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Treatment of Eating Disorders

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Eating Disorder Treatment and the Treatment Team

The treatment of eating disorders is partly medical, partly nutritional, and partly psychological -- just like the diseases themselves. It's rare for a single person to be expert in all three of these areas, and therapy often must include the patient's family as well as the patient as an individual, so an eating-disorder patient must be treated by a team that includes a doctor, a dietitian, and at least one therapist. The treatment of anorexia nervosa, bulimia nervosa, and the similar but less well-defined eating disorders share many common features, and so I talk about them in a single page, but there are also treatment features unique to the different disorders.

Nutritional Treatment

Recovery from eating disorders cannot happen without restoring proper nutrition. The patient wants to "eat healthy", and we want her to "eat healthy", too; the problem is teaching her what "eating healthy" really means. This is a job for a dietitian, who can help her learn to choose a well-balanced diet that provides enough nutrition to meet her baseline needs (few people realize that an adult merely laying in bed doing nothing still burns about 1200 calories each day), energy for her activity and exercise, and nutrition for restoring lost organ and muscle tissue (we refer to the last as repletion).

However, really poor nutrition can interfere with the rest of the recovery process. This is because your brain needs a certain level of nutrition to function properly. One example I use when speaking with a patient's parents: the brain needs protein, carbohydrates, and -- yes -- some fatty nutrients just to lay down memory patterns. I have (too) often seen severely malnourished patients hospitalized for several weeks who, when they are sent home, do not remember very much of their first week in the hospital. It's hard to learn anything if your memory doesn't work.

For this and other reasons, most of us who manage eating disorder (especially anorexic) patients in the hospital are rather aggressive about refeeding: although we start refeeding at relatively low levels to avoid the refeeding syndrome, we also increase a patient's nutritional intake as quickly as is safe for her. There are two ways to do this: one is to feed her by a tube (through the nose or mouth, into the stomach) or with IV nutritional solutions (total parenteral nutrition, or TPN), and the other is to give her actual food. Because of the learning issues and problems with psychotherapy in severely malnourished patients, some doctors will feed a severely anorexic patient by tube or TPN, with little or no "real food", until her weight and metabolism improve, and then switch her to real food at or just before discharging her from the hospital. This may allow safer and more rapid refeeding, and bring her nutritional state to a point where she can benefit from therapy, but it also means that she may suddenly have to change from a large amount of tube or IV nutrition to an equivalent amount of food in a few days or less, just before she goes home. This may be very hard to do for a patient who is in the hospital largely because she's afraid of food, and who is so badly malnourished that she needs large amounts of food even for slow repletion, let alone base and energy requirements.

To avoid the abrupt and possibly scary transition from no apparent food to a large diet, some doctors -- including myself -- take a different approach. We start giving a patient food when we admit her, beginning at a low level (1000 calories/day or so -- which may be much more then she's used to, but is often still a safe place to start). We then increase every day by a small amount, and stop when she is gaining a certain amount of weight every day. We do not use TPN unless she is extremely malnourished, we do not use liquid supplements such as Boost or Ensure routinely, and we do not feed her by tube unless she cannot finish a meal. We give her 3 meals and 1-3 snacks each day (they start out very small but increase gradually) and set a time limit for each meal and snack. If she cannot finish a meal we take the leftover food away and give her supplement to drink to make up for the food she could not finish. If she cannot drink the supplement, then and only then we will give her the supplement through a temporary feeding tube.

Note that we do all these "extra" measures when she cannot eat her food, not when she will not eat her food. This is an important point: we feel that an anorexic cannot eat a healthy diet because of her disease process, and is not deliberately avoiding food -- which means that we are helping her to overcome the effects of her disease rather than punishing her for actions that are really beyond her control.

Initially, of course, an anorexic patient will not be able to make healthy food choices on her own. This is also part of the dietitian's role: at the beginning of a hospital stay, the dietitian has to plan the patient's menus. However, since one of our immediate goals is to teach her to choose her own meals, her dietitian will almost immediately start having her pick her menus. Early on, the menu she picks may not provide her with enough nutrition for her basic needs, let alone activity and repletion, so her dietitian may have to add food items. As she progresses through her treatment, though, she should become better at choosing and eating food, and as she nears discharge she should be able to go to the hospital cafeteria with her dietitian or her family and choose and eat an appropriate meal herself. Once she goes home we expect her to continue to choose healthy foods in healthy amounts.

Most anorexic patients never need to be admitted to the hospital. These patients still need to learn how to eat healthy, though, and support and education from a dietitian is still quite necessary. I depend on dietitians to let me know how much nutrition each of my patients need and how much each one is actually getting. (Yes, some patients occasionally tell us they are eating more than they are actually eating. Ultimately, though, the patient's weight will tell us if she is eating a healthy diet.)

Bulimic patients are managed differently, and often do not have to be put in the hospital for refeeding. Nutritional education for bulimic patients is also important, of course, but total nutritional intake is usually not as much of a problem as with an anorexic patient. The important aspect of nutritional treatment is to help the patient reduce her bingeing and avoid purging, and this is very closely intertwined with her psychologic treatment.

Medical Treatment

An anorexic patient may not have to be hospitalized as long as she is stable medically -- in fact, only about 20% of my anorexic patients are ever admitted to the hospital, and we try quite hard to keep our patients out. The medical problems we see most often in our patients are the result of long-term malnutrition, which causes depletion of many important nutrients including

Phosphorus and the Refeeding Syndrome
Phosphorus and calcium are the material of which bone is made. However, they have other important uses. Phosphorus is part of the system cells use to store and manage biochemical energy. Without enough phosphorus, cells -- especially muscle cells, including those in the heart -- cannot use energy even if it is available. In the refeeding syndrome the patient's body runs out of available phosphorus as soon as she starts taking the nutrition she needs, and if not caught in time her muscles stop working -- which may result in heart failure if not treated in time. We can avoid refeeding syndrome by
  • starting refeeding with a low-level diet (usually 1000 calories/day or so, which may still be much more than she was eating before treatment).
  • checking phosphorus levels often (sometimes daily or even 2-3 times each day -- testing this often can't be done unless she's in the hospital).
  • giving phosphorus supplements if her phosphorus level starts to fall.
Body stores of calcium may also be depleted. This can produce metabolic problems, and patients with very low blood calcium levels can have seizures, but another problem with calcium depletion is osteopenia (loss of bone mass). Osteopenia is a long-term problem, and we can watch for it by special X-ray tests that tell us whether or not a patient's bone density is normal. More immediate calcium-related problems can be picked up early by blood tests, and can often be treated with supplemental calcium and vitamin D (which regulates calcium metabolism and may also be low in a starving patient).
The electrical systems in your body -- nerves and muscles -- depend on a tightly controlled potassium level. If the level is either too low or too high all sorts of problems happen, from seizures to a stopped heart. Potassium levels are most often thrown out of whack in bulimia but can be abnormal in anorexia as well because of chronic malnutrition. Potassium levels in the blood can actually fall briefly when you eat, because your body's cells absorb potassium as they absorb glucose (the main sugar most of your cells use to produce energy). If you have low potassium stores to begin with your potassium may fall much too far. We can avoid low-potassium problems by checking levels regularly and by keeping hospitalized patients on continuous heart monitors.
Our bodies contain small amounts of zinc, but that small amount is important for many metabolic processes, some of which have to do with our ability to think. A patient's zinc level usually falls only after a long period of starvation; since hospitalized anorexic patients have been starving for long periods, many of them have low zinc. I usually check the zinc level when I admit a patient with anorexic and malnutrition, and give a zinc supplement only if her level is low.

Another problem seen occasionally in anorexic patients is refeeding edema. Edema is swelling of tissue due to fluid accumulation, which can be a sign of infection or of allergic reactions such as hay fever. Edema can also be caused by shifts in mineral balance like those we talked about above which may cause a patient's body to retain excess fluid. Although diuretics will cause you to lose fluid, this doesn't necessarily help the edema and can even make it worse. There is little agreement on how to get rid of edema in refeeding in the short term; refeeding edema eventually goes away once the patient's nutrition has been restored.

Bulimic patients need to be hospitalized less often than do anorexic patients. We have to watch for (mal)nutrition-related problems in malnourished bulimic patients, of course, but bulimic patients have their own specific problems, usually related to their purging methods. Some but not all of these problems may require hospitalization. They include:

Hypokalemia (low potassium)
This is more of a problem in bulimic patients, in whom it it a direct result of purging by vomiting or by abusing diuretics (medicines that make you urinate), than in anorexic patients whose potassium usually falls with refeeding after a period of starvation. With repeated vomiting and/or diuretic abuse a bulimic patient's potassium level can fall so low that her heart stops. The heart can sometimes be restarted, but not necessarily fast enough to avoid brain damage. (This has happened in some well-known patients.) Some bulimic patients try to eat potassium-rich foods or take potassium supplements to avoid this problem; this isn't a bad idea, but taking in too much potassium can lead to other problems, especially if something else they are taking or doing affects the kidneys' ability to control potassium levels.
Aspiration and windpipe blockage after vomiting
Usually, when you vomit the stuff that comes up goes right out of your mouth. Sometimes, though, the vomitus goes into your mouth and then enters your trachea (windpipe), from where it can go farther down into your lungs. We call this aspiration. If you aspirate enough (of anything) you can suffocate. Even if you don't, the stomach contents (being very acid) can damage your lungs, and bacteria from your mouth and from the stomach contents can start a pneumonia that can be quite nasty.
Toxic effects of purging medicines
Some medicines used to induce vomiting can be poisonous if you take too much or take them for too long. Ipecac, in particular, can cause myopathy (muscle malfunction) both in your skeletal muscles and in your heart muscle if you take it for long enough. The latter, cardiomyopathy, can lead to heart failure. Usually ipecac myopathy resolves once the patient stops using ipecac, but often we need to watch these patient closely, with 24 hour/day heart monitors. Diuretics and laxatives, by changing the way your intestines and kidneys process body fluids, can also produce toxic effects, including acid-base changes, kidney failure, and intestinal problems.
Changes in the body's acid-base balance
Stomach fluid contains lots of acid, as well as potassium; frequent vomiting will cause you to lose acid as well as potassium. (This is also how babies with pyloric stenosis get into trouble, although they vomit because their stomach outlets are blocked.) This can affect many body processes, including breathing. As I mention above, diuretic and laxative abuse can also mess with acid-base balance.
Lacerations of the palate (the roof of the mouth)
These are caused when a patient makes herself vomit by sticking something (usually her fingers or a toothbrush handle) down her throat.
Lacerations of the backs of the knuckles
These happen when a patient uses her fingers to make herself vomit and her teeth scrape against her knuckles. (These lacerations are known as the Russell sign, after the adolescent medicine specialist who first described bulimia nervosa in a medical journal.)
Damage to the back surfaces of the teeth
This damage is caused by acid coming up from the stomach and eating away the tooth enamel. This usually happens after more than six months of frequent vomiting.

A physician manages medical treatment, including setting weight and nutrition goals, prescribing medication if and when needed, keeping an eye on the patient's physical condition and checking laboratory tests when needed, and treating the medical problems that come along with malnutrition.

Usually, especially if the patient is not so sick that she needs to be in the hospital, she can be taken care of by her primary caregiver, who may be a pediatrician, internist, or family practitioner. Patients with more complex problems, including those who need to be treated in the hospital, are more often managed by doctors with more extensive and specific experience in eating disorder management. These doctors are most often specialists in adolescent medicine (a subspecialty of pediatrics) or psychiatrists; they may also be pediatric hospitalists (pediatricians who specialise in caring for hospitalised children). (I myself am mainly a pediatric hospitalist, although I do a fair amount of outpatient pediatric practice and teaching as well. My first few years of experience in eating disorder treatment came through working closely with adolescent medicine specialists with expertise in eating disorder management. I now have over a decade of experience in eating disorder treatment, and although I still work often with my old colleagues I manage and consult on many patients independently, especially those in my practice region who are most challenging to manage.)

Psychologic Treatment

Anorexia and other eating disorders are psychologic and social problems as well as medical problems. Therefore, anorexic patients need therapy for themselves, and almost always for their families as well, for the best chance of recovery from their disease.

An anorexic patient who is very malnourished is a particular challenge for the treatment team. As I mentioned above, it's hard to learn when your memory doesn't work properly, and it's hard to remember things without proper nutrition. It is possible to start talking with a malnourished patient about her underlying issues early, but we can't expect her to remember new information until she is better nourished. For this reason we usually have to limit the therapy we give badly-malnourished anorexic patients to supportive counseling, together with simple explanations of anorexia and its effects that can be repeated many times, with occasional variations.

Some years ago I came up with an analogy that I have found useful when explaining nutritional needs to ED patients in the early stages of inpatient treatment -- the “cabin in the Arctic” analogy.

Imagine that your body is a cabin in the Arctic in winter. Like other cabins up there, it is built of wood. There's a fireplace inside to keep you warm, a woodpile outside the door to fuel the fire, and wooden furniture for you to sit and sleep on.

Your body is the cabin (skeletal and important connective tissues, the body's organs, and critical muscle including cardiac muscle) and furniture (muscles), and the woodpile is your body’s natural energy reserve (mainly body fat, but also including other places such as the liver where the body stores energy). Normally you gather enough firewood each day (eating) to keep the fire burning and keep you warm. You have to keep the fire burning, though: even if you have no wood in the woodpile you have to throw whatever you have around that will burn on the fire to stay warm (this refers to "catabolism", or breakdown of muscle and other tissue to provide energy when your body does not have enough immediate nutrition or available energy stores).

Right now (at the beginning of therapy) you have burned the woodpile, you have burned most of the furniture, and you’re working on burning the walls...

This analogy may be a bit corny (and no -- the food pun was not deliberate...) but it is simple enough for many severely malnourished patients to grasp. I can also extend it as the patient's nutrition -- and with it her ability to remember and think -- improves: for example, I can compare the different nutrients her body needs to different kinds of wood for rebuilding different parts of the cabin and furniture.

Some anorexic patients may be helped with medications. Clinical trials of antidepressants (specifically the selective serotonin reuptake inhibitors, or SSRIs, such as Prozac® -- serotonin is a chemical that the brain uses to transmit signals having to do with mood, and lack of serotonin seems to be associated with depression) have so far shown little or no benefit to patients who are acutely ill because of their malnutrition, but may help prevent relapses later. Anorexia may result from depression (many of us lose our appetites when we're depressed, after all -- some for longer than others), and if this is the case antidepressants may be very helpful.

There are two potential problems with SSRI therapy in anorexia. One is that weight gain has been reported as a side effect with some of the SSRIs This may not be a significant side effect -- we don't depend on it to improve weight and nutrition -- but many anorexics are aware of the side effect, or find out about it when they look up the medication we just prescribed for them, and stop taking the medication without telling anyone about it. The other problem is that our bodies make serotonin from tryptophan, an essential amino acid (one of the building blocks of proteins). "Essential" means that our bodies cannot make their own tryptophan: we have to get it from the protein in our diet. If someone isn't eating well she likely won't be able to make her own serotonin, and almost every antidepressant works by (trying to) affecting serotonin levels. I try to avoid any antidepressant in a patient until she reaches 85 to 90% of her ideal body weight. Even then, some studies have shown that SSRIs don't help with the anorexia itself in the long run. However, they may help with depression or other psychologic problems that a patient with anorexia has at the same time.

Other medications have not been studied as thoroughly in anorexic patients. Frankly, one reason why is that it's hard to do studies on medication in anorexia, largely because anorexic patients generally avoid anything that they think may make them gain weight. There are some medications that sometimes help with weight recovery in anorexic patients, but the effects of these medicines hasn't been shown to be consistent.

Ultimately, more intensive therapy is needed for both patients and their families. The goals of therapy include persuading patients that anorexia nervosa is a serious disease and not a lifestyle (yes, there are anorexics who claim that their "anorexic lifestyle" is just that), and helping them to deal with their view of their own body and with their diet choices. Therapy also has to include work on other psychologic problems such as obsessive-compulsive disorder, which may be easier to treat but which may also have been behind the development of anorexia.

There are several different approaches to therapy, including

traditional psychoanalysis
(as originally practiced by Sigmund Freud), where the therapist helps the patient to analyse and understand the reasons behind her behaviour.
cognitive-behavioural therapy (CBT)
in which, instead of concentrating on the reasons behind the problem, the therapist helps the patient learn to think about the actual behaviours themselves and about ways that she can avoid or change those behaviours.
group therapy
where several patients with the same problem talk about their -- and each other's -- issues in (relatively structured) sessions. A therapist may serve as "facilitator", or moderator, but in some cases the group members work without a facilitator present. Often group members may confront each other about their problems and the underlying causes; this can be a good thing, depending on how it's done.
family-based therapy
in which the patient's parents have complete control of refeeding while the patient and therapist work on eating-related issues. The parents stay in charge of feeding until the patient is able to eat appropriately. The best-known family-based treatment is the Maudsley approach, named after the psychiatric hospital in London where the treatment protocol was developed. Eating with Your Anorexic, by Laura Collins, is a good explanation of the Maudsley approach from the parents' point of view. When she and her husband were trying to treat their daughter the Maudsley approach was not well-known, and they practically put the diet part of the treatment together themselves. The Maudsley approach is now one of the most commonly-used protocols for anorexic patients who are stable enough to be treated outside the hospital. It does require firm, dedicated parents for the best outcomes. Several studies have shown that patients treated with family-based therapy do better in the long run than similar patients treated with individual therapy, including a recent study whose results were published in the Archives of General Psychiatry (vol 67, issue 10, pages 1025-1032) in October, 2010.

CBT has been shown in clinical trials to be effective in treating bulimia. It is also used in treatment of anorexic adults, and may be helpful in treating anorexic teenagers as well, but this hasn't been studied as well as CBT for bulimia. Group therapy is also potentially helpful for anorexic patients, although again this hasn't been studied well in clinical trials.

Anorexic and bulimic patients who continue to relapse in spite of outpatient therapy and repeated hospitalizations may require intensive residential treatment. Most of these programs combine multiple forms of recreational therapy (one well-known program is located on a ranch in the Southwest, and horseback riding is part of the treatment protocol) with intensive individual and group therapy and supervising feeding and nutritional education. Patients usually spend 1-2 months in these programs before returning home to continued outpatient care. On the other hand, patients in these programs usually have better rates of recovery than similar patients have with only outpatient treatment. As you can imagine, this type of treatment program is very expensive, and many insurance companies balk at paying the fees -- which most patients' families cannot afford. Fortunately, more enlightened insurers are beginning to realize that residential treatment for the severely-ill anorexic patient is cheaper in the long run than repeated hospitalizations for the medical complications.

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PLEASE NOTE: As with all of this Web site, I try to give general answers to common questions my patients and their parents ask me in my (real) office. If you have specific questions about your child you must ask your child's regular doctor. No doctor can give completely accurate advice about a particular child without knowing and examining that child. I will be happy to try and answer general questions about children's health, but unless your child is a regular patient of mine I cannot give you specific advice.

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Copyright © 2007, 2008, 2010 Vinay N. Reddy, M.D. All rights reserved.
Written 02/09/07; last revised 12/14/10 counter