Risk assessment in eating disorders: using MEED to reduce mortality

Author/s
Paul Robinson, Darren Cutinha
Citation
Focus Issue 6: Eating disorders
CEPiP.2024.1.150-158
Abstract

Eating disorders (EDs) are potentially fatal illnesses. Sadly, over the years, we have become aware of several deaths where detailed review suggests that they could have been avoided. This was the motivation to write what is now known as MEED, Medical Emergencies in Eating Disorders, published in 2022.

MEED is the most developed guidance on treating severely medically ill patients with EDs and should be used by all clinicians having contact with ED patients. This article documents the physical risks that EDs present, and the preventable deaths, particularly of the most unwell patients. It introduces MEED as a system which has the potential to avoid some of those deaths and improve management. A new website is introduced, meed.org.uk, which may make MEED more accessible to frontline staff and improve its uptake.

Staff are encouraged to be trained to use MEED and to familiarise themselves with the Risk Assessment Framework it contains. Each group of clinical staff as well as patients and carers will find summary sheets and specific advice in MEED. In this article, we have provided links to each problem area we anticipate will be encountered and links to the summary sheets for clinicians, patients and carers. We also provide two clinical vignettes, one a child and one a young adult, to demonstrate how MEED can be used in real-life situations with substantial clinical risk.

We strongly advocate for training to be made mandatory for any staff likely to be assessing or treating a patient with an ED so that the avoidable deaths, mostly in adults, which continue to be reported by coroners, can be eliminated.

Refeeding of severely malnourished patients often takes place in medical or paediatric settings, and previous guidance has led to overcautious refeeding, resulting in "underfeeding syndrome". MEED provides clear, up-to-date, evidence-based guidance which allows essential treatment of low weight by safe refeeding, thereby avoiding refeeding syndrome while avoiding underfeeding syndrome, which has resulted in several documented deaths.

Keywords: eating disorders, risk management, anorexia nervosa, bulimia nervosa, guidance, MEED

Cite as: Cutting Edge Psychiatry in Practice 2025, 6(1):150-158; https://doi.org/10.65031/ukel2758

References

  1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry. 2011;68(7):724-31. https://doi.org/10.1001/archgenpsychiatry.2011.74
  2. United Kingdom Parliamentary and Health Service Ombudsman (PHSO). Ignoring the alarms: How NHS eating disorder services are failing patients. 2017. Accessed 04 April 2024. Available from: https://www.ombudsman.org.uk/publications/ignoring-alarms-how-nhs-eatingdisorder-services-are-failing-patients
  3. Robinson P. Avoiding deaths in hospital from anorexia nervosa: the MARSIPAN project. The Psychiatrist. 2012;36(3):109-13. https://doi.org/10.1192/pb.bp.111.036699
  4. Kearsley J. Regulation 28: Report to prevent future deaths (1) - A report of the Senior Coroner for the Coroner area of Manchester North. 2021. Accessed 26 November 2024. Available from: https://www.judiciary.uk/wp-content/uploads/2021/12/Nichola-Lomax-Prevention-offuture- deaths-report-2021-0433_Published.pdf                 
  5. Mehler PS, Blalock DV, Walden K, Kaur S, McBride J, Walsh K, et al. Medical findings in 1,026 consecutive adult inpatient–residential eating disordered patients. International Journal of Eating Disorders. 2018;51(4):305-13. https://doi.org/10.1002/eat.22830
  6. Kjeldsen K. Hypokalemia and sudden cardiac death. Experimental and Clinical Cardiology. 2010;15(4):e96.        
  7. Farrell D, Bower L. Fatal water intoxication. Journal of Clinical Pathology. 2003;56(10):803-4.             
  8. Sanvictores T, Casale J, Huecker M. Physiology, fasting. 2023. Accessed 04 April 2024. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK534877/#:~:text=After%20fasting%20for%20around%2024,triglyceride%20stores%20in%20adipose%20tissue.          
  9. Kerruish KP, O'Connor J, Humphries IR, Kohn MR, Clarke SD, Briody JN, et al. Body composition in adolescents with anorexia nervosa. The American Journal of Clinical Nutrition. 2002;75(1):31-7. https://doi.org/10.1093/ajcn/75.1.31
  10. Rosen E, Bakshi N, Watters A, Rosen HR, Mehler PS. Hepatic complications of anorexia nervosa. Digestive Diseases and Sciences. 2017;62:2977-81. https://doi.org/10.1007/s10620-017-4766-9
  11. O'Connor G, Nicholls D, Hudson L, Singhal A. Refeeding low weight hospitalized adolescents with anorexia nervosa: a multicenter randomized controlled trial. Nutrition in Clinical Practice. 2016;31(5):681-9. https://doi.org/10.1177/0884533615627267
  12. Misra M, Klibanski A. Anorexia nervosa and bone. Journal of Endocrinology. 2014;221(3):R163-R76. https://doi.org/10.1530/joe-14-0039
  13. Loud KJ, Gordon CM. Adolescent bone health. Archives of Pediatrics and Adolescent Medicine. 2006;160(10):1026-32. https://doi.org/10.1001/archpedi.160.10.1026
  14. Royal College of Psychiatrists. Medical Emergencies in Eating Disorders: Guidance on Recognition and Management 2022. Accessed 04 April 2024. Available from: https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/collegereports/2022-college-reports/cr233.         
  15. Office for National Statistics. Deaths that involved an eating disorder, England and Wales, 2001 to 2018. 2019. Accessed 26 November 2024 Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/adhocs/10948deathsthatinvolvedaneatingdisorderenglandandwales2001to2018.    
  16. Mehler PS, Watters A, Joiner T, Krantz MJ. What accounts for the high mortality of anorexia nervosa? International Journal of Eating Disorders. 2022;55(5):633-6. https://doi.org/10.1002/eat.23664
  17. Fichter MM, Quadflieg N. Mortality in eating disorders‐results of a large prospective clinical longitudinal study. International Journal of Eating Disorders. 2016;49(4):391-401. https://doi.org/10.1002/eat.22501
  18. Java Discover | Free Global Documentaries and Clips. Emma Wants to Live | Emma Wil Leven Full Documentary | Anorexia & Eating Disorders Film. YouTube (2016). Accessed 12 December 2024. Available from: https://www.youtube.com/watch?v=YNcElGJlTeE          
  19. National Institute for Health and Care Excellence (NICE). Eating disorders: recognition and treatment. NICE guideline [NG69] 2017. Updated 16 December 2020;. Accessed 6 October 2023. Available from: https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#identification-and-assessment. https://doi.org/10.24292/01.mf.0120.14
  20. Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. Journal of Eating Disorders. 2022;10(1):23. https://doi.org/10.1186/s40337-022-00548-3
  21. Guarda AS, Hanson A, Mehler P, Westmoreland P. Terminal anorexia nervosa is a dangerous term: it cannot, and should not, be defined. Journal of Eating Disorders. 2022;10(1):79. https://doi.org/10.1186/s40337-022-00599-6
  22. Gibson D, Watters A, Cost J, Mascolo M, Mehler PS. Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort. Journal of Eating Disorders. 2020;8:1-10. https://doi.org/10.1186/s40337-020-00303-6
  23. Robinson P, Cutinha D. Specialist Medical Assessment of Eating Disorders. In: Wade T, Herpertz-Dahlmann B, Fernandez-Aranda F, Treasure J, Wonderlich S, editors. Eating Disorders: An International Comprehensive View. Springer (2024) p. 1-15. https://doi.org/10.1007/978-3-031-46096-8
  24. Gawande A. The Checklist Manifesto: How to Get Things Right. London, UK. Profile Books (2011).     
  25. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009;360(5):491-9. https://doi.org/10.1016/j.spinee.2010.04.021
  26. Gorrell S, Murray SB. Eating disorders in males. Child and Adolescent Psychiatric Clinics. 2019;28(4):641-51. https://doi.org/10.1016/j.chc.2019.05.012
  27. Horstead S. Regulation 28: Report to prevent future deaths (redacted) - Report of the Assistant Coroner for the Coroner area of Cambridgeshire and Peterborough. 2021. Accessed 04 April 2024. Available from: https://www.judiciary.uk/wp-content/uploads/2021/03/ Averil-Hart-2021-0058-Redacted.pdf
  28. BEAT Eating Disorders. Worth more than 2 hours. Accessed 17 April 2024. Available from: https://www.beateatingdisorders.org.uk/supportour-work/campaign-for-beat/current/campaign-worth-more-than-2-hours.