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Brewerton TD, Dennis K, Wiss DA. Dismantling the myth of "all foods fit" in eating disorder treatment. J Eat Disord 2024; 12:60. [PMID: 38760858 PMCID: PMC11102136 DOI: 10.1186/s40337-024-01017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 05/09/2024] [Indexed: 05/19/2024] Open
Abstract
We call for a reevaluation of the long-standing dogmatic nutritional principle that "all foods fit" for all cases of eating disorders (EDs) and its corollary, "there are no bad foods" (for anyone ever) during ED treatment. Based on accumulated scientific research, we challenge these ideologies as outdated, confusing, and potentially harmful to many patients. We review the evidence that indicates the folly of these assumptions and show there are a variety of exceptions to these rules, including (1) food allergies, sensitivities, and intolerances, (2) religious and spiritual preferences or doctrines, and (3) the ubiquitous emergence and widespread availability of ultra-processed foods leading to the potential development of addiction-like eating and a higher prevalence of various medical and psychiatric comorbidities, as well as higher mortality. This evidence supports a nutritional psychiatry approach that should be integrated into (rather than dissociated from) ED treatment research and practice.
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Affiliation(s)
- Timothy D Brewerton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Kim Dennis
- SunCloud Health, Chicago, IL, USA
- Department of Psychiatry, University of Illinois Chicago College of Medicine, Chicago, IL, USA
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2
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Jatkowska A, Gkikas K, Nichols B, Short B, Rizou VK, Kapranos P, Gunnewiek JK, Christina E, Svolos V, Quince C, Gerasimidis K. Dose-dependent effects of enteral nutrition on the faecal microbiota and short chain fatty acids. Clin Nutr 2024; 43:1200-1207. [PMID: 38615449 DOI: 10.1016/j.clnu.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/20/2024] [Accepted: 04/05/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Enteral nutrition (EN) involves replacing all or part of a person's habitual diet with a nutritional formula. The impact of varying doses of EN on the gut microbiome remains understudied. METHODS Healthy adults replaced all (100% EN) or part (85% EN, 50% EN and 20% EN) of their energy requirements with EN for 7 days. Faecal samples were collected before and on day 7 of interventions. Faecal pH, short chain fatty acids (SCFAs), branched-chain fatty acids (BCFAs) and 16S rRNA sequencing were performed. Dietary assessment was performed with 7-day food diaries. RESULTS Sixty-one participants (31 females; median (IQR) age: 24.7 (23.0-27.8) years) were recruited. A dose-dependent impact of EN on faecal microbiota, SCFAs, BCFAs) and pH was observed, with changes detectable at EN intakes of at least 50% of energy requirements. 100% and 85% EN reduced the abundance of fibre-fermenting taxa such as Agathobacter, Faecalibaterium, Succinivibrio and Acidaminococcus. In parallel, potentially harmful organisms like Eubacterium, Actinomyces, and Klebsiella increased. In the 50% EN group, adherence to a diet high in fish, vegetables, potatoes, non-alcoholic beverages, and fat spreads, and low in cereal products, milk, and meat negatively correlated with changes in microbiota structure (r = -0.75, P = 0.025). This signal was not observed when using compositional tools for microbiota analysis. CONCLUSIONS EN detrimentally influences the faecal microbiota and diet-related bacterial metabolites in a dose-dependent manner, particularly at doses of at least 50%. The findings of this study have implications for the dietary management and counselling of patients receiving high volume EN.
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Affiliation(s)
- Aleksandra Jatkowska
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Konstantinos Gkikas
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Ben Nichols
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Bryn Short
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Panagiotis Kapranos
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Edelyn Christina
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Vaios Svolos
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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3
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Katole A, Naik G, Kujur A, Kumar M. Functioning of a Nutritional Rehabilitation Center against acceptable levels of care. Med J Armed Forces India 2023; 79:S20-S25. [PMID: 38144655 PMCID: PMC10746723 DOI: 10.1016/j.mjafi.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background Establishment of Nutritional Rehabilitation Centers (NRCs) is an initiative under National Rural Health Mission to provide institutional care for children with severe acute malnutrition (SAM). The aim of the study was to assess the effectiveness of nutritional interventional measures in improving the nutritional status of children admitted to an NRC. Methods A retrospective health facility-based descriptive study was conducted in the NRC, Rural Health Training Center, All India Institute of Medical Sciences, Raipur. Results A total of 765 children were enrolled in the NRC between March 2015 and November 2019, and majority (87.97%) were admitted as per weight for height/length (<-3SD) criteria. The total number of SAM children with complications were 428 (55.94%). Of the 724 total discharges, 498 (68.78%) were cured, 197 (27.2%) were nonresponders and 28 (3.87%) were defaulters. Conclusion The findings suggest factors affecting nutritional rehabilitation that are complex and require a more integrated management in the health system and community. Regular review, supportive supervision and identification of nutrient-dense food from locally available low-cost ingredients is the need of the hour.
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Affiliation(s)
- Ashwini Katole
- Assistant Professor (Community Medicine), Raipur Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Gitismita Naik
- Senior Resident (Community & Family Medicine), All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Anubhuti Kujur
- Senior Resident (Community & Family Medicine), All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Mohan Kumar
- Junior Resident (Community & Family Medicine), All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Fischer LK, Schreyer CC, Pletch A, Cooper M, Vanzhula IA, Redgrave GW, Guarda AS. Monitoring and treating hypoglycemia during meal-based rapid nutritional rehabilitation in patients with extreme anorexia nervosa. Eat Weight Disord 2022; 27:3301-3308. [PMID: 35994205 DOI: 10.1007/s40519-022-01460-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/23/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Hypoglycemia, a complication of prolonged starvation, can be life-threatening and is presumed to contribute to the high mortality of anorexia nervosa. Furthermore, early refeeding in severe anorexia nervosa can precipitate paradoxical post-prandial hypoglycemia. Few studies have analyzed the course of hypoglycemia during nutritional rehabilitation in patients with extremely low-weight anorexia nervosa. No standard practice guidelines exist and recommended strategies for managing hypoglycemia (i.e., nasogastric feeds, high-fat diets) have limitations. METHODS This cohort study assessed prevalence and correlates of hypoglycemia in 34 individuals with very low body mass index (BMI < 14.5 kg/m2) anorexia nervosa treated in an intensive eating disorders program with an exclusively meal-based rapid weight gain nutritional protocol. Hypoglycemia was monitored with frequent point of care (POC) glucose testing and treated with oral snacks and continuous slow intravenous 5% dextrose in 0.45% saline (IV D5 1/2 NS) infusion. RESULTS POC hypoglycemia was detected in 50% of patients with highest prevalence noted on the day of admission. Hypoglycemia resolved during the first week of hospitalization in most cases and was generally asymptomatic. Seven patients (20.6%) experienced at least one episode of severe hypoglycemia with POC glucose < 50 mg/dl. Lower admission BMI was associated with higher likelihood of developing hypoglycemia and longer duration of hypoglycemia. CONCLUSION Meal-based management of hypoglycemia supplemented by continuous IV D5 1/2 NS appears a viable alternative to alternate strategies such as enteral tube feeding. We discuss recommendations for hypoglycemia monitoring during nutritional rehabilitation and directions for future research. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Laura K Fischer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA.,Childrens National Hospital, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Allisyn Pletch
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Marita Cooper
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA.,Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19104, USA
| | - Irina A Vanzhula
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA. .,Department of Psychiatry and Behavioral Science, Johns Hopkins Eating Disorders Program, The Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA.
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Pietravalle A, Baraldi A, Scilipoti M, Cavallin F, Lonardi M, Tshikamb IM, Robbiati C, Trevisanuto D, Putoto G. Influence of a quality improvement intervention on rehabilitation outcomes of children (6-24 months) with acute malnutrition: a retrospective study in rural Angola. BMC Pediatr 2022; 22:532. [PMID: 36071395 PMCID: PMC9454221 DOI: 10.1186/s12887-022-03585-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Defaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate. METHODS Retrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6-24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate. RESULTS The intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil. CONCLUSIONS The present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.
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Bühren K. 3.14 Nutritional Rehabilitation in Eating Disorders. World Rev Nutr Diet 2022; 124:315-320. [PMID: 35240633 DOI: 10.1159/000516734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/20/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Katharina Bühren
- kbo-Heckscher Klinikum, Academic Teaching Hospital, Ludwig Maximilian University, Munich, Germany
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Jini P, Prasad A, Lomash A, Bhardwaj N, Singh R, Agrawal A, Kapoor S. Aminoacid Profiling of Children with Severe Acute Malnutrition Pre and Post Nutritional Rehabilitation. Indian J Clin Biochem 2022; 37:93-99. [PMID: 35125698 PMCID: PMC8799827 DOI: 10.1007/s12291-020-00926-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 10/12/2020] [Indexed: 01/03/2023]
Abstract
Malnutrition is a significant comorbidity in nearly one-third of the 8 million deaths in children under five years of age worldwide. Children with severe acute malnutrition have severely disturbed physiology and metabolism. Considering the vital importance of amino acids and the likely changes with the therapeutic diet, we aimed at evaluating these changes in children with SAM at baseline and after rehabilitation with a therapeutic diet at 14 days. Severe acute malnutrition defined as per WHO, for children between 6 months and 5 years with weight for height/length < -3SD of WHO charts, bilateral pitting edema, and mid-upper arm circumference (MUAC) < 1.5 cm. A total of 38 children were enrolled as cases, whereas the control group comprised of 37 children. Anthropometric measurement and estimation of amino acids in the blood were done at the baseline and after dietary rehabilitation. The individual levels of the essential and non-essential amino acids were significantly lower in the cases as compared to the controls, except for Aspartate and Threonine. The levels of amino acids increased significantly after dietary rehabilitation except for arginine, however not to the levels of those in controls. Most of the metabolites were reflective of maladaptation in SAM. Though nutritional rehabilitation of children with SAM improved the levels of amino acids, these levels were still low when compared to the controls, stipulating that complete metabolic recovery may take a longer duration of time. This necessitates the continuation of nutritional rehabilitation for a longer time and regular follow up of these children to ensure better compliance.
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Affiliation(s)
- Pepu Jini
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Anupa Prasad
- Biochemistry Department, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand India
| | - Avinash Lomash
- Division of Genetics, Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Namita Bhardwaj
- Division of Genetics, Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Raghavendra Singh
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Anurag Agrawal
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Seema Kapoor
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
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8
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Pietravalle A, Scilipoti M, Cavallin F, Lonardi M, Tshikamb IM, Robbiati C, Trevisanuto D, Putoto G. Nutritional education during rehabilitation of children 6-24 months with acute malnutrition, under unavailability of therapeutic/supplementary foods: a retrospective study in rural Angola. BMC Pediatr 2021; 21:94. [PMID: 33627083 PMCID: PMC7903716 DOI: 10.1186/s12887-021-02560-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/09/2021] [Indexed: 01/10/2023] Open
Abstract
Background Dietary counseling can play an important role in managing child malnutrition but is often inadequate or absent. Moreover, little emphasis is given to the usefulness of local available foods in the rehabilitation of malnourished children. This study aimed to evaluate the adherence and effectiveness of nutritional education during rehabilitation of children (6–24 months) with acute malnutrition, in a setting of unavailability of therapeutic/supplementary foods. Methods Retrospective observational study on the adherence to dietary counseling and the impact on growth in children 6–24 months who were referred for acute malnutrition at the Catholic Mission Hospital of Chiulo (Angola) from August 2018 to January 2019. Main outcome measures were change in dietary habits and growth gain. Results Sixty-four out of 120 children returned at first follow-up visit (default rate 47%). A change in dietary habits was reported in 32/64 (50%) children. Changing dietary habits was associated with an improved change in weight gain (MD 9.3 g/kg/day, 95%CI 4.2 to 14.3; p = 0.0005) and in weight/height ratio (MD 1.1 SD, 95%CI 0.7 to 1.4; p < 0.0001). Conclusions A change in dietary habits after discharge was noted in only half of the patients who returned at first follow up visit, but it provided some advantages in term of weight gain and weight/height ratio. Further studies are needed to identify children at risk of low adherence to follow-up visits and low compliance to the nutritional recommendations, in order to increase the effectiveness of rehabilitation programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02560-z.
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Ruusunen A, Rocks T, Jacka F, Loughman A. The gut microbiome in anorexia nervosa: relevance for nutritional rehabilitation. Psychopharmacology (Berl) 2019; 236:1545-58. [PMID: 30612189 DOI: 10.1007/s00213-018-5159-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/21/2018] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Andrea K. Garber
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, Benioff Children’s Hospital, 3333 California St., Suite 245, Box 0503, San Francisco, CA 94118 USA
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Maginot TR, Kumar MM, Shiels J, Kaye W, Rhee KE. Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. J Eat Disord 2017; 5:1. [PMID: 28053702 PMCID: PMC5209953 DOI: 10.1186/s40337-016-0132-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/14/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Current guidelines for nutritional rehabilitation in hospitalized restrictive eating disorder patients recommend a cautious approach to refeeding. Several studies suggest that higher calorie diets may be safe and effective, but have traditionally excluded severely malnourished patients. The goal of this study was to evaluate the safety of a higher calorie nutritional rehabilitation protocol (NRP) in a broad sample of inpatients with restrictive eating disorders, including those who were severely malnourished. METHODS A retrospective chart review was conducted among eating disorder inpatients between January 2015 and March 2016. Patients were started on a lower calorie diet (≤1500 kcals/day) or higher calorie diet (≥1500 kcals/day). Calorie prescription on admission was based on physician clinical judgement. The sample included patients aged 8-20 years with any DSM-5 restrictive eating disorder. Those who were severely malnourished (<75% expected body weight [EBW]) or required tube feeding during admission were included. Multivariable regression models were used to determine whether level of nutritional rehabilitation was associated with hypophosphatemia, hypomagnesemia, or hypokalemia. RESULTS The sample included 87 patients; mean age was 14.4 years (S.D. 32.7); 29% were <75% EBW. The majority (75.8%) was started on higher calorie diets (mean 1781 kcal/day). Controlling for rate of calorie change, initial %EBW, age, race/ethnicity, insurance, diagnosis, and NG/NJ tube placement, higher calorie diets were not associated with hypophosphatemia, hypomagnesemia, or hypokalemia on admission or within the first 72 h. Increased risk of hypophosphatemia on admission was associated with lower baseline %EBW. CONCLUSION A higher calorie NRP was tolerated in this broad population of inpatients with restrictive eating disorders. Lower %EBW on admission was a more important predictor of hypophosphatemia than initial calorie level. Larger studies are required to demonstrate the safety of higher calorie diets in severely malnourished patients.
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Affiliation(s)
- Tamara R. Maginot
- Department of Psychiatry, University of California, San Diego School of Medicine, 4510 Executive Drive, Suite 315, San Diego, CA 92121 USA
| | - Maya M. Kumar
- Division of Academic General Pediatrics and Community Health, Department of Pediatrics, University of California, San Diego School of Medicine and Rady Children’s Hospital of San Diego, 7910 Frost Street, Suite 300, San Diego, CA 92123 USA
| | - Jacqueline Shiels
- Department of Psychiatry, University of California, San Diego School of Medicine, 4510 Executive Drive, Suite 315, San Diego, CA 92121 USA
| | - Walter Kaye
- Department of Psychiatry, University of California, San Diego School of Medicine, 4510 Executive Drive, Suite 315, San Diego, CA 92121 USA
| | - Kyung E. Rhee
- Division of Academic General Pediatrics and Community Health, Department of Pediatrics, University of California, San Diego School of Medicine and Rady Children’s Hospital of San Diego, 7910 Frost Street, Suite 300, San Diego, CA 92123 USA
- 9500 Gilman Drive, MC 0874, La Jolla, CA 92093 USA
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Peebles R, Lesser A, Park CC, Heckert K, Timko CA, Lantzouni E, Liebman R, Weaver L. Outcomes of an inpatient medical nutritional rehabilitation protocol in children and adolescents with eating disorders. J Eat Disord 2017; 5:7. [PMID: 28265411 PMCID: PMC5331684 DOI: 10.1186/s40337-017-0134-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/26/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Medical stabilization through inpatient nutritional rehabilitation is often necessary for patients with eating disorders (EDs) but includes the inherent risk of refeeding syndrome. Here we describe our experience of implementing and sustaining an inpatient nutritional rehabilitation protocol designed to strategically prepare patients with EDs and their families for discharge to a home setting in an efficient and effective manner from a general adolescent medicine unit. We report outcomes at admission, discharge, and 4-weeks follow-up. METHODS Protocol development, implementation, and unique features of the protocol, are described. Data were collected retrospectively as part of a continuous quality improvement (QI) initiative. Safety outcomes were the clinical need for phosphorus, potassium, and magnesium supplementation, other evidence of refeeding syndrome, and unexpected readmissions within one month of discharge. The value outcome was length of stay (LOS). Treatment outcomes were the percentage median BMI (MBMI) change from admission to discharge, and from discharge to 4-weeks follow-up visit. RESULTS A total of 215 patients (88% F, 12% M) were included. Patients averaged 15.3 years old (5.8-23.2y); 64% had AN, 18% had atypical anorexia (AtAN), 6% bulimia nervosa (BN), 5% purging disorder (PD), 4% avoidant-restrictive food intake disorder (ARFID), and 3% had an unspecified food and eating disorder (UFED). Average LOS was 11 days. Initial mean calorie level for patients at admission was 1466 and at discharge 3800 kcals/day. Phosphorus supplementation for refeeding hypophosphatemia (RH) was needed in 14% of inpatients; full-threshold refeeding syndrome did not occur. Only 3.8% were rehospitalized in the thirty days after discharge. Patients averaged 86.1% of a median MBMI for age and gender, 91.4% MBMI at discharge, and 100.9% MBMI at 4-weeks follow-up. Mean percentage MBMI differences between time points were significantly different (admission-discharge: 5.3%, p <0.001; discharge-follow-up: 9.2%, p <0.001). CONCLUSIONS Implementation of the CHOP inpatient nutritional rehabilitation protocol aimed at rapid, efficient, and safe weight gain and integration of caregivers in treatment of patients with diverse ED diagnoses led to excellent QI outcomes in percentage MBMI at discharge and 4-weeks follow-up, while maintaining a short LOS and low rates of RH phosphorus supplementation.
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Affiliation(s)
- Rebecka Peebles
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.,The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA
| | - Andrew Lesser
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA
| | - Courtney Cheek Park
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA
| | - Kerri Heckert
- The Children's Hospital of Philadelphia, Department of Clinical Nutrition, Philadelphia, Pennsylvania USA
| | - C Alix Timko
- The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.,The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA
| | - Eleni Lantzouni
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.,The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA
| | - Ronald Liebman
- The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.,The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA
| | - Laurel Weaver
- The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.,The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA
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Hother AL, Girma T, Rytter MJH, Abdissa A, Ritz C, Mølgaard C, Michaelsen KF, Briend A, Friis H, Kæstel P. Serum phosphate and magnesium in children recovering from severe acute undernutrition in Ethiopia: an observational study. BMC Pediatr 2016; 16:178. [PMID: 27814707 PMCID: PMC5097423 DOI: 10.1186/s12887-016-0712-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/19/2016] [Indexed: 11/23/2022] Open
Abstract
Background Children with severe acute malnutrition (SAM) have increased requirements for phosphorus and magnesium during recovery. If requirements are not met, the children may develop refeeding hypophosphatemia and hypomagnesemia. However, little is known about the effect of current therapeutic diets (F-75 and F-100) on serum phosphate (S-phosphate) and magnesium (S-magnesium) in children with SAM. Methods Prospective observational study, with measurements of S-phosphate and S-magnesium at admission, prior to rehabilitation phase and at discharge in children aged 6–59 months admitted with SAM to Jimma Hospital, Ethiopia. Due to shortage of F-75, 25 (35 %) children were stabilized with diluted F-100 (75 kcal/100 ml). Results Of 72 children enrolled, the mean age was 32 ± 14 months, and edema was present in 50 (69 %). At admission, mean S-phosphate was 0.92 ± 0.34 mmol/L, which was low compared to normal values, but increased to 1.38 ± 0.28 mmol/L at discharge, after on average 16 days. Mean S-magnesium, at admission, was 0.95 ± 0.23 mmol/L, and increased to 1.13 ± 0.17 mmol/L at discharge. At discharge, 18 (51 %) children had S-phosphate below the normal range, and 3 (9 %) had S-phosphate above. Most children (83 %) had S-magnesium above normal range for children. Both S-phosphate and S-magnesium at admission were positively associated with serum albumin (S-albumin), but not with anthropometric characteristics or co-diagnoses. Using diluted F-100 for stabilization was not associated with lower S-phosphate or S-magnesium. Conclusion Hypophosphatemia was common among children with SAM at admission, and still subnormal in about half of the children at discharge. This could be problematic for further recovery as phosphorus is needed for catch-up growth and local diets are likely to be low in bioavailable phosphorus. The high S-magnesium levels at discharge does not support that magnesium should be a limiting nutrient for growth in the F-100 diet. Although diluted F-100 (75 kcal/100 mL) is not designed for stabilizing children with SAM, it did not seem to cause lower S-phosphate than in children fed F-75.
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Affiliation(s)
- Anne-Louise Hother
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark.
| | - Tsinuel Girma
- Department of Pediatric and Child Health, Jimma University Specialized Hospital, Jimma, Ethiopia
| | - Maren J H Rytter
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark
| | - Alemseged Abdissa
- Department of Laboratory Sciences and Pathology, Jimma University Specialized Hospital, Jimma, Ethiopia
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark.,Department for International Health, University of Tampere, Tampere, Finland
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark
| | - Pernille Kæstel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, Frederiksberg C, DK-1958, Denmark
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14
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Abstract
Weight restoration is considered a principal outcome for treatment of Anorexia Nervosa (AN) due to the significant physiological disturbances resultant from acute states of malnutrition. Treatment outcomes for populations with AN are relatively poor, with increasing evidence suggesting that weight restoration alone is insufficient for long-term recovery. Research aimed at understanding the psychological sequaele of AN, in particular during weight restoration, nevertheless remain scarce. This systematic review aimed to evaluate existing research regarding anxiety symptoms during treatment for AN, and the relationship of anxiety symptomology and weight restoration. Twelve articles were identified from a systematic search of three electronic databases (PsycINFO, MEDLINE, and Web of Science), and were eligible for inclusion. Study methodology, results and quality were reviewed. Results regarding change in anxiety symptomology were inconsistent, though evidence did not support a relationship between anxiety change and weight restoration. Reasons for these inconsistencies and limitations of included studies were reviewed. Further research is warranted to elucidate the role of anxiety in AN and its implications for treatment and longer-term outcome.
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Affiliation(s)
- Sarah Kezelman
- School of Psychology, University of Sydney, Sydney, Australia
| | - Stephen Touyz
- School of Psychology, University of Sydney, Sydney, Australia
| | - Caroline Hunt
- School of Psychology, University of Sydney, Sydney, Australia
| | - Paul Rhodes
- School of Psychology, University of Sydney, Sydney, Australia
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15
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Abstract
Failure to thrive is a commonly encountered problem in Paediatric practice. This essentially generic term refers to children whose attained weight or rate of weight gain is significantly below that of other children of similar age and same sex. Several defining criteria have been proposed and help to differentiate true failure to thrive from other conditions causing apparent growth failure. There are numerous organic causes of failure to thrive, but non-organic failure to thrive is also an important entity and is caused by social, psychological and environmental factors. The clinical features are those of malnutrition, signs of underlying organic cause and specific manifestations of environmental/psychosocial deprivation. Indiscriminate laboratory investigations are usually non-contributory and have no role in evaluation. Management requires a multidisciplinary approach and hospitalization has a specific role. Although nutritional rehabilitation is the cornerstone of therapy, treatment of underlying factors-medical, psychological, social and environmental-should receive equally important attention. Long term physical, developmental and behavioural sequelae are known to occur in children with failure to thrive.
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Affiliation(s)
- V Venkateshwar
- Graded Specialist (Paediatrics), 7 Air Force Hospital, Kanpur 208 004
| | - T S Raghu Raman
- Senior Adviser, Department of Paediatrics, Command Hospital (Air Force), Bangalore 560 007
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