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Anorexia Nervosa

Extreme anorexia nervosa: medical findings outcomes, and inferences from a retrospective cohort

Journal of Eating Disorders
By Philip S. Mehler, MD, FACP, FAED, CEDS Dennis Gibson, MD, FACP, CEDS Jeana Cost, MS, LPC, CEDS

Gibson D, Watters A, Cost J, Mascolo M, Mehler PS. Extreme anorexia nervosa: medical findings outcomes, and inferences from a retrospective cohort. J of Eating Disorders. 8:25-36, 2020.

Background

Extreme anorexia nervosa (AN) is defined as a BMI < 15 kg/m2 in those meeting DSM-V diagnostic criteria for AN. This study seeks to define the frequency of medical complications in this group of patients in order to help inform the care of individuals < 65% ideal body weight who seek treatment for their extreme eating disorders.

Methods

Through retrospective chart review and computerized data collection, we obtained the baseline characteristics and medical findings of 281 adult patients, with AN restricting and binge-purge subtypes, admitted to the ACUTE unit for medical stabilization between May 2013 and August 2018.

Results

In this population, with a mean admitting BMI of 12.1 kg/m2 (range = 7.5–15.7), 56% admitted with bradycardia, 45% demonstrated increased liver function tests (LFTs) on admission, 64% admitted with leukopenia, 47% with anemia, and 20% presented with thrombocytopenia. During admission, 38% developed hypoglycemia, 35% developed refeeding hypophosphatemia, nearly 33% of patients developed edema, and low bone mineral density was diagnosed in almost 90% of the patients. Highly elevated LFTs (>3x upper limits of normal) predicted hypoglycemia, and low BMI predicted refeeding hypophosphatemia (p = .001).

Conclusions

Although conclusions drawn from the findings presented in this descriptive study must be tempered by relevant clinical judgement, these findings showcase that patients with extreme AN are at significantly increased risk for many serious medical complications secondary to their state of malnutrition and also with initial refeeding.

Plain English summary

Extreme anorexia nervosa (AN) is defined as a BMI < 15 kg/m2 in those meeting DSM-5 diagnostic criteria for AN. However, the frequency of medical complications specific to those meeting this greatest amount of weight loss is unknown. This retrospective study seeks to better define the frequency of medical complications in individuals < 65% ideal body weight admitting to an inpatient medical stabilization unit. We found that patients with extreme AN present with similar medical complications, although at a more frequent occurrence, to those at higher percent ideal body weights. Low bone mineral density is an almost universal finding in this population, with 45% of individuals presenting with osteopenia and 43% with osteoporosis. 35% of individuals developed hypophosphatemia and 38% developed hypoglycemia in this population, both more frequent in the restricting than binge-purge subtype of AN. Elevated liver function tests predict the development of hypoglycemia. Patients with extreme AN are at a significantly increased risk for many serious medical complications secondary to their state of malnutrition and also with initial refeeding.

Philip S. Mehler, MD, FACP, FAED, CEDS
Written by

Philip S. Mehler, MD, FACP, FAED, CEDS

Dr. Philip Mehler, MD, FACP, FED, CEDS founded ACUTE at Denver Health, the country’s only designated Center of Excellence for those with the most extreme forms of eating disorders and severe malnutrition, and continues to serve as its Chief Executive Officer. He began his career at Denver Health more than 30 years ago and was formerly its Chief of Internal Medicine. He was Denver Health’s Chief Medical Officer (CMO) for 10 years until he was promoted to its Medical Director, a position he held until his retirement in 2014. He is also the Glassman Professor of Medicine at the University of Colorado School of Medicine, and has conducted research into the optimal medical treatment of the most severe cases of Anorexia Nervosa and Bulimia. Dr. Mehler has authored more than 500 scientific publications, including four textbooks, Medical Complications of Eating Disorders, published by Johns Hopkins University Press and with a fourth edition slated for release in 2021. Dr. Mehler was the recipient of the Academy of Eating Disorders 2012 Outstanding Clinician Award, has been recognized among the “Best Doctors in America” for the past 22 years in a row, and was voted the “Top Internal Medicine physician in Denver” multiple times by 5280 Magazine. Dr. Mehler is a member and fellow of the Eating Disorders Research Society and the Academy of Eating Disorders, as well as a member of the editorial board of the International Journal of Eating Disorders and serves as the Senior Editor of The Journal of Eating Disorders. He has lectured extensively on a national and international level as the leading medical expert on the topic of the medical complications of eating disorders.   

Dennis Gibson, MD, FACP, CEDS
Written by

Dennis Gibson, MD, FACP, CEDS

Dennis Gibson, MD, FACP, CEDS serves as the Medical Director at ACUTE. Dr. Gibson joined ACUTE in 2017 and has since dedicated his clinical efforts to the life-saving medical care of patients with extreme forms of eating disorders and severe malnutrition. He has quickly developed an expertise in the treatment of this extremely ill and underserved population, and he is actively involved in several research initiatives to help identify evidence-based treatment best practices to address the serious medical complications of eating disorders. Dr. Gibson is also an Assistant Professor of Medicine at the University of Colorado School of Medicine. He completed his undergraduate degree at Albion College in Michigan and earned his medical degree at Southern Illinois University. He completed his internal medicine residency at University of South Florida, is Board certified in Internal Medicine and earned the prestigious CEDS credential from iaedp, underscoring his commitment to effective care and clinical excellence in the treatment of eating disorders.  

Jeana Cost, MS, LPC, CEDS
Written by

Jeana Cost, MS, LPC, CEDS

Jeana Cost is the Vice President of Operations and Medical Services of the ACUTE Center for Eating Disorders & Severe Malnutrition. In her role, she is tasked with ensuring an excellent patient care and referral experience at ACUTE, coordinating among medical, clinical and administrative teams within ACUTE and the greater Denver Health Medical Center community. Prior to joining ACUTE, Jeana served as Vice President, Patient Engagement at Eating Recovery Center and Pathlight Mood & Anxiety Center, as well as several other admissions-facing roles since joining the organization in 2010.  

Jeana brings more than 15 years mental health experience to ACUTE, including extensive experience in pre-admission patient assessment, treatment recommendations and collaboration with families and outpatient teams. She actively and compassionately collaborates with medical and clinical leadership to identify the best care for patients and families. 

Jeana earned a BA in Psychology, a BS in Health Care Administration and an MS in Community Counseling from Minnesota State University Moorhead. She is recognized by the state of Colorado as a Licensed Professional Counselor and recently earned her Certified Eating Disorder Specialist (CEDS) credential from iaedp. 

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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