in Practice Any decision to proceed to treatment without consent should only be taken when the
physical risk clearly justifies this, and all other options have been considered. It is
essential that treatment is carried out in a setting with an appropriate level of expertise
and experience.
When the patient does not consent to nutrition by artificial means, it is essential that
his or her individual needs be taken into account. This includes careful consideration
of the specific, individual reasons that may be leading the patient to refuse treatment
at that time. Even where there may not be overall agreement to the recommended
treatment approach, there should be negotiation as to the details of how, when and
where the treatment is to be provided.
The 2003 Act allows for the use of force, but only where the patient is in the hospital
that has been authorised to provide treatment. Force should only be used if:

The patient has persistently resisted treatment (it is best to wait and try later
unless the situation is urgent)

Treatment is necessary and cannot be achieved in other ways

The principles of the Act are applied
Any force should be the minimum necessary and only for as long as necessary. Any
care plan, which may include the use of force, should only be carried out where there
are sufficient numbers of trained staff available.
A distinction should be drawn between the use of force as a restraint and forcible
insertion of a nasogastric tube. The code of practice for the Act says that force should
not be used to insert a nasogastric tube. Medication may be used as a restraint and
may be preferable in some situations. Where force or restraint is required, it is
important to consider how to ensure that the methods used are not punitive or
degrading.
Assessment of Capacity in the Presence of Anorexia Nervosa Questions to be asked of the patient by the clinician:

What is the nature of your illness and its risks at present?

What are the risks and benefits of inpatient treatment?

What do you understand to be the outcome if you do not have this treatment?

What is your decision regarding the treatment you are being offered?
Decisions for the Clinician are whether or not the patient is able to:

Understand the nature of the risks

Understand the risks and benefits of treatment versus no treatment

Believe the nature of the risks

Believe the risks and benefits of treatment versus no treatment

Weigh up the information rationally

Make a fully informed choice with full capacity
Eating Disorders and Fitness to Drive
What Does the DVLA Say?
Although eating disorders are not mentioned specifically, the guidance says that any
serious mental disorder should be reported to the DVLA. It is clear from the guidance
that individual clinicians must use their own judgement in deciding a) whether they
advise the patient not to drive, and b) whether they breach confidentiality and report
directly to the DVLA if the patient continues to drive.
What Impairs Fitness to Drive in Patients with Eating Disorders?

While there is no minimum BMI that makes someone unfit to drive, it is
generally accepted that if a patient has severe emaciation, cannot complete a
squat test or rise from the horizontal on a bed, they should be advised not to
drive. Their unfitness to drive will be from a combination of factors, but a
simple lack of muscle tone and power may be the most relevant

Assessment in anorexia nervosa is complicated by markedly fluctuating
nutritional status. Periods of fasting and relative hypoglycemia can make
someone sluggish, inattentive and slow, but this may rapidly reverse with
appropriate nutrition

Relative hypothermia will impair concentration and slow reaction time

Hypokalemia, which may be fluctuating, will have similar effects, but may
also cause muscle twitching and jerking

Patients with severe osteoporosis have been known to sustain fractures
performing driving manoeuvres
Advice to Patients:

All patients with a BMI <16, patients who have periods of extreme fasting,
and patients who have marked hypokalemia, should be advised that their
ability to drive will be compromised

Patients who have prolonged fasts should be advised to take appropriate
nutrition an hour before they are going to drive, and to maintain this during
their driving

Patients should be informed that voluntary compliance with advice on driving
is strongly recommended for their own, and other road users’, safety, and that
non-compliance may mean that they are reported to the DVLA

Patients should be advised that the DVLA will more than likely require a
formal medical assessment, and may impose a driving ban that may last for
some months after recovery, requiring re-examination by a DVLA doctor