This article was originally published on September 11, 2023, and is among Healthcare Design’s most-read articles of 2023. To see a full list, click here.

Eating disorders are serious and complex mental health conditions that require a comprehensive care approach to treat potentially life-threatening medical complications caused by malnourishment, disordered eating behaviors such as purging and restrictive eating, and co-occurring psychological issues such as anxiety and depression.

Two of the most common eating disorders are anorexia nervosa, characterized by an abnormally low body weight resulting from starvation and overexercise, and bulimia nervosa characterized by overeating followed by purging to lose weight. Because severe malnutrition impacts nearly every organ of the body, eating disorders—particularly anorexia nervosa—have a high mortality rate compared with other mental health disorders.

Growing need for eating disorder treatment

Since the pandemic, visit volumes for eating disorders account for the highest increase among all behavioral health conditions, according to Trilliant Health’s analysis of national payer claims. Additionally, patients with eating disorders are increasingly becoming more complex and more acute. Increases in diagnoses may be the result of rises in risk factors correlated with eating disorders. Thi scan include depression and anxiety, and social isolation, which makes it easier to hide unhealthy eating-related behaviors.

Treatment for eating disorders is in many cases fragmented. Medical stabilization and feeding tube placement often happen in a hospital setting. Once stabilized, or in cases where stabilization is not required, patients may receive care through outpatient programs often housed under general behavioral health departments. Taken together, treatment of those with eating disorders requires comprehensive care.

Design lessons for eating disorder facilities

The complexity of eating disorders and treatment translates downstream into complex challenges in the design of these care spaces. The waiting list for persons with eating disorders to be admitted for treatment is long.

Eating Recovery Center (ERC; Denver, Colo.), which operates 35 care centers across the country, delivers specialized, multidisciplinary inpatient and outpatient treatment for adults, children, and adolescents of all genders, including the medical, psychiatric, psychological, and behavioral aspects of the illness. In 2008, Boulder Associates (Boulder, Colo.) began partnering with ERC on its first 12-bed unit, and since have designed most of ERC’s care centers.

To date, most ERC projects have been renovations and tenant improvements of existing buildings to minimize construction time so as not to delay treatment to patients urgently needing care. ERC’s inpatient and residential units typically have an equal mix of adult and adolescent 18-bed units in three-story buildings that range in size from 100,000 to 125,000 square feet.

The layout includes a ground floor dedicated to outpatient programming while inpatient and residential patient spaces, such as dining, spa bath, community room, bedrooms, and therapy rooms, are on upper floors. Child and adolescent units include classrooms, and buildings also have shared spaces for art therapy and yoga.

With an aim to continually improve spaces supporting recovery from eating disorders, ERC committed to an ongoing facility evaluation process across its building portfolio every three to five years and to update design standards in response to new findings.

To date, two large-scale assessments have been conducted, in 2016 and in 2021. These included literature searches, patient and staff surveys, staff interviews, onsite observations, Lean value stream mapping and design workshop events with staff, simulation modeling, and virtual reality testing.

4 design strategies for treatment centers

From this process, several lessons have been learned focusing on specialized strategies for treatment spaces for this continuously evolving patient population:

  1. Providing calm and safe bathroom routines
    Behaviors such as purging and exercising to burn calories often take place in hidden places. Thus, a key challenge for ERC was how to design the most private spaces: toilets, showering, and grooming spaces. To support dignity and calm while decreasing opportunities for hiding unhealthy behaviors, ERC designed spa baths as shared, semi-private space versus having private bathrooms. Spa baths are similar in layout and finishes to restroom and shower spaces found in upscale spas.

To address challenges with monitoring hidden spaces, the layout was designed to be more open and compact to improve staff’s visible and auditory awareness of activities happening in the space. Bathroom finishes were brightened and included ceiling sky panels helping to lift patient gaze—and by association mood—upwards.

  1. Reducing social density during dining
    Findings from a 2017 article, “Perception of Peripersonal and Interpersonal Space in Patients with Restrictive-type Anorexia” by Jean-Louis Nandrino and colleagues published in European Eating Disorders Review, showed that persons with anorexia nervosa needed more than 1.5 times a greater distance from other people to feel comfortable.

Additionally, they may use interpersonal distance to regulate the emotional load of social interactions. Given this finding, decreasing social density and increasing interpersonal distances—particularly in spaces where the most challenging activities occur such as dining—may reduce anxiety and increase comfort.

For example, survey responses from former ERC patients revealed a strong sense of crowding in group dining areas. To address this issue, ERC dining activities in newer facilities are distributed across smaller dining rooms versus within one higher-occupancy space.

Additionally, while 18 inches between diners and 15 square feet per diner are minimum benchmarks, ERC dining standards allow 30 inches between diners and more than 30 square feet per diner to provide extra personal space.

Additionally, dining chairs also are oriented to offer more expansive views outside to help support a greater sense of spaciousness, and acoustic baffles are used to reduce noise-induced stress. In response,

ERC has found that facilities built after the 2016 assessment, which have greater space per diner and lower room occupancy, have more positive staff ratings of comfortable group size and adequate personal space compared to facilities built before 2016 with higher-capacity dining areas.

  1. Using daylighting for circadian health

In persons with eating disorders, food intake irregularities can cause circadian disturbance. It has been proposed that maximizing exposure to natural light during the day and minimizing light exposure at night, in addition to regulating eating patterns, can help re-entrain circadian rhythms.

When adult patient alumni were asked to rank types of environmental features they found most healing from a list of nine items, such as sunlight, familiar and homelike qualities, plants and nature, and bright colors, nearly two-thirds of the 192 respondents selected sunlight as either one of their top three features, with nearly one-third of participants selecting sunlight as their first-choice feature.

Given that average length of stays can range from 6 to 12 weeks,  finding more opportunities to bring natural light into patient spaces housing daytime activities becomes an important design goal to support recovery.

Limitations of perimeter building space due to requirements that patient bedrooms have window access provide challenges to bringing daylight into spaces where daytime patient activities take place. For ERC, the solution was to use an outboard location for inpatient dining spaces to maximize access to morning and afternoon light.

Glazing was used on the inboard community room to borrow light from adjacent corridor windows while also supporting greater staff visibility of patients from the corridor and staff station. Across the corridor, an outdoor seating area offers the opportunity to go outside without leaving the unit.

  1. Reducing opportunities for excess movement

While there is a need to maximize perimeter space to bring daylight to daytime spaces, there is an equally important need to minimize corridor lengths and loops as they present opportunities for patients to overexercise and burn calories.

Secure cross-corridor doors offer a way to break down unit sizes based on how spaces are used throughout a day, as well as offer flexibility to create different-sized units based on patient census as it fluctuates by acuity or age.

Corridors in more recent ERC buildings have evolved from earlier sites to include seating in response to staff and patient survey feedback suggesting that corridors are used as hang-out spaces for social interactions, particularly in child and adolescent units where patients like to be around staff.

Moreover, because high-acuity patients may experience extreme physical weakness and mobility limitations, corridor seating provides a resting point and may help minimize falls.

Findings from studies related to spatial perception in persons with anorexia nervosa suggest that overestimating body size may influence a person to move through space as though having a larger body.

Based on this finding, intersections and transitions between spaces, such as between community room and corridor, were widened at newer ERC facilities to lessen a sense of compression by expanding person-boundary distances and encourage entry into social spaces.

Need for ongoing evaluation

Floorplan analyses, in conjunction with ERC staff survey results, have validated performance optimizations such as benefits of increased daylight in patient spaces, increased square foot per patient ratios in dining areas, and increased staff visibility and situational awareness in spa baths and corridors.

However, patient complexity among persons with eating disorders continues to evolve, and design strategies implemented today will need to be revisited for tomorrow’s patients.

This ongoing, collaborative study among design professionals, treatment experts, front-line staff, and patients paves the way for more effective and supportive specialized care environments.

Through continuous evaluation and refinement, there is an opportunity to optimize spaces, care delivery, and patient outcomes for persons with eating disorders.

Meredith Banasiak, EDAC, MArch, is director of research at Boulder Associates (Boulder, Colo.) and can be reached at mbanasiak@boulderassociates.com

For more on this topic, find the author speaking with a panel in session “E17 – Designing for Persons with Eating Disorders,” at the 2023 HCD Conference + Expo, Nov. 4-7 in New Orleans. For conference and registration details, visit hcdexpo.com.