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Quatromoni PA. A Tale of Two Runners: A Case Report of Athletes' Experiences with Eating Disorders in College. J Acad Nutr Diet 2017; 117:21-31. [PMID: 28010854 DOI: 10.1016/j.jand.2016.09.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Abstract
Athletes are at higher risk than the general population for eating disorders, and risk is heightened for athletes in thin-build sports, including track. Collegiate athletes are particularly vulnerable to disordered eating when the transition from home to the college environment adds to the stress of performance pressures and the high demands of the sport environment. Male and female athletes who develop eating disorders share some common characteristics, yet their experiences can be quite different, in part as a consequence of their sex and how eating disorders develop, and are recognized, acknowledged, and treated, within the culture of sports. This case report describes the experiences of two track athletes, one male and one female, who were recruited to the same Division 1 collegiate track program. Both were elite athletes, freshmen in the same year, experiencing the same urban college environment, and experiencing an eating disorder characterized by restrictive eating, significant weight loss, injury, and compromised performance in sport. Both received treatment from a multidisciplinary team of professionals. Both athletes achieved weight restoration, recovery from the disorder, and success in their sport. In spite of the similarities, striking differences were apparent in clinical presentation, predisposing features, onset of symptoms, entry points to treatment, interventions received, and clinical courses through treatment that depict sex differences in how eating disorders present in athletes and are addressed in the sport environment. Findings endorse the need for research and inform prevention strategies, risk assessment, and intervention approaches for nutrition and sports medicine professionals and collegiate athletic departments.
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Guarda AS, Schreyer CC, Fischer LK, Hansen JL, Coughlin JW, Kaminsky MJ, Attia E, Redgrave GW. Intensive treatment for adults with anorexia nervosa: The cost of weight restoration. Int J Eat Disord 2017; 50:302-306. [PMID: 28130794 DOI: 10.1002/eat.22668] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/16/2016] [Accepted: 12/16/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Weight restoration in anorexia nervosa (AN) is associated with lower relapse risk; however rate of weight gain and percent of patients achieving weight restoration (BMI ≥ 19 at discharge) vary among treatment programs. We compared both cost/pound of weight gained and cost of weight restoration in a hospital-based inpatient (IP)-partial hospitalization (PH) eating disorders program to estimates of these costs for residential treatment. METHOD All adult first admissions to the IP-PH program with AN (N = 314) from 2003 to 2015 were included. Cost of care was based on hospital charges, rates of weight gain, and weight restoration data. Results were compared with residential treatment costs extracted from a national insurance claims database and published weight gain data. RESULTS Average charge/day in the IP-PH program was $2295 for IP and $1567 for PH, yielding an average cost/pound gained of $4089 and $7050, respectively, with 70% of patients achieving weight restoration. Based on published mean weight gain data and conservative cost/day estimates, residential treatment is associated with higher cost/pound, and both higher cost and lower likelihood of weight restoration for most patients. DISCUSSION The key metrics used in this study are recommended for comparing the cost-effectiveness of intensive treatment programs for patients with AN.
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Affiliation(s)
- Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura K Fischer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer L Hansen
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael J Kaminsky
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Evelyn Attia
- Department of Psychiatry, Columbia University Medical Center, New York.,Department of Psychiatry, Weill Cornell Medical College, New York
| | - Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Makhzoumi SH, Coughlin JW, Schreyer CC, Redgrave GW, Pitts SC, Guarda AS. Weight gain trajectories in hospital-based treatment of anorexia nervosa. Int J Eat Disord 2017; 50:266-274. [PMID: 28186654 DOI: 10.1002/eat.22679] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 01/30/2023]
Abstract
Weight gain is a primary treatment goal for anorexia nervosa (AN); however little is known about heterogeneity in weight gain pattern during treatment. Preliminary evidence suggests weight gain trajectory is associated with treatment outcome. This study grouped patients using mixture modeling into weight gain trajectories, and compared predictors and treatment outcomes between trajectory groups. Women diagnosed with AN or subthreshold AN (N = 211) completed self-report measures at admission and six-months after discharge from an integrated inpatient (IP)-partial hospitalization (PH) behavioral specialty eating disorders program. Gowned weights were measured daily. Three distinct trajectories emerged: negative quadratic (Optimal), negative quadratic with fast weight gain (Fast), and positive linear with slower weight gain (Slow). The majority of patients were assigned to the Optimal group. Trajectory groups differed on admission, discharge, and follow-up variables. The Fast group emerged as most distinct. Women in this group were more than twice as likely to binge and or vomit regularly compared with the other two groups and were most likely to achieve weight restoration by discharge and to have more positive weight outcomes at short-term follow-up. There were no group differences in eating disorder behavioral frequencies at follow-up when adjusting for behavioral severity at admission. Weight gain trajectory may serve as a personalized in-treatment marker of outcome and could inform research on moderators and mediators of treatment response. Randomized controlled treatment studies, utilizing weight gain trajectories to determine group membership, may help identify subgroups of patients with differential responses to treatment interventions.
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Affiliation(s)
- Saniha H Makhzoumi
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland
| | - Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven C Pitts
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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54
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Revisiting the refeeding syndrome: Results of a systematic review. Nutrition 2017; 35:151-160. [DOI: 10.1016/j.nut.2016.05.016] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/28/2016] [Accepted: 05/28/2016] [Indexed: 01/26/2023]
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55
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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] [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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Fischer LK, Schreyer CC, Coughlin JW, Redgrave GW, Guarda AS. Neuroticism and clinical course of weight restoration in a meal-based, rapid-weight gain, inpatient-partial hospitalization program for eating disorders. Eat Disord 2017; 25:52-64. [PMID: 27775490 DOI: 10.1080/10640266.2016.1241056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We evaluated the impact of personality on weight restoration in 211 underweight (BMI ≤ 19 kg/m2) females admitted to an inpatient-partial hospitalization program for eating disorders. Symptomatology and personality were assessed by questionnaires, and clinical and demographic variables were assessed by chart review. Neuroticism, a personality trait associated with reactivity to stress, was correlated with higher symptomatology, chronicity, length of stay, and income source. Contrary to our hypothesis, neuroticism was positively associated with weight restoration. Length of stay mediated this relationship such that longer length of stay in patients with high neuroticism explained their higher likelihood of weight restoration prior to program discharge. Higher neuroticism is therefore associated with better weight restoration outcomes but may also indicate greater difficulty transitioning out of intensive treatment.
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Affiliation(s)
- Laura K Fischer
- a Department of Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Colleen C Schreyer
- a Department of Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Janelle W Coughlin
- a Department of Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Graham W Redgrave
- a Department of Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Angela S Guarda
- a Department of Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , Maryland , 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] [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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58
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Smith K, Lesser J, Brandenburg B, Lesser A, Cici J, Juenneman R, Beadle A, Eckhardt S, Lantz E, Lock J, Le Grange D. Outcomes of an inpatient refeeding protocol in youth with Anorexia Nervosa and atypical Anorexia Nervosa at Children's Hospitals and Clinics of Minnesota. J Eat Disord 2016; 4:35. [PMID: 28018595 PMCID: PMC5165845 DOI: 10.1186/s40337-016-0124-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Historically, inpatient protocols have adopted relatively conservative approaches to refeeding in Anorexia Nervosa (AN) in order to reduce the risk of refeeding syndrome, a potentially fatal constellation of symptoms. However, increasing evidence suggests that patients with AN can tolerate higher caloric prescriptions during treatment, which may result in prevention of initial weight loss, shorter hospital stays, and less exposure to the effects of severe malnutrition. Therefore the present study sought to examine the effectiveness of a more accelerated refeeding protocol in an inpatient AN and atypical AN sample. METHODS Participants were youth (ages 10-22) with AN (n = 113) and atypical AN (n = 16) who were hospitalized for medical stabilization. A retrospective chart review was conducted to assess changes in calories, weight status (percentage of median BMI, %mBMI), and indicators of refeeding syndrome, specifically hypophosphatemia, during hospitalization. Weight was assessed again approximately 4 weeks after discharge. RESULTS No cases of refeeding syndrome were observed, though 47.3 % of participants evidenced hypophosphatemia during treatment. Phosphorous levels were monitored in all participants, and 77.5 % were prescribed supplemental phosphorous at the time of discharge. Higher rates of caloric changes were predictive of greater changes in %mBMI during hospitalization. Rates of caloric and weight change were not related to an increased likelihood of re-admission. CONCLUSIONS Results suggest that a more accelerated approach to inpatient refeeding in youth with AN and atypical AN can be safely implemented and is not associated with refeeding syndrome, provided there is close monitoring and correction of electrolytes. These findings suggest that this approach has the potential to decrease length of stay and burden associated with inpatient hospitalization, while supporting continued progress after hospitalization.
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Affiliation(s)
- Kathryn Smith
- Neuropsychiatric Research Institute, Fargo, North Dakota USA
| | - Julie Lesser
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota USA
| | - Beth Brandenburg
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota USA
| | - Andrew Lesser
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania USA
| | - Jessica Cici
- Fairview Health Services, Minneapolis, Minnesota USA
| | - Robert Juenneman
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota USA
| | - Amy Beadle
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota USA
| | - Sarah Eckhardt
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota USA
| | - Elin Lantz
- Drexel University, Philadelphia, Pennsylvania USA
| | - James Lock
- Department of Psychiatry, Stanford University School of Medicine, Stanford, California USA
| | - Daniel Le Grange
- University of California, San Francisco Department of Psychiatry, San Francisco, California USA
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The medical risks of severe anorexia nervosa during initial re-feeding and medical stabilisation. Clin Nutr ESPEN 2016; 17:92-99. [PMID: 28361754 DOI: 10.1016/j.clnesp.2016.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 09/02/2016] [Accepted: 09/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND & AIMS Objective evidence about the risks associated with anorexia nervosa and how to manage them, is limited. The aim of this study is to describe the medical risk profile, management and outcomes of a cohort of patients with severe anorexia nervosa (sAN) during medical stabilisation treatment. METHODS Retrospective analysis of case records gathered medical risk data for a 90 day high risk period, on 65 patients with sAN admitted to two specialist services. Prospectively established definitions of medical risk variables and significant complications were applied to the data to describe the risk profiles and outcomes. RESULTS Amongst this population with an average initial BMI of 12.8 kg/m2, 74% developed no significant medical complications. Oral re-feeding over 60 days achieved an increase in mean BMI to 14.4 kg/m2 and mean weight gain of 4 kg. No patients developed severe hypophosphatemia (<0.45 mmol/L) or any other indicators of a re-feeding syndrome. All the medical complications that arose were temporary. CONCLUSIONS Initial re-feeding and medical stabilisation of patients with severe AN can be managed safely in specialist inpatient and community settings with slow re-feeding. Although the prevalence of complications was shown to be low, slight worsening of medical risk markers and increased incidence of complications did occur during initial re-feeding. The limited comparable published data appears to support slower rates of re-feeding, showing fewer abnormal results and complications. There is however a need for a definitive prospective multi-centre observational cohort study to investigate risks factors, and the effects of treatment on medical outcomes, in a large sample with varied rates of re-feeding.
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Ridout KK, Kole J, Fitzgerald KL, Ridout SJ, Donaldson AA, Alverson B. Daily Laboratory Monitoring is of Poor Health Care Value in Adolescents Acutely Hospitalized for Eating Disorders. J Adolesc Health 2016; 59:104-9. [PMID: 27338666 PMCID: PMC11346632 DOI: 10.1016/j.jadohealth.2016.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/01/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE This study investigates how the clinical practice guideline-recommended laboratory monitoring for refeeding syndrome impacts management and outcomes of adolescents with eating disorders hospitalized for acute medical stabilization and examines the value of laboratory monitoring (defined as the patient health outcomes achieved per dollar spent). METHODS A retrospective chart review of medical admissions in a children's hospital between October 2010 and February 2014 was performed. Encounters were identified using International Classification of Diseases, Ninth Revision codes of eating disorders as primary or secondary diagnoses. Exclusion criteria included systemic diseases associated with significant electrolyte abnormalities. Chart abstraction was performed using a predetermined form. Costs were estimated by converting hospital-fixed Medicaid charges using a statewide cost-to-charge ratio. RESULTS Of the 196 patient encounters, there were no cases of refeeding syndrome. A total of 3,960 key recommended laboratories were obtained; 1.9% were below normal range and .05% were critical values. Of these, .28% resulted in supplementation; none were associated with a change in inpatient management. Total laboratory costs were $269,250.85; the calculated health care value of this monitoring is 1.04 × 10(-8) differential outcomes per dollar spent. CONCLUSIONS This study provides evidence to suggest that daily laboratory monitoring for refeeding syndrome is a poor health care value in the management of adolescents hospitalized for acute medical stabilization with eating disorders. This initial analysis suggests that starting at a relatively low caloric level and advancing nutrition slowly may negate the need for daily laboratory assessment, which may have important implications for current guidelines.
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Affiliation(s)
- Kathryn K Ridout
- Department of Psychiatry and Human Behavior, Mood Disorders Research Program, Laboratory for Clinical and Translational Neuroscience, Butler Hospital, Providence, Rhode Island; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Jonathan Kole
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kelly L Fitzgerald
- Department of Medical Education, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Samuel J Ridout
- Department of Psychiatry and Human Behavior, Mood Disorders Research Program, Laboratory for Clinical and Translational Neuroscience, Butler Hospital, Providence, Rhode Island; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Abigail A Donaldson
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Pediatrics, Division of Adolescent Medicine, Hasbro Children's Hospital, Providence, Rhode Island
| | - Brian Alverson
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Pediatrics, Division of Hospitalist Medicine, Hasbro Children's Hospital, Providence, Rhode Island
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61
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Kezelman S, Rhodes P, Hunt C, Anderson G, Clarke S, Crosby RD, Touyz S. Adolescent patients’ perspectives on rapid-refeeding: a prospective qualitative study of an inpatient population. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/21662630.2016.1202124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Higher Caloric Refeeding Is Safe in Hospitalised Adolescent Patients with Restrictive Eating Disorders. J Nutr Metab 2016; 2016:5168978. [PMID: 27293884 PMCID: PMC4880718 DOI: 10.1155/2016/5168978] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/16/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction. This study examines weight gain and assesses complications associated with refeeding hospitalised adolescents with restrictive eating disorders (EDs) prescribed initial calories above current recommendations. Methods. Patients admitted to an adolescent ED structured “rapid refeeding” program for >48 hours and receiving ≥2400 kcal/day were included in a 3-year retrospective chart review. Results. The mean (SD) age of the 162 adolescents was 16.7 years (0.9), admission % median BMI was 80.1% (10.2), and discharge % median BMI was 93.1% (7.0). The mean (SD) starting caloric intake was 2611.7 kcal/day (261.5) equating to 58.4 kcal/kg (10.2). Most patients (92.6%) were treated with nasogastric tube feeding. The mean (SD) length of stay was 3.6 weeks (1.9), and average weekly weight gain was 2.1 kg (0.8). No patients developed cardiac signs of RFS or delirium; complications included 4% peripheral oedema, 1% hypophosphatemia (<0.75 mmol/L), 7% hypomagnesaemia (<0.70 mmol/L), and 2% hypokalaemia (<3.2 mmol/L). Caloric prescription on admission was associated with developing oedema (95% CI 1.001 to 1.047; p = 0.039). No statistical significance was found between electrolytes and calories provided during refeeding. Conclusion. A rapid refeeding protocol with the inclusion of phosphate supplementation can safely achieve rapid weight restoration without increased complications associated with refeeding syndrome.
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Schreyer CC, Coughlin JW, Makhzoumi SH, Redgrave GW, Hansen JL, Guarda AS. Perceived coercion in inpatients with Anorexia nervosa: Associations with illness severity and hospital course. Int J Eat Disord 2016; 49:407-12. [PMID: 26578421 DOI: 10.1002/eat.22476] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/22/2015] [Accepted: 09/28/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of coercion in the treatment for anorexia nervosa (AN) is controversial and the limited studies to date have focused on involuntary treatment. However, coercive pressure for treatment that does not include legal measures is common in voluntarily admitted patients with AN. Empirical data examining the effect of non-legal forms of coerced care on hospital outcomes are needed. METHOD Participants (N = 202) with AN, Avoidant/Restrictive Food Intake Disorder (ARFID), or subthreshold AN admitted to a hospital-based behavioral specialty program completed questionnaires assessing illness severity and perceived coercion around the admissions process. Hospital course variables included inpatient length of stay, successful transition to a step-down partial hospitalization program, and achievement of target weight prior to program discharge. RESULTS Higher perceived coercion at admission was associated with increased drive for thinness and body dissatisfaction, but not with admission BMI. Perceived coercion was not related to inpatient length of stay, rate of weight gain, or achievement of target weight although it was predictive of premature drop-out prior to transition to an integrated partial hospitalization program. DISCUSSION These results, from an adequately powered sample, demonstrate that perceived coercion at admission to a hospital-based behavioral treatment program was not associated with rate of inpatient weight gain or achieving weight restoration, suggesting that coercive pressure to enter treatment does not necessarily undermine formation of a therapeutic alliance or clinical progress. Future studies should examine perceived coercion and long-term outcomes, patient views on coercive pressures, and the effect of different forms of leveraged treatment.
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Affiliation(s)
- Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Saniha H Makhzoumi
- Department of Psychology, University of Maryland, Baltimore County, 1000 Hilltop Circle, Catonsville, Maryland, 21250
| | - Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Jennifer L Hansen
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
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Kameoka N, Iga JI, Tamaru M, Tominaga T, Kubo H, Watanabe SY, Sumitani S, Tomotake M, Ohmori T. Risk factors for refeeding hypophosphatemia in Japanese inpatients with anorexia nervosa. Int J Eat Disord 2016; 49:402-6. [PMID: 26446402 DOI: 10.1002/eat.22472] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Refeeding in patients with anorexia nervosa (AN) is associated with a risk of refeeding syndrome, which is a disruption in metabolism with a variety of features including hypophosphatemia. We evaluated the risk factors for refeeding hypophosphatemia (RH) during nutritional replenishment in Japanese patients with AN. METHODS We retrospectively examined clinical data for 99 female inpatients (mean age 30.9 ± 10.7 years; range, 9 - 56 years). RESULTS RH (phosphate < 2.3 mg/dL) occurred within 4.8 ± 3.7 days of hospital admission and was still observed at 28 days after admission in 21 of the 99 cases (21.2%). Oral or intravenous phosphate was given to some patients to treat or prevent RH. Patients with RH had a significantly lower body mass index, were older, and had higher blood urea nitrogen than those without RH. Severe complications associated with RH were recorded in only one patient who showed convulsions and disturbed consciousness at Day 3 when her serum phosphate level was 1.6 mg/dL. CONCLUSIONS The significant risk factors for RH that we identified were lower body mass index, older age, and higher blood urea nitrogen at admission. No significant difference in total energy intake was seen between the RH and no RH groups, suggesting that RH may not be entirely correlated with energy intake. Precisely predicting and preventing RH is difficult, even in patients with AN who are given phosphate for prophylaxis. Thus, serum phosphate levels should be monitored for more than 5 days after admission.
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Affiliation(s)
- Naomi Kameoka
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Jun-ichi Iga
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Mai Tamaru
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Takeo Tominaga
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Hiroko Kubo
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Shin-Ya Watanabe
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Satsuki Sumitani
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Masahito Tomotake
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
| | - Tetsuro Ohmori
- Department of Psychiatry, Course of Integrated Brain Sciences, University of Tokushima School of Medicine, Tokushima, 770-8503, Japan
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Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman DK, Kohn MR, Le Grange D, Madden S, Whitelaw M, Redgrave GW. A systematic review of approaches to refeeding in patients with anorexia nervosa. Int J Eat Disord 2016; 49:293-310. [PMID: 26661289 PMCID: PMC6193754 DOI: 10.1002/eat.22482] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings. METHODS Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic. RESULTS Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown; DISCUSSION Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent & Young Adult Medicine, University of California, San Francisco Benioff Children’s Hospital
| | - Susan M Sawyer
- Centre for Adolescent Health, Royal Children’s Hospital; , Department of Paediatrics, The University of Melbourne, Faculty of Medicine, Dentistry, Health Sciences, The University of Melbourne, and Murdoch Childrens Research Institute
| | - Neville H. Golden
- Division of Adolescent Medicine The Marron and Mary Elizabeth Kendrick; Stanford University
| | - Angela S. Guarda
- Johns Hopkins School of Medicine; Johns Hopkins Eating Disorders Program The Johns Hopkins Hospital
| | - Debra K. Katzman
- Division of Adolescent Medicine, Department of Pediatrics The Hospital for Sick Children and University of Toronto
| | - Michael R Kohn
- Adolescent Medicine, Sydney Children’s Hospital Network, Westmead; The University of Sydney
| | - Daniel Le Grange
- Eating Disorders Program Departments of Psychiatry and Pediatrics University of California, San Francisco
| | - Sloane Madden
- Eating Disorder Coordinator Sydney Children’s Hospital Network
| | - Melissa Whitelaw
- Department of Nutrition and Food Services Centre for Adolescent Health The Royal Children’s Hospital Melbourne
| | - Graham W. Redgrave
- Johns Hopkins School of Medicine, Johns Hopkins Eating Disorders Program Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine
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O'Connor G, Nicholls D, Hudson L, Singhal A. Refeeding Low Weight Hospitalized Adolescents With Anorexia Nervosa: A Multicenter Randomized Controlled Trial. Nutr Clin Pract 2016; 31:681-9. [PMID: 26869609 DOI: 10.1177/0884533615627267] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Refeeding patients with anorexia nervosa (AN) is associated with high morbidity and mortality. A lack of evidence from interventional studies has hindered refeeding practice and led to worldwide disparities in management recommendations. In the first randomized controlled trial in this area, we tested the hypothesis that refeeding adolescents with AN with a higher energy intake than what many guidelines recommend improved anthropometric outcomes without adversely affecting cardiac and biochemical markers associated with refeeding. MATERIALS AND METHODS Participants aged 10-16 years with a body mass index (BMI) <78% of the median (mBMI) for age and sex were recruited from 6 UK hospitals and randomly allocated to start refeeding at 1200 kcal/d (n = 18, intervention) or 500 kcal/d (n = 18, control). RESULTS Compared with controls, adolescents randomized to high energy intake had greater weight gain (mean difference between groups after 10 days of refeeding, -1.2% mBMI; 95% confidence interval, -2.4% to 0.0%; P = .05), but randomized groups did not differ statistically in QTc interval and other outcomes. The nadir in postrefeeding phosphate concentration was significantly related to percentage mBMI at the start of refeeding (baseline; P = .04) and baseline white blood cell count (P = .005) but not to baseline energy intake (P = .08). CONCLUSIONS Refeeding adolescents with AN with a higher energy intake was associated with greater weight gain but without an increase in complications associated with refeeding when compared with a more cautious refeeding protocol-thus challenging current refeeding recommendations.
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Affiliation(s)
- Graeme O'Connor
- Great Ormond Street Children's Hospital Foundation Trust, London, UK Childhood Nutrition Research Centre, UCL Institute of Child Health, London, UK
| | - Dasha Nicholls
- Great Ormond Street Children's Hospital Foundation Trust, London, UK Childhood Nutrition Research Centre, UCL Institute of Child Health, London, UK
| | - Lee Hudson
- Great Ormond Street Children's Hospital Foundation Trust, London, UK
| | - Atul Singhal
- Childhood Nutrition Research Centre, UCL Institute of Child Health, London, UK
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67
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Haynos AF, Snipes C, Guarda A, Mayer LE, Attia E. Comparison of standardized versus individualized caloric prescriptions in the nutritional rehabilitation of inpatients with anorexia nervosa. Int J Eat Disord 2016; 49:50-8. [PMID: 26769581 PMCID: PMC4717916 DOI: 10.1002/eat.22469] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Sparse research informs how caloric prescriptions should be advanced during nutritional rehabilitation of inpatients with anorexia nervosa (AN). This study compared the impact of a standardized caloric increase approach, in which increases occurred on a predetermined schedule, to an individualized approach, in which increases occurred only following insufficient weight gain, on rate, pattern, and cumulative amount of weight gain and other weight restoration outcomes. METHOD This study followed a natural experiment design comparing AN inpatients consecutively admitted before (n = 35) and after (n = 35) an institutional change from individualized to standardized caloric prescriptions. Authors examined the impact of prescription plan on weekly weight gain in the first treatment month using multilevel modeling. Within a subsample remaining inpatient through weight restoration (n = 40), multiple regressions examined the impact of caloric prescription plan on time to weight restoration, length of hospitalization, maximum caloric prescription, discharge BMI, and incidence of activity restriction and edema. RESULTS There were significant interactions between prescription plan and quadratic time on average weekly weight gain (p = .03) and linear time on cumulative weekly weight gain (p < .001). Under the standardized plan, patients gained in an accelerated curvilinear pattern (p = .04) and, therefore, gained cumulatively greater amounts of weight over time (p < .001). Additionally, 30% fewer patients required activity restriction under the standardized plan. DISCUSSION Standardized caloric prescriptions may confer advantage by facilitating accelerated early weight gain and lower incidence of bedrest without increasing the incidence of refeeding syndrome.
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Affiliation(s)
- Ann F. Haynos
- Department of Psychiatry, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Cassandra Snipes
- Department of Psychiatry, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Angela Guarda
- Department of Psychology, University of Nevada, Reno, Reno, Nevada
| | - Laurel E. Mayer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Evelyn Attia
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mayr M, Imgart H, Skala K, Karwautz A. [Quality management in weight restitution in Anorexia nervosa--pathophysiology, evidence-based practice and prevention of the refeeding syndrome]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2015; 29:200-211. [PMID: 26596577 DOI: 10.1007/s40211-015-0165-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/16/2015] [Indexed: 06/05/2023]
Abstract
During refeeding syndrome-a well-known and dreaded complication of weight-restauration in anorexia nervosa-a shift of electrolytes and fluid can occur in malnourished patients and might therefore lead to-potentially fatal-cardiovascular, respiratory and neurological symptoms. Causes of this are metabolic and hormonal changes during re-establishment of a carbohydrate-rich diet. This syndrome is most commonly associated with hypophosphatemia, which can however be accompanied by other chemical laboratory abnormalities. Standardized guidelines for the prevention and management of the refeeding syndrome have not yet been established. In case and cohort studies different low- and high-calorie diet protocols led to comparable results with similar complication rates. A focus should be placed on prevention of serious complications by careful monitoring. The pathophysiology, the main constituents in the development of the refeeding syndrome, recommendations for risk assessment and treatment, and current evidence are discussed.
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Affiliation(s)
- Michael Mayr
- Eating Disorders Unit, Universitätsklinik für Kinder- und Jugendpsychiatrie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Hartmut Imgart
- Kompetenzzentrum für Essstörungen und Adipositas, Parklandklinik, Bad Wildungen, Deutschland.
| | - Katrin Skala
- Eating Disorders Unit, Universitätsklinik für Kinder- und Jugendpsychiatrie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Andreas Karwautz
- Eating Disorders Unit, Universitätsklinik für Kinder- und Jugendpsychiatrie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Herpertz-Dahlmann B, van Elburg A, Castro-Fornieles J, Schmidt U. ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa--a European perspective. Eur Child Adolesc Psychiatry 2015; 24:1153-67. [PMID: 26226918 PMCID: PMC4592492 DOI: 10.1007/s00787-015-0748-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/15/2015] [Indexed: 01/20/2023]
Abstract
Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.
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Affiliation(s)
- Beate Herpertz-Dahlmann
- Department of Child & Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics, RWTH Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany.
| | - Annemarie van Elburg
- Department of Social Sciences, Rintveld, Center for Eating Disorders, Altrecht Mental Health Institute, Utrecht University, Utrecht, The Netherlands
| | - Josefina Castro-Fornieles
- Department of Child & Adolescent Psychiatry, Neurosciences Institute, Hospital Clinic of Barcelona, CIBERSAM, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ulrike Schmidt
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Podfigurna-Stopa A, Czyzyk A, Katulski K, Smolarczyk R, Grymowicz M, Maciejewska-Jeske M, Meczekalski B. Eating disorders in older women. Maturitas 2015; 82:146-52. [DOI: 10.1016/j.maturitas.2015.06.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 06/22/2015] [Accepted: 06/23/2015] [Indexed: 11/26/2022]
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Guarda AS, Schreyer CC, Boersma GJ, Tamashiro KL, Moran TH. Anorexia nervosa as a motivated behavior: Relevance of anxiety, stress, fear and learning. Physiol Behav 2015; 152:466-72. [PMID: 25846837 DOI: 10.1016/j.physbeh.2015.04.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 04/02/2015] [Indexed: 12/12/2022]
Abstract
The high comorbidity between anorexia nervosa (AN) and anxiety disorders is well recognized. AN is a motivated behavioral disorder in which habit formation is likely to contribute to the persistence of abnormal eating and exercise behaviors. Secondary alterations in brain circuitry underlying the reward value of food and exercise, along with disturbances in neuroendocrine hunger and satiety signaling arising from starvation and excessive exercise, are likely contributors to the maintenance of anorectic behaviors in genetically vulnerable individuals. The potential role of fear conditioning in facilitating onset of AN, or of impaired fear extinction in contributing to the high relapse rates observed following weight restoration, is of interest. Evidence from animal models of anxiety and human laboratory studies indicate that low estrogen impairs fear extinction. Low estradiol levels in AN may therefore play a role in perpetuating fear of food and fat in recently weight restored patients. Translational models including the activity based anorexia (ABA) rodent model of AN, and neuroimaging studies of fear extinction and conditioning, could help clarify the underlying molecular mechanisms and neurocircuitry involved in food avoidance behaviors in AN. Moreover, the adaptation of novel treatment interventions with efficacy in anxiety disorders may contribute to the development of new treatments for this impairing disorder.
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Affiliation(s)
- Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | - Gretha J Boersma
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | - Kellie L Tamashiro
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | - Timothy H Moran
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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Madden S, Miskovic-Wheatley J, Clarke S, Touyz S, Hay P, Kohn MR. Outcomes of a rapid refeeding protocol in Adolescent Anorexia Nervosa. J Eat Disord 2015; 3:8. [PMID: 25830024 PMCID: PMC4379764 DOI: 10.1186/s40337-015-0047-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/28/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The impact of severe malnutrition and medical instability in adolescent Anorexia Nervosa (AN) on immediate health and long-term development underscores the need for safe and efficient methods of refeeding. Current refeeding guidelines in AN advocate low initial caloric intake with slow increases in energy intake to avoid refeeding syndrome. This study demonstrates the potential for more rapid refeeding to promote initial weight recovery and correct medical instability in adolescent AN. METHODS Seventy-eight adolescents with AN (12-18 years), hospitalised in two specialist paediatric eating disorder units, for medical instability (bradycardia, hypotension, hypothermia, orthostatic instability and/or cardiac arrhythmia) were followed during a 2.5 week admission. Patients were refed using a standardised protocol commencing with 24-72 hours of continuous nasogastric feeds (ceased with daytime medical stability) and routine oral phosphate supplementation, followed by nocturnal feeds and a meal plan of 1200-2400 kcal/day aiming for a total caloric intake of 2400-3000 kcal/day. Along with indicators of medical stability, weight, phosphate and glucose levels were recorded. RESULTS All patients gained weight in week one (M = 2.79 kg, SD = 1.27 kg) and at subsequent measurement points with an average gain of 5.12 kg (SD = 2.96) at 2.5 weeks. No patient developed hypophosphatemia, hypoglycaemia, or stigmata of the refeeding syndrome. CONCLUSIONS The refeeding protocol resulted in immediate weight gain and was well tolerated with no indicators of refeeding syndrome. There were no significant differences in outcomes between the treatment sites, suggesting the protocol is replicable. TRIAL REGISTRATION Australian Clinical Trials Register number: ACTRN012607000009415.
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Affiliation(s)
- Sloane Madden
- Eating Disorder Service, The Sydney Children's Hospitals Network, Westmead Campus, Locked Bag 4001, Westmead, 2145, NSW Australia ; Discipline of Psychiatry, Faculty of Medicine, The University of Sydney, Sydney, Australia ; Westmead Clinical School, The Sydney Children's Hospitals Network, Westmead Campus, Sydney, Australia
| | - Jane Miskovic-Wheatley
- Eating Disorder Service, The Sydney Children's Hospitals Network, Westmead Campus, Locked Bag 4001, Westmead, 2145, NSW Australia ; Westmead Clinical School, The Sydney Children's Hospitals Network, Westmead Campus, Sydney, Australia
| | - Simon Clarke
- Discipline of Paediatrics, Faculty of Medicine, University of Sydney, Sydney, Australia ; Centre for Research into AdolescentS' Health (CRASH), University of Sydney, Sydney, Australia
| | - Stephen Touyz
- Clinical Psychology Unit, University of Sydney, Sydney, Australia
| | - Phillipa Hay
- School of Medicine, University of Western Sydney, Sydney, Australia
| | - Michael R Kohn
- Eating Disorder Service, The Sydney Children's Hospitals Network, Westmead Campus, Locked Bag 4001, Westmead, 2145, NSW Australia ; Westmead Clinical School, The Sydney Children's Hospitals Network, Westmead Campus, Sydney, Australia ; Discipline of Paediatrics, Faculty of Medicine, University of Sydney, Sydney, Australia ; Centre for Research into AdolescentS' Health (CRASH), University of Sydney, Sydney, Australia
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