Outcomes of an inpatient refeeding protocol in youth with Anorexia Nervosa and atypical Anorexia Nervosa at Children's Hospitals and Clinics of Minnesota

The Inpatient Management of Adolescents with Eating Disorders

Eating disorders affect individuals of all ages, genders, sexual orientations, ethnicities, races, and socioeconomic statuses. They can lead to serious medical complications that require inpatient treatment. The eating disorders that are most likely to lead to medical complications requiring medical inpatient stabilization include anorexia nervosa, atypical anorexia nervosa, avoidant-restrictive food intake disorder, bulimia nervosa, and purging disorder. There are criteria that can help determine if a patient requires inpatient stabilization. Nearly all body systems may be affected. Patients are often treated by following a refeeding protocol that reduces the risk of developing refeeding syndrome, a dangerous and life-threatening state of metabolic derangements that can arise when a malnourished individual begins a renourishment process. Following stabilization, patients should receive further care through a number of different treatment options directed at their underlying eating disorder and by working with a multidisciplinary team. [Pediatr Ann. 2024;53(8):e283-e287.].

Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders

BACKGROUND

This study investigated changes of lipid parameters in children with severe eating disorders during refeeding in order to explore the optimal timing for lipid preparation administration.

METHODS

We prospectively assessed the physical conditions of patients with eating disorders after the start of nutrition therapy. The assessments were performed at admission and at 2 and 4 weeks. Lipid metabolism was assessed based on triglyceride (TG), total cholesterol (TC), and free carnitine (FC) levels, as well as acylcarnitine/free carnitine (AC/FC) ratio.

RESULTS

A total of 18 patients were included. Of these, 12 and 6 received an oral diet (OD group) and total parenteral nutrition (TPN group), respectively. The mean body mass indexes at hospital admission were 12.8 kg/m2 in the OD group and 12.7 kg/m2 in the TPN group. At 2 weeks after the start of refeeding, TC, TG, and AC/FC levels were significantly lower in the TPN group than in the OD group. Other blood test results did not show any significant differences between the two groups.

CONCLUSIONS

Fat-free glucose-based nutrition promoted lipid metabolism over a 2-week period after the start of refeeding, suggesting that balanced energy and lipid intake are essential, even in TPN.

High-calorie refeeding in adolescents with anorexia nervosa: a narrative review

Background and objectives

Recent studies about refeeding in anorexia nervosa (AN) suggest starting with a high calorie diet. This narrative review aims to understand the initial refeeding management in hospitalized children and adolescents with AN and to develop a practical protocol.

Methods

We performed a comprehensive database search in June 2023 for abstracts published between January 2010 and May 2023 in different databases: Pubmed, The Cochrane Library and Embase with the terms refeeding syndrome, energy intake, diet therapy, weight restoration, hypophosphatemia, nutritional rehabilitation, anorexia nervosa, restrictive eating disorders, child, adolescent and young adult.

Results

Fifteen papers were included in this review. Twelve studies were retrospective or observational. Only 3 randomized controlled trials were found. Initial energy intake varies within a wide range between 500 and 2800 kcal per day but generally begins with higher calories than current recommendations. Only hypophosphatemia was often described without clinical refeeding syndrome. Initial weight restoration was better with high calorie refeeding (HCR). Length of stay was shorter with HCR in some studies. Long term outcomes were unknown. Only two studied severely malnourished patients (< 70 % mBMI).

Conclusion

In adolescents with AN and with a low risk of RS, high calorie refeeding is possible under close medical monitoring and with prompt electrolyte correction. Robust studies with a unified protocol are needed to confirm the safety of high calorie refeeding especially in severely malnourished adolescents with AN.

Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders

BACKGROUND

This study investigated changes of lipid parameters in children with severe eating disorders during refeeding in order to explore the optimal timing for lipid preparation administration.

METHODS

We prospectively assessed the physical conditions of patients with eating disorders after the start of nutrition therapy. The assessments were performed at admission and at 2 and 4 weeks. Lipid metabolism was assessed based on triglyceride (TG), total cholesterol (TC), and free carnitine (FC) levels, as well as acylcarnitine/free carnitine (AC/FC) ratio.

RESULTS

A total of 18 patients were included. Of these, 12 and 6 received an oral diet (OD group) and total parenteral nutrition (TPN group), respectively. The mean body mass indexes at hospital admission were 12.8 kg/m2 in the OD group and 12.7 kg/m2 in the TPN group. At 2 weeks after the start of refeeding, TC, TG, and AC/FC levels were significantly lower in the TPN group than in the OD group. Other blood test results did not show any significant differences between the two groups.

CONCLUSIONS

Fat-free glucose-based nutrition promoted lipid metabolism over a 2-week period after the start of refeeding, suggesting that balanced energy and lipid intake are essential, even in TPN.

The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study

OBJECTIVE

Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED.

METHOD

This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change.

RESULTS

Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission.

DISCUSSION

The incidence of severe RFS was low in this cohort and was associated with lower admission weight.

PUBLIC SIGNIFICANCE

This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.

Cardiac involvement and its clinical significance in patients with anorexia nervosa

Cardiac complications are a major concern in patients with anorexia nervosa (AN) which contribute to morbidity and mortality. However, limited information exists regarding risk factors for the development of these complications. Our objective was to investigate the prevalence and associated risk factors of cardiac involvement among children and adolescents with AN admitted to a tertiary pediatric hospital. We collected demographic, clinical, and laboratory data from individuals with AN hospitalized between 2011 and 2020 in Schneider Children's Medical Center in Israel. Diagnosis was based on established criteria (DSM-5). Patients with other co-morbidities were excluded. Cardiac investigations included electrocardiograms (ECG) and echocardiograms. We conducted correlation tests between cardiac findings and clinical and laboratory indicators. A total of 403 AN patients (81.4% were females) with a median age of 15 ± 2 years were included in the study. Sinus bradycardia was the most common abnormality, observed in 155 (38%) participants. Echocardiogram was performed in 170 (42.2%) patients, of whom 37 (22%) demonstrated mild cardiac aberrations. Among those aberrations, 94.6% could be attributed to the current metabolic state, including pericardial effusion (15.3%) and valve dysfunction (8.8%). Systolic or diastolic cardiac dysfunction, tachyarrhythmias, or conduction disorders were not observed. Patients with new echocardiographic aberration had significantly lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension was higher in this group.

CONCLUSIONS

The prevalence of cardiac involvement, except for sinus bradycardia, was notably low in our cohort. The presence of cardiac aberrations is correlated with several clinical variables: lower body mass index (BMI) and the presence of amenorrhea and hypotension at admission. Patients presenting with these variables may be at high risk for cardiac findings per echocardiography. Dividing the patients into high and low risk groups may enable targeted evaluation, while avoiding unnecessary cardiac investigations in low-risk patients.

WHAT IS KNOWN

• Cardiac involvement in anorexia nervosa (AN) patients is a major concern, which contributes to morbidity and mortality. • It is unknown which patients are prone to develop this complication.

WHAT IS NEW

• Cardiac complications in our cohort are less frequent compared to previous studies, and it is correlated with lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension.

Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review

PURPOSE

To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN).

METHODS

This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS).

RESULTS

Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies.

CONCLUSION

All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.

Hospital-based higher calorie refeeding and mealtime distress in adolescents and young adults with anorexia nervosa or atypical anorexia nervosa

OBJECTIVE

The StRONG study demonstrated that higher calorie refeeding (HCR) restored medical stability faster in patients hospitalized with anorexia nervosa (AN) and atypical AN (AAN), with no increased safety events compared with standard-of-care lower calorie refeeding (LCR). However, some clinicians have expressed concern about potential unintended consequences of HCR (e.g., greater mealtime distress). The purpose of this study was to examine patient treatment preference and compare mealtime distress, food refusal, and affective states between treatments.

METHOD

Participants (N = 111) in this multisite randomized clinical trial were ages 12-24 years, with AN or AAN, admitted to hospital with medical instability who received assigned study treatment (HCR or LCR). Treatment preference was assessed prior to randomization in the full sample. In a subset of participants (n = 45), linear mixed effect models were used to analyze momentary ratings of mealtime distress (pre, during, and post-meals) and daily affective state during the hospitalization.

RESULTS

About half (55%) of participants reported a preference for LCR. Treatment assignment was not associated with food refusal, mealtime distress, or affective states in the subsample. Food refusal increased significantly over the course of refeeding (p = .018). Individuals with greater depression experienced more negative affect (p = .033), with worsening negative affect over time for individuals with higher eating disorder psychopathology (p = .023).

DISCUSSION

Despite understandable concerns about potential unintended consequences of HCR, we found no evidence that treatment acceptability for HCR differed from LCR for adolescents and young adults with AN and AAN.

PUBLIC SIGNIFICANCE

The efficacy and safety of higher calorie refeeding in hospitalized patients with anorexia nervosa has been demonstrated. However, it is not known whether higher calorie refeeding (HCR) increases meal-time distress. This study demonstrated that HCR was not associated with increased mealtime distress, food refusal, or affective states, as compared with lower calorie refeeding. These data support HCR treatment acceptability for adolescents/young adults with anorexia nervosa and atypical anorexia nervosa.

Clinical Outcomes of Refeeding Syndrome: A Systematic Review of High vs. Low-Calorie Diets for the Treatment of Anorexia Nervosa and Related Eating Disorders in Children and Adolescents

Over the years, the standard of care for re-alimentation of patients admitted for the treatment of anorexia nervosa (AN) has been a conservative or cautious approach described as "start low and go slow." These traditional refeeding protocols advocate for a low-calorie diet that restricts carbohydrates, with the primary goal of hypothetically lowering the risk of refeeding syndrome (RFS) and its complication. However, no consensus exists for the optimal inpatient approach to refeeding children and adolescents with AN. There is still some disagreement about what constitutes an ideal pace for nutritional rehabilitation. Varying treatment protocols have emerged across the globe, often reflecting the preferences and biases of individual practitioners and contributing to the lack of a universally accepted protocol for refeeding in AN. Although it is widely accepted that low-caloric refeeding (LCR) is safe for inpatient treatment of AN, this strategy has been shown to have several significant drawbacks, leading to increased criticism of the LCR method. Research from the last decade has led to calls for a more aggressive refeeding protocol, one that suggests a higher caloric intake from the offset. As a result, this research aimed to conduct a systematic review of the existing literature on strategies for refeeding hospitalized pediatric/adolescent patients with AN and related eating disorders. We aimed to compare high-caloric refeeding (HCR) and LCR in terms of weight gain, length of stay, and risk of RFS. We conducted a thorough search of medical databases for abstracts published in English, including Google Scholar, PubMed, and MEDLINE, to find relevant studies published between 2010 and February 2023. Our focus was on articles that evaluated high versus low refeeding protocols in children and adolescents hospitalized for treating AN and related eating disorders. Only articles that reported on at least one of the outcome variables of interest, such as hypophosphatemia, weight gain, RFS, or length of hospital stay, were considered. This review included 20 full-text articles published in the last decade on the HCR protocol in children and adolescents, with a total sample size of 2191 participants. In only one of the 20 studies did researchers find evidence of a true clinical case of RFS. We, therefore, found no evidence that HCR increased the risk of RFS in adolescents, even in those with a very low body mass index (BMI). However, evidence suggests a lower BMI at the time of hospital admission is a better predictor of hypophosphatemia than total caloric intake. In conclusion, based on the evidence from this review, a high-caloric diet or rapid refeeding in children/adolescents suffering from AN may be both safe and effective, with serial laboratory investigations and phosphate supplementation as needed. Hence, more research, particularly, randomized controlled trials, is required to help shape an evidence-based refeeding guideline outlining target calorie intakes and rates of advancement to assist clinicians in the treatment of adolescents with AN and related eating disorders.

Rapid refeeding does not worsen anxiety in adolescents with anorexia nervosa: a pilot study

The study aimed to describe the progression of state anxiety in adolescents with anorexia nervosa (AN) hospitalized on a high calorie refeeding (HCR) protocol. Participants, 12-21 years, admitted for malnutrition due to AN were placed on a HCR protocol in which calories were advanced by 300 kcal/day. The State-Trait Anxiety Inventory for Children (STAIC) was given to participants within 24 hours of hospitalization and the state anxiety component of the STAIC was administered daily immediately before and after breakfast until discharge. Of 22 patients enrolled, 86% were female, mean age was 14.9 ± 2.0 years, and 95% had AN-restrictive type. The median state and trait anxiety scores at time of admission were 37.0 (28-55) and 35.5 (23-51), respectively. There was no significant difference in median pre-meal state anxiety from hospital day 1 to 6 (34.0(26-55) vs. 38.5(25-55), p-value = 0.079) or in median post-meal state anxiety from hospital day 1 to 6 (35.5(29-56) vs. 37(24-56), p-value = 0.484). Similarly, we found minimal correlation between change in caloric intake and change in pre-meal S-anxiety (Spearman correlation coefficient = -0.032) or post-meal S-anxiety (Spearman correlation = 0.032). While this was a small sample observing anxiety over one week, we found no evidence that state anxiety increased with advancing calories, providing additional support for the use of more rapid refeeding protocols.

Implementation of Standardized Care for the Medical Stabilization of Patients With Anorexia Nervosa

Approaches to refeeding patients with anorexia nervosa for medical stabilization vary across institutions, and there is no established standard of care. This study assessed the impact of a refeeding pathway on hospital length of stay and transfer to the psychiatry unit.

Outcomes of a Standardized, High-Caloric, Inpatient Re-Alimentation Treatment Protocol in 120 Severely Malnourished Adolescents with Anorexia Nervosa

Evidence accumulates that, with close medical monitoring and phosphate supplementation, higher-caloric re-alimentation protocols beginning at 2000 kcal/day (HCR) are not associated with an increased incidence of electrolyte abnormalities in patients with anorexia nervosa (AN) but rather result in faster weight gain. These studies are still scant and have largely been performed in adults or moderately malnourished adolescents. Methods: A retrospective chart review of patients with AN aged 12−20 years and with a body mass index (BMI) < 15 kg/m2 alimented according to a standardized treatment protocol in a German clinic specialized in AN was conducted. All patients received 2000 kcal/day from day one. The effect of HCR was examined with respect to laboratory changes and weight development over 4 weeks. Results: In 120 youth (119 (99.2%) females and 1 (0.8%) male, the mean BMI was 13.1 ± 1.1 (range = 10.2−15.0), %mBMI was 62.1 ± 6.0% and weight gain was 0.76 ± 0.22 kg per week, with the highest rate of weight gain during week 1 (1.25 ± 1.28 kg/week). Over 4 weeks, the total weight gain was 3.00 ± 1.92 kg. Nine patients (7.5%) developed mild hypophosphatemia, and none developed refeeding syndrome. Conclusions: Starting re-alimentation with 2000 kcal/d under close medical surveillance, severely malnourished youth with AN met the recommended weight gain targets between 0.5 and 1 kg/week according to current treatment guidelines, without anyone developing refeeding syndrome.

Rapid refeeding in anorexia nervosa: A dialectic balance

OBJECTIVE

To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion.

METHOD

This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m² and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant.

RESULTS

Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol.

DISCUSSION

This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life.

PUBLIC SIGNIFICANCE

This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost-savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life.

Sex differences in refeeding among hospitalized adolescents and young adults with eating disorders

OBJECTIVE

To determine sex differences in refeeding (i.e., short-term nutritional rehabilitation) outcomes among hospitalized adolescents and young adults with eating disorders.

METHODS

We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical and nutritional management between May 2012 and August 2020. Descriptive statistics, crude, and adjusted linear regression models were used to assess the association between sex and nutritional outcomes and predictors of length of stay.

RESULTS

A total of 588 adolescents and young adults met eligibility criteria (16% male, mean [SD] age 15.96  [2.75], 71.6% anorexia nervosa, admission percent median body mass index [%mBMI] 87.1 ± 14.1). In unadjusted comparisons, there were no significant sex differences in prescribed kilocalories (kcal) per day at admission (2013 vs. 1980, p = .188); however, males had higher estimated energy requirements (EER, kcal) (3,694 vs. 2,925, p < .001). In linear regression models adjusting for potential confounders, male sex was associated with higher prescribed kcals at discharge (B = 835 kcal, p < .001), greater weight change (B = 0.47 kg, p = .021), and longer length of stay (B = 1.94 days, p = .001) than females. Older age, lower admission weight, lower prescribed kcal at admission, higher EER, and lower heart rate at admission were factors associated with longer length of stay in a linear regression model.

DISCUSSION

These findings support the development of individualized approaches for males with eating disorders to improve quality of care and health care efficiency among an underserved population.

A standard enteral formula versus an iso-caloric lower carbohydrate/high fat enteral formula in the hospital management of adolescent and young adults admitted with anorexia nervosa: a randomised controlled trial

BACKGROUND

The nutritional rehabilitation of malnourished patients hospitalised with anorexia nervosa is essential. The provision of adequate nutrition must occur, while simultaneously, minimising the risk of refeeding complications, such as electrolyte, metabolic, and organ dysfunction. The aim of this study was to compare the efficacy and safety of an iso-caloric lower carbohydrate/high fat enteral formula (28% carbohydrate, 56% fat) against a standard enteral formula (54% carbohydrate, 29% fat).

METHODS

Patients (aged 15-25 years) hospitalised with anorexia nervosa were recruited into this double blinded randomised controlled trial. An interim analysis was completed at midpoint, when 24 participants, mean age 17.5 years (± 1.1), had been randomly allocated to lower carbohydrate/high fat (n = 14) or standard (n = 10) feeds.

RESULTS

At baseline, there was no significant difference in degree of malnutrition, medical instability, history of purging or serum phosphate levels between the two treatment arms. A significantly lower rate of hypophosphatemia developed in patients who received the lower carbohydrate/high fat formula compared to standard formula (5/14 vs 9/10, p = 0.013). The serum phosphate level decreased in both feeds, however it decreased to a larger extent in the standard feed compared to the lower carbohydrate/high fat feed (standard feed 1.11 ± 0.13 mmol/L at baseline vs 0.88 ± 0.12 mmol/L at week 1; lower carbohydrate/high fat feed 1.18 ± 0.19 mmol/L at baseline vs 1.06 ± 0.15 mmol/L at week 1). Overall, serum phosphate levels were significantly higher in the lower carbohydrate/high fat feed compared with standard feed treatment arm at Week 1 (1.06 ± 0.15 mmol/L vs 0.88 ± 0.12 mmol/L, p < 0.001). There was no significant difference in weight gain, number of days to reach medical stability, incidence of hypoglycaemia, or hospital length of stay.

CONCLUSIONS

The results of this study indicate that enteral nutrition provided to hospitalised malnourished young people with anorexia nervosa using a lower carbohydrate/high fat formula (28% carbohydrate, 56% fat) seems to provide protection from hypophosphatemia in the first week compared to when using a standard enteral formula. Further research may be required to confirm this finding in other malnourished populations.

TRIAL REGISTRATION

ANZCTR, ACTRN12617000342314. Registered 3 March 2017, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000342314.

Qualitative patient experiences from the Self-Blame and Perspective-Taking Intervention for eating disorders

BACKGROUND

Problems in social cognition and social support contribute to eating disorders (ED). Group therapy provides an ideal format to create an experiential learning environment focused on understanding social interactions. This pilot study examined the qualitative content of the participants' experiences in the Self-Blame and Perspective-Taking Intervention (SBPI) for ED.

METHODS

The SBPI was a 4-week group therapy intervention involving art therapy and psychoeducation that focused on social behaviors in ED patients. Participants received surveys immediately after the intervention and at 1 to 4 weeks after the post-intervention. Thematic analyses of qualitative feedback were performed using Braun and Clarke's thematic analysis framework.

RESULTS

Inductive analyses revealed three main themes: (1) Developing self-acceptance through emotional reflection, (2) Changing expectations with neurosocial knowledge, and (3) Bonding and vulnerability in social interactions; all concepts intentionally targeted by the SBPI. Participants varied in their support of a guideline to exclude personal discussion of ED-related cognitions and behaviors in the group.

CONCLUSIONS

As a whole, patients valued the combination of psychosocial education with group experientials focused on social behavior. Positive feedback from the SBPI suggests that adjunctive treatments that target mental-wellness constructs indirectly related to ED pathology may be helpful by allowing patients to see themselves as separable from the illness. Trial registration ClinicalTrials.gov, NCT0487758. Registered 7 May 2021-Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04877158 .

Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature

OBJECTIVE

Currently, there is debate in the eating disorders field regarding how to define atypical anorexia (AAN), how prevalent it is in community and clinical settings, and how AAN rates compare with low-weight AN. This systematic review assesses AAN literature from 2007 to 2020, to investigate: (a) the demographic characteristics of AAN studies, (b) the prevalence of AAN compared with AN, (c) the range of operational definitions of AAN and the implications of these definitions, and (d) the proportion of patients with AAN and AN represented in consecutive admission and referral samples.

METHOD

PsychINFO, CINAHL, PubMed, Greylit.org, and ProQuest databases were searched according to methods for Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic reviews, yielding 3,184 potential articles. Seventy-five eligible studies were coded for sixty-one variables.

RESULTS

Clinical samples predominantly included younger, female, white samples with limited diversity. In epidemiological designs, AAN was typically as common or more common than AN, and AAN rates varied significantly based on the population studied and operational definitions. In consecutive clinical samples, AAN was frequently less represented.

DISCUSSION

Although AAN appears to occur more frequently than AN in communities, fewer patients with AAN are being referred and admitted to eating disorder specific care, particularly in the United States. Given the significant medical and psychosocial consequences of AAN, and the importance of early intervention, this represents a crucial treatment gap. Additionally, results suggest the need for fine-tuning diagnostic definitions, greater diversity in AAN studies, and increased screening and referral for this vulnerable population.

Restrictive Eating Disorders: Accelerating Treatment Outcomes in the Medical Hospital

Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children's hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.

Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations.

METHODS

In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time.

RESULTS

Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR.

CONCLUSIONS

The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.

Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial

IMPORTANCE

The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome.

OBJECTIVE

To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach.

INTERVENTIONS

Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day.

MAIN OUTCOMES AND MEASURES

Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay.

RESULTS

Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant.

CONCLUSIONS AND RELEVANCE

In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02488109.

Study protocol for a randomised controlled trial investigating two different refeeding formulations to improve safety and efficacy of hospital management of adolescent and young adults admitted with anorexia nervosa

INTRODUCTION

Providing effective nutritional rehabilitation to patients hospitalised with anorexia nervosa (AN) is challenging, partly due to conservative recommendations that advocate feeding patients at low energy intakes. An 'underfeeding syndrome' can develop when patients are not provided with adequate nutrition during treatment, whereby malnourished patients fail to restore weight in a timely matter, and even lose weight. Of particular concern, the reintroduction of carbohydrate in a starved patient can increase the risk of developing electrolyte, metabolic and organ dysfunction. The proposed trial assesses the efficacy and safety of a lower carbohydrate enteral formula (28% carbohydrate) against a standard enteral formula (54% carbohydrate), in adolescent and young adult patients (aged 15-25 years), hospitalised with AN.

METHODS AND ANALYSIS

The study employs a double-blind randomised controlled trial design. At admission to hospital, malnourished adolescent and young adults with AN will be randomly allocated to commence feeding on a standard enteral feeding formula (1.5 kcal/mL, 54% carbohydrate) or a lower carbohydrate isocaloric enteral feeding formula (1.5 kcal/mL, 28% carbohydrate). Assessments of nutritional intake, weight and biochemistry (phosphate, magnesium, potassium) will be conducted at baseline and during the first 3 weeks of hospital admission. The primary outcome measure will be incidence of hypophosphatemia. Secondary outcomes include weight gain, oedema, other electrolyte distortion, length of hospital admission, admission to the Intensive Care Unit (ICU) and number of days to reach medical stability, using defined parameters.

ETHICS AND DISSEMINATION

The protocol was approved by the Western Sydney Local Health District Human Research Ethics Committee and institutional research governance approvals were granted. Written informed consent will be sought prior to study enrolment. Study findings will be widely disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12617000342314); Pre-results.

Outcomes of an Accelerated Inpatient Refeeding Protocol in 103 Extremely Underweight Adults with Anorexia Nervosa at a Specialized Clinic in Prien, Germany

BACKGROUND

In mildly to moderately malnourished adolescent patients with anorexia nervosa (AN), accelerated refeeding protocols using higher initial calory supply coupled with phosphate supplements were not associated with a higher incidence of refeeding syndrome (RS). It is unclear whether this is also a feasible approach for extremely malnourished, adult AN patients.

METHODS

Outcomes of a clinical refeeding protocol involving a targeted initial intake of ≥2000 kcal/day, routine supplementation of phosphate and thiamine as well as close medical monitoring, were evaluated. A retrospective chart review including AN patients with a body mass index (BMI) <13 kg/m² was conducted, to describe changes in weight, BMI, and laboratory parameters (phosphate, creatine kinase, hematocrit, sodium, liver enzymes, and blood count) over four weeks.

RESULTS

In 103 female patients (age, mean ± standard deviation (SD) = 23.8 ± 5.3 years), BMI between admission and follow-up increased from 11.5 ± 0.9 to 13.1 ± 1.1 kg/m² and total weight gain within the first four weeks was 4.2 ± 2.0 kg (mean, SD). Laboratory parameter monitoring indicated no case of RS, but continuous normalization of blood parameters.

CONCLUSIONS

Combined with close medical monitoring and electrolyte supplementation, accelerated refeeding may also be applied to achieve medical stabilization in extremely underweight adults with AN without increasing the risk of RS.

An audit of the changes in thiamine levels during higher caloric nutritional rehabilitation of adolescent patients hospitalised with a restrictive eating disorder

BACKGROUND

Routine supplementation of thiamine in patients with restrictive eating disorders prior to initiation of nutritional rehabilitation, is an example of a clinical guideline based on expert opinion rather than evidence-based recommendations. This study investigates whether adolescents hospitalised with a restrictive eating disorder commenced on a higher caloric refeeding regimen, present with or develop thiamine deficiency during their admission.

METHODS

An eighteen month retrospective audit of 119 consecutive admissions for nutritional rehabilitation was conducted on patients admitted with an eating disorder in a large tertiary teaching hospital in Western Sydney. Data from paper-based and electronic medical records were collected. Baseline and weekly blood thiamine levels were documented, as well as patient demographic information including admission weight, age, length of stay, percentage median body mass index, weight change throughout admission and caloric prescription.

RESULTS

Sixty admissions met inclusion criteria, mean age 17.2 years (SD 1.2); 88% female; BMI 16.8 kg/m² (SD 1.8) on admission. A linear mixed effects model identified that median thiamine levels increased by 9.2 nmol/L per week (p < 0.001). No patient developed thiamine deficiency during their admission, one patient was admitted with thiamine levels below the normal range at 62 nmol (normal range 67 - 200 nmol/L) which resolved by the second week of admission. In 15 out of 60 patients (25%), thiamine levels were observed to rise above the upper limit.

CONCLUSIONS

Nutritional management of 60 malnourished adolescents hospitalised with an eating disorder was conducted safely with the provision of only 10 mg thiamine in a multivitamin daily, and no additional thiamine supplementation. The high caloric refeeding protocol, inclusive of a daily multivitamin, provided adequate thiamine to prevent thiamine deficiency. Further research should examine thiamine requirements in an exclusive severely malnourished population to assess the need for thiamine replacement in the most vulnerable group.

Nutrition Approach for Inpatients With Anorexia Nervosa: Impact of a Clinical Refeeding Guideline

OBJECTIVE

This study assesses the impact of a clinical refeeding guideline on weight restoration, length of stay, rate of refeeding complications, and rehospitalizations.

METHOD

This retrospective study included patient records of 107 participants aged 13-55 years with a diagnosis of AN, admitted for at least 7 days for renutrition before and after introduction of the refeeding guideline. Weight evolution graphs were rated by 2 clinical experts independently. Binary logistic regression models were erected to identify clinical outcomes associated independently with the guideline as well as to control for potential confounding by sociodemographic and clinical characteristics at admission.

RESULTS

The proportion of patients achieving optimal weight gain after the first 2 weeks increased significantly from 6.3% pre-guideline to 41.8% post guideline (adjusted odds ratio [AOR] = 37.6; 95% confidence interval [CI], 2.77-510.3; P = 0.006). Average length of hospitalization was reduced from 96.7 (SD 48.3) days pre-guideline to 62.2 (SD 45.5) days post guideline (AOR = 0.99; 95% CI, 0.97-1.01; P = 0.18). None of the patients developed a full refeeding syndrome. There was no significant change in the rate of rehospitalization: 48.5% pre-guideline to 43.2% post guideline (OR = 0.81; 95% CI, 0.36-1.84; P = 0.62).

DISCUSSION

The clinical guideline proved highly effective in bolstering weight gain via intensive refeeding procedures while also being safe. Harmonizing clinical practices improves quality of care for patients with anorexia and, interestingly, may decrease costs by cutting average length of stay by a third without increasing the rehospitalization rate.

Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa

BACKGROUND

Anorexia Nervosa (AN) is a psychiatric disorder characterised by a physical and psychosocial deterioration due to an altered pattern on the intake and weight control. The severity of the disease is based on the degree of malnutrition. The objective of this article is to review the scientific evidence of the refeeding process of malnourished inpatients with AN; focusing on the clinical outcome.

METHODS

We conducted an extensive search in Medline and Cochrane; on April 22; 2019; using different search terms. After screening all abstracts; we identified 19 papers that corresponded to our inclusion criteria.

RESULTS

The article focuses on evidence on the characteristics of malnutrition and changes in body composition; energy and protein requirements; nutritional treatment; physical activity programmes; models of organisation of the nutritional treatment and nutritional support related outcomes in AN patients.

CONCLUSION

Evidence-based standards for clinical practice with clear outcomes are needed to improve the management of these patients and standardise the healthcare process.

The gut microbiome in anorexia nervosa: relevance for nutritional rehabilitation

Rapidly accumulating evidence supports the important role of gut microbiome in the regulation of mood, behaviour, appetite, gastrointestinal symptomology, and nutrient metabolism. These are all core features frequently altered in individuals with anorexia nervosa (AN). Current treatment recommendations for AN support the use of high-calorie diets as an essential part of nutritional rehabilitation, commonly achieved by elevating the fat content of the diet. However, in contrast to this approach, there is accumulating evidence suggesting the importance of balanced, high-fibre diets on the gut microbiome. Studies have demonstrated profound differences in the microbial composition of underweight people with AN and those of normal- or overweight individuals. Specific alterations vary widely between studies. It is thus far unclear to what extent the observed differences are brought on by iatrogenic effects of nutritional rehabilitation or the disorder itself. To date, only two studies have investigated the changes in the intestinal microbiota during nutritional rehabilitation and corresponding weight restoration. These studies suggest that the gut microbiome of AN patients was different to healthy controls both prior and following nutritional rehabilitation, though it is noted that these states were associated with lower and higher nutritional intakes, respectively. There is a clear need for further investigation regarding the effects of nutritional rehabilitation on the gut microbiome. Such research would provide insights into the potential role of gut microbiome in modulating the pathophysiology of AN and inform future treatment strategies.