Bradycardia, hypotension, hypothermia, electrolyte disturbance, or rapid weight loss: high medical risk needing admission, even if the BMI is not extremely low. Use the MEED framework (which replaced MARSIPAN).
High-risk markers (MEED)
- Bradycardia, hypotension or postural drop, hypothermia
- Potassium, phosphate, magnesium or glucose low; QTc prolonged on ECG
- Rapid weight loss, very low BMI, poor muscle power (sit-up-squat-stand test)
- Suicide risk or acute food and fluid refusal
Refeeding syndrome
- Falling phosphate, potassium and magnesium when feeding restarts
- Risk of arrhythmia, cardiac failure, seizures
- Start cautious feeding with electrolyte monitoring and replacement, and thiamine
- Do not under-feed either: both over- and under-feeding are dangerous
Lower risk
- Measures in the safer range
- Outpatient monitoring
- Psychological therapy
Alert / medium risk
- Low BMI, bradycardia, orthostatic drop
- ECG, electrolytes, phosphate
- Watch for refeeding
High risk (MEED red)
- Very low BMI, HR under 40, hypotension
- ECG changes, low potassium or phosphate
- Admit, cautious refeeding, senior
Management
1
1. Assess risk and admit
Use MEED to grade risk. Medical stabilisation first on an appropriate ward with eating disorder input.
Use MEED to grade risk. Medical stabilisation first on an appropriate ward with eating disorder input.
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2
2. Monitor
ECG and electrolytes (phosphate, potassium, magnesium, glucose), observations, and weight. More frequent monitoring at the start of refeeding.
ECG and electrolytes (phosphate, potassium, magnesium, glucose), observations, and weight. More frequent monitoring at the start of refeeding.
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3
3. Refeed safely
Multidisciplinary refeeding plan with electrolyte replacement and thiamine; increase intake gradually but avoid prolonged underfeeding (the underfeeding syndrome).
Multidisciplinary refeeding plan with electrolyte replacement and thiamine; increase intake gradually but avoid prolonged underfeeding (the underfeeding syndrome).
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4
4. Mental health and law
Involve the specialist eating disorder team. Consider the Mental Health Act and best-interests decisions if the person refuses life-saving treatment and lacks capacity.
Involve the specialist eating disorder team. Consider the Mental Health Act and best-interests decisions if the person refuses life-saving treatment and lacks capacity.
Beware
- A 'normal' BMI does not exclude high medical risk
- Compensatory behaviours (vomiting, laxatives, exercise) worsen electrolytes
- Involve carers and be alert to safeguarding
Pitfalls
- Reassurance from a near-normal weight
- Aggressive refeeding causing refeeding syndrome
- Under-feeding out of caution
- Not monitoring or replacing phosphate
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026