Weight loss exclusively by dieting, fasting, excessive exercise. No binge-purge behaviour. Most medically severe at low weights.
Meets AN criteria (low weight, fear of gain) but also engages in binge/purge episodes. Electrolyte abnormalities more prominent.
Avoidance of food based on sensory characteristics (texture, colour, smell), fear of choking/vomiting, or apparent lack of interest. NOT driven by body image concerns. Common in autism, anxiety disorders. Significant nutritional deficits without deliberate weight loss intent.
MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) provides a structured framework for assessing medical risk and determining appropriate care setting.
| Parameter | Low Risk | Medium Risk | High Risk — Admit |
|---|---|---|---|
| BMI (adults) | ≥15 | 13–14.9 | <13 |
| Heart rate (resting) | ≥60 | 50–59 | <50 |
| Systolic BP | ≥100 | 90–99 | <90 |
| Postural drop | <5 mmHg | 5–10 mmHg | >10 mmHg |
| Temperature | ≥35.5°C | 34.5–35.4°C | <34.5°C |
| Muscle function | Sit up unaided | Difficulty rising | Cannot rise from squat |
| QTc interval | <450 ms | 450–470 ms | >470 ms |
Any single HIGH RISK criterion = medical admission required. Do not manage in community. Involve physician and eating disorder team immediately.
Eating disorders are significantly underreported across GCC countries due to cultural stigma, family shame, and low awareness among primary care providers. Families often perceive low weight as a spiritual or physical illness rather than psychiatric.
Increasing prevalence has been documented among Gulf women, particularly university-aged students in Saudi Arabia, UAE, and Kuwait. Rates comparable to Western populations in younger cohorts.
Rapid adoption of social media platforms — Instagram, TikTok, Snapchat — is directly linked to increasing body dissatisfaction among Gulf adolescents. "Fitspiration" culture, filters, and influencer culture drive unrealistic body ideals.
Anorexia Nervosa has the highest mortality rate of any psychiatric disorder — approximately 10% (5–6% from medical complications, 2–5% suicide). Early identification and medical monitoring are critical.
| Electrolyte | AN | BN / AN-BP | Clinical Risk |
|---|---|---|---|
| Potassium (K+) | Low-normal or low | Significantly low (purging) | Arrhythmias, muscle weakness, ileus |
| Phosphate | Low (especially refeeding) | Low-normal | Refeeding syndrome, cardiac failure |
| Magnesium | Low | Low (laxative misuse) | Arrhythmias, seizures, worsens hypokalaemia |
| Sodium | Low (water loading) | Low or normal | Hyponatraemic encephalopathy |
| Chloride | Normal | Low (vomiting) | Metabolic alkalosis |
| Calcium | Low (poor intake) | Normal | Osteoporosis, tetany |
Osteoporosis is one of the most significant long-term complications of AN, driven by prolonged oestrogen deficiency, low calcium/vitamin D intake, elevated cortisol, and IGF-1 deficiency.
Refeeding syndrome is potentially fatal. It occurs when carbohydrate-driven insulin surge causes massive intracellular shift of phosphate, potassium, and magnesium, leading to hypophosphataemia, fluid shifts, and multi-organ failure. Prevention requires slow caloric escalation and proactive electrolyte/vitamin replacement.
A patient is at HIGH RISK if they meet ONE or more of the following:
Patient is at risk if they meet TWO or more of the following:
In eating disorders, BMI <16 alone qualifies as high-risk. Do not wait for additional criteria.
Thiamine Dose Reminder: Oral thiamine 200–300 mg/day OR Pabrinex IV (Pairs 1+2) twice daily for first 3–5 days if patient severely malnourished or IV nutrition planned. Must be given BEFORE any carbohydrate load.
| Time Period | Target Calories | Monitoring | Action |
|---|---|---|---|
| Days 1–2 | 5–10 kcal/kg/day (maximum) | Daily U&E, phosphate, Mg, glucose, ECG | Thiamine + electrolytes replaced BEFORE starting |
| Days 3–4 | Increase by 5 kcal/kg if electrolytes stable | Continue daily bloods | Vigilant for oedema, tachycardia, respiratory changes |
| Days 5–7 | Titrate towards 20 kcal/kg/day | Daily bloods until stable | Involve dietitian — oral diet preferred; NG if unable |
| Week 2+ | Advance toward full requirements (25–35 kcal/kg/day) | 3× weekly bloods | Continue vitamin supplementation; weight monitoring |
Phosphate Replacement Threshold: Phosphate <0.6 mmol/L = oral supplementation. Phosphate <0.5 mmol/L = IV replacement required. Replace before and during refeeding. Check phosphate daily for minimum 2 weeks.
Unlike many psychiatric conditions, AN is often ego-syntonic — the illness aligns with the patient's sense of self and values. Patients typically do not identify the disorder as a problem or desire recovery. This profoundly challenges engagement.
NG feeding in the context of meal refusal requires a formal legal and ethical framework. The approach differs between countries but must be documented, proportionate, and regularly reviewed.
FBT is the most evidence-based treatment for adolescent AN. Parents are externalised as agents of recovery, not causes of illness. Three phases: Phase 1 — parents take control of refeeding; Phase 2 — gradual return of control to adolescent; Phase 3 — establishing healthy identity. Nurse's role: support family, psychoeducation, reinforce consistency.
Eating disorders carry significant suicide risk. AN has a 2–5% suicide mortality. BN and BED carry elevated self-harm risk. All patients require regular risk assessment.
Leads diagnostic assessment, prescribing (antidepressants, antipsychotics cautiously), MHA/MCA decisions, compulsory treatment, mental health comorbidity management.
Coordinates meal support, observation, therapeutic relationship, nursing care plan, patient advocacy, staff education, discharge planning. Key point of contact.
Nutritional assessment, meal planning, refeeding protocol design, caloric targets, NG feed prescribing, vitamin/mineral supplementation, weight monitoring.
CBT-E (Enhanced CBT), FBT facilitation, schema therapy, trauma-focused work, neuropsychological assessment, group therapy, family work.
Medical monitoring, electrolyte management, ECG interpretation, cardiac assessment, bone health (DEXA), refeeding syndrome management.
Safe graded activity and exercise prescription (avoids compulsive exercise trigger), muscle rehabilitation, bone health programme, body awareness therapy.
| Setting | Criteria for | Key Features |
|---|---|---|
| Outpatient | BMI >15, medically stable, motivated, strong support | Weekly EDNS appointments, dietitian, psychology. GP monitoring. Suitable for BN, BED, mild AN. |
| Day Programme | BMI 13–15, partial engagement, step-up or step-down | Structured meal support daytime, therapy groups, overnight at home. 5 days/week intensity. |
| Inpatient (Psych) | BMI <13, MARSIPAN medium-high, treatment refusal, suicide risk | 24-hour observation, medical monitoring, structured meals, psychological programme. |
| Inpatient (Medical) | Any MARSIPAN HIGH criteria, refeeding, electrolyte instability | HDU/general medical ward. Stabilise medically before transfer to psychiatric setting. |
Ramadan fasting represents a significant clinical risk for patients with eating disorders. Fasting behaviour during Ramadan can mirror and reinforce ED restricting patterns, increasing relapse risk.
Male eating disorders are significantly underdiagnosed globally and particularly in GCC due to cultural attitudes to masculinity, reduced help-seeking, and clinician bias toward female patients.
"Reverse anorexia" — pathological preoccupation with body being insufficiently muscular. Compulsive exercise, restrictive eating, protein supplement overuse, and anabolic steroid use. High prevalence in GCC gym culture.
Anabolic steroid use in GCC is increasing among young men seeking muscular physiques. Associated with muscle dysmorphia, cardiac complications (LVH, arrhythmias), hepatotoxicity, psychiatric comorbidity (aggression, depression on cessation).
Transition from adolescent to adult services is a period of high risk. Ensure structured transition planning begins at 16, with named adult clinician from age 17. Avoid any gap in care.
High-yield exam content for DHA, DOH, SCFHS, QCHP, and MOH nursing licensing exams. Eating disorders appear in psychiatry and medical nursing sections. Focus on diagnostic criteria, refeeding protocol, and electrolyte patterns.
ARFID differs from AN: avoidance is driven by sensory features, fear of adverse consequences (choking, vomiting), or lack of interest — NOT by fear of weight gain or distorted body image. Normal BMI possible. Common in children and ASD.
| Electrolyte | AN (Restrictive) | BN / Purging | Refeeding Syndrome |
|---|---|---|---|
| Phosphate | Low (starvation) | Normal or low | Severely LOW — hallmark |
| Potassium | Low-normal | Significantly LOW | Low (intracellular shift) |
| Magnesium | Low | Low (laxatives) | Low (intracellular shift) |
| Sodium | Low (water loading) | Low or normal | May drop (fluid shifts) |
| Glucose | Low (hypoglycaemia) | Variable | Rises then drops — glucose drive |
| Acid-base | Normal or acidosis | Metabolic ALKALOSIS | Variable |
Any ONE of the following warrants immediate medical admission (MARSIPAN HIGH risk):
Mnemonic — REFEEDING: Replace electrolytes first, Escalate calories slowly, Feed orally if possible, ECG and electrolytes daily, Dietitian involvement essential, Involve MDT, NG if necessary, Give thiamine BEFORE glucose load.
Answer: Refeeding syndrome — caused by hypophosphataemia, hypokalaemia, and hypomagnesaemia due to intracellular shift on reintroduction of carbohydrates. Presents with cardiac arrhythmias, respiratory failure, oedema, and Wernicke's encephalopathy. Prevented by slow caloric escalation, thiamine supplementation, and electrolyte correction BEFORE refeeding begins.
Answer: Phosphate (hypophosphataemia) — phosphate is required for ATP production. Refeeding triggers insulin-mediated intracellular uptake of phosphate, causing plasma levels to fall precipitously. Clinical result: ATP depletion affecting cardiac muscle, diaphragm, and erythrocyte function.
Answer: Bulimia Nervosa (and AN binge-purge type). Russell's sign refers to calluses or scarring on the dorsal surface of the knuckles (metacarpophalangeal joints) caused by repeated self-induced vomiting. The teeth abrade the skin as fingers are used to stimulate the gag reflex.
Answer: 0.5–1 kg per week inpatient. Outpatient target is 0.5 kg/week. Rapid weight gain (>1 kg/week) risks refeeding syndrome and is not therapeutic. Too slow (<0.5 kg/week) suggests insufficient nutrition or ongoing compensatory behaviours.
Answer: Thiamine (Vitamin B1) — thiamine is a co-factor for glucose metabolism (pyruvate dehydrogenase). In thiamine-depleted malnourished patients, administering glucose without thiamine causes accumulation of pyruvate and lactate, leading to Wernicke's encephalopathy (confusion, ophthalmoplegia, ataxia). Dose: 200–300 mg oral/day or Pabrinex IV in severe cases.
Answer: Immediate medical admission. All three parameters meet MARSIPAN HIGH risk criteria: HR <50, SBP <90, temp <34.5°C. This patient requires urgent medical stabilisation on a general medical ward or HDU — NOT management in the community or psychiatric unit without concurrent medical input. Call senior clinician immediately.