Inpatient Nutrition Care

In the past two issues, we’ve examined different aspects of nasogastric tube feeding. This month’s column is devoted to inpatient nutrition care. I recently spoke with a colleague, Donald Barker, RD, inpatient dietitian for the St. Paul’s Hospital Eating Disorder Clinic in Vancouver. Until a short time ago, inpatient treatment services at St. Paul’s were limited to a four-bed, short-term program known as “Extra Care.” The Clinic has just opened a three-bed, long-term program, the “Quest Program.” Donald is responsible for the care of all inpatients in both programs.

LW: How do the nutrition goals of the two inpatient programs differ?

DB: In both programs, nutrition intervention is largely determined by the client’s individual goals. However, during preparation for admission to either program, I discuss the non-negotiable aspects of treatment and how they affect or relate to the client’s goals.

In Extra Care, the non-negotiables are: (1) completing 100% of their meal plan (energy content varies greatly); (2) including foods from all food groups in their meal plan (although clients can choose to replace foods with oral supplements); and (3) increasing the energy content of the meal plan to improve nutrition recovery and prevent weight loss.

In Quest, the non-negotiables are slightly different. They include: (1) completing the basic minimum meal plan (~1500-1600 kcal/day), regardless of weight status; (2) reducing dependency on oral supplements (unless needed for significant weight gain); and (3) setting a specific weight change goal before coming into the program.

The Extra Care Program is a 1- to 4-week admission that focuses primarily on nourishment, rest, medical stabilization and/or assessment for suitability for other types of treatment. This program is usually the first treatment experience for most of our clients in our entire clinic; thus, development of a strong therapeutic alliance is always a primary objective.

Clients admitted to this program have generally been unsuccessful in maintaining or improving their nutritional status as outpatients. Because of this, most are willing to try challenging their eating disorder within the program guidelines to gain insight as to how much work they are currently ready to do. Others are so medically compromised that they have been admitted under certification or threat of certification. Clients’ nutrition goals are generally quite simple and specific, such as: interrupting restrictive behaviors and excessive exercise patterns, stopping or reducing binge-eating/purge cycles, decreasing laxative misuse, or correcting micronutrient, electrolyte and hydration imbalances.

The Quest Program is a 2- to 4-month inpatient admission with an outpatient transition module. Participants in this program have historically not responded well to the structure or expectations of other intensive inpatient and outpatient treatment options. They are not ready for complete recovery from their eating disorder, but they are motivated to work on improving their quality of life. Participation in the Quest Program is voluntary and participants are motivated to challenge their ambivalence around certain aspects of the eating disorder. Their nutrition goals are more ambitious or complex than those of the Extra Care program. Some examples of goals include slow yet significant weight gain (6.8-9.0 kg), overcoming barriers around food preparation, grocery shopping and social meal situations, or preparation to participate in the Clinic’s intensive outpatient program.

LW: What are your role and responsibilities as the dietitian involved in these treatment programs?

DB: With respect to direct patient care, the role of the dietitian is somewhat multi-faceted. My responsibilities fall into five major themes. The first three are: clinical assessment, including management of refeeding syndrome and tube feeding issues, nutrition education (both one-to-one and in groups), and nutrition intervention (through community living activities such as cooking, grocery shopping and restaurant/social meals). The last two are: helping clients’ understand the value they place on their nutrition-related behaviors, and exploration of how clients’ eating behaviors and beliefs oppose or relate to their nutrition goals and overall quality of life.

The Quest program offers significantly more potential for creativity and community integration work. It is very difficult to foster enough self-sufficiency in short-term inpatients so that they are actually able to develop new skills and coping strategies before being discharged back to their former environment. With Quest, participants have more time to challenge their nutrition-related fears in their natural surroundings, away from the hospital. It is amazing how much a dietitian can learn when interacting with clients in real-life settings.

LW: Donald, has your opinion of effective nutrition intervention changed over the years? And, if so, what impact has this had on the nutrition care you provide?

DB: It’s changed tremendously! In the past, the general focus was on maximum weight gain, to improve cognitive and physical status. Now I tend to focus more on patients’ perception of nutritional progress by relating all nutrition interventions to their goals. There is much less emphasis on mandatory weight gain and much more effort in understanding, accepting and supporting clients’ readiness to make only small changes.

This shift would seem obvious since all the Clinic’s programs are actively involved in research on motivational interviewing techniques. However, the change in my stance has also allowed me to more effectively engage patients in making decisions around their care. I always find it difficult when clients depend on me to determine which nutrition goals are in their best interest. This does nothing to improve their perception of self-sufficiency. Instead, I communicate to clients that the responsibility for change is ultimately up to them. When they recognize their active involvement in decisions around their treatment, there is more opportunity to discuss how difficult it is to willfully relinquish nutrition-based coping mechanisms. It also allows patients to recognize their strengths and ability to change.

LW: When and how do you decide to use nasogastric tube feeding with patients?

DB: I rarely use nasogastric tube feeding any more in the Extra Care Program. Most Extra Care patients are well prepared for their admission and are fully aware of the nutrition guidelines. For those who are not emotionally ready to eat enough orally, tube feeding is offered as adjunct nutrition therapy for a short period of time only (i.e., one week). This is rationalized by emphasizing that one of the primary goals of the program is to work on issues related to eating regular-sized meals and feeling the normal sensation of being full. I never describe or perceive the need for tube feeding beyond one week as negative or ineffectual.

All treatment needs to be individualized, and tube feeding does not always interfere with clients’ other nutrition goals. Some critically ill clients, who need tube feeding, are more appropriately treated on the medical wards at St. Paul’s because of their inability to participate effectively in program group work and/or meals. Clients in the Quest Program are generally not offered tube feeding as part of their treatment, especially since weight change is gradual (0.5-1.0 kg/week) and not as difficult to achieve using food and oral supplements alone.

When patients are tube-fed, formula is almost always delivered as bolus feeds during supported meal times in order to reduce any urges to manipulate or purge the supplement as it is flowing. Most patients receiving feeds quickly express negative reactions towards it. They experience more anxiety and less control around their renourishment process and often switch to oral supplements within the first week of tube feeding. I suspect this negative attitude is partially related to the fact that all (or most) of their co-patients are accepting 100% of food and supplements orally.

Adverse staff reactions and overwhelming feelings of invasiveness are also possible contributing factors. As a result, tube-feeding rarely continues beyond one week.

LW: How do you evaluate the impact of inpatient treatment on clients’ nutrition progress?

DB: With the help of our research psychologist, I have recently developed a self-reflection questionnaire that asks patients to consider both quantitative and qualitative aspects of their nutrition progress. The quantitative components include topics such as changes in binge-eating and/or purging behaviors, ability to improve fluid intake, and shifts in food avoidance patterns. The qualitative aspects focus on how and why clients were or were not able to make specific changes to their eating disorder behaviors and beliefs. I plan to use this questionnaire as a monthly follow-up device, and hope to use it beginning next year.

The questionnaire has not been validated for research purposes. Instead, I want to use it as more of a discussion and reflection tool between clients and myself. It may provide a way to increase clients’ self-awareness about why they have or haven’t reached some of their nutrition goals. It may also give them a chance to indicate what type of support they need to continue with their work towards nutrition recovery.

— Linda M. Watts, MA, RD