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Staab R, Campagna J, Ma J, Sengar A. Rapid refeeding in anorexia nervosa: A dialectic balance. Int J Eat Disord 2022; 55:653-663. [PMID: 35332954 PMCID: PMC9315141 DOI: 10.1002/eat.23698] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion. METHOD This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m2 and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant. RESULTS Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol. DISCUSSION This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life. PUBLIC SIGNIFICANCE This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost-savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life.
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Affiliation(s)
- Randolf Staab
- Trillium Health PartnersMississaugaOntarioCanada,Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | | | - Julia Ma
- Institute for Better Health, Trillium Health PartnersMississaugaOntarioCanada
| | - Anjana Sengar
- Trillium Health PartnersMississaugaOntarioCanada,Institute for Better Health, Trillium Health PartnersMississaugaOntarioCanada
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Kolar DR, Meule A, Naab S, Voderholzer U. Early within-person weight gain and variability during inpatient treatment for anorexia nervosa: Age-dependent effects on treatment outcome. EUROPEAN EATING DISORDERS REVIEW 2022; 30:328-340. [PMID: 35297141 DOI: 10.1002/erv.2893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/31/2022] [Accepted: 02/22/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Early weight gain during inpatient treatment for anorexia nervosa (AN) is a dynamic process characterised by within-person variability that may be age-dependent. We examined whether age moderates the effect of within-person weight gain and variability on treatment outcome. METHOD Within-person level estimates of N = 2881 underweight adolescents and adults with AN for daily average weight gain (linear slope) and variability (root mean squared errors) were obtained using random-effects modelling. Between-person level regression analyses were calculated to assess effects on weight, eating disorder psychopathology and attaining normal body weight (body mass index [BMI]: 18.5-25 kg/m2 ). RESULTS Higher weight gain during first 2 weeks of inpatient treatment predicted higher weight, lower drive for thinness and lower body dissatisfaction at discharge, but not lower bulimic symptoms. Moreover, it predicted a higher probability of discharge weight within normal range. Younger age was associated with stronger effects of early weight gain on weight, drive for thinness and body dissatisfaction at discharge. Weight variability was not associated with any outcome. CONCLUSIONS Age moderated effects of early weight gain on treatment outcomes, with larger effects for younger patients. Weight variability alone did not influence treatment across age and should be of lesser clinical concern during early inpatient treatment.
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Affiliation(s)
- David R Kolar
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Adrian Meule
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-University, Munich, Germany.,Schoen Clinic Roseneck, Prien am Chiemsee, Germany
| | - Silke Naab
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
| | - Ulrich Voderholzer
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-University, Munich, Germany.,Schoen Clinic Roseneck, Prien am Chiemsee, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
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3
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Chatelet S, Wang J, Gjoertz M, Lier F, Monney Chaubert C, Ambresin AE. Factors associated with weight gain in anorexia nervosa inpatients. Eat Weight Disord 2020; 25:939-950. [PMID: 31119585 DOI: 10.1007/s40519-019-00709-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Nutrition restoration in inpatients with anorexia nervosa (AN) is a core element in treatment, enabling recovery of cognitive functions essential for psychological care. This study aims to identify factors associated with inpatient weight gain. METHODS Medical records from 107 inpatients aged 13-55 years with AN, hospitalized for more than 7 days at a specialized unit, were examined in a retrospective study. Weight evolution graphs were created for each patient and graded independently as optimal, moderate, and inadequate weight gain after 2 weeks and increasing, flat or decreasing weight in the first 2 weeks by expert clinicians. Driven by explicit hypotheses, bivariable analyses were carried out to detect relevant factors associated with weight gain during and after the first 2 weeks of admission. RESULTS Initial weight gain in the first 2 weeks of hospitalization and the introduction of a protocol harmonizing treatment procedures around rapid refeeding were strong factors associated with optimal weight gain after 2 weeks of hospitalization, whereas prior hospitalization in a psychiatric unit, diagnosis with binge-eating/purging subtype and age over 18 years were significantly associated with inadequate weight gain (p < 0.001-0.05). CONCLUSION To promote weight gain during hospitalization, clinicians should consider the following therapeutic measures: rapid refeeding strategies, renutrition protocols, and controlling purging behaviors. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Solène Chatelet
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Jen Wang
- Interdisciplinary Division for Adolescent Health (DISA), Lausanne University Hospital (CHUV), Hôpital Nestlé 04-312, Avenue de la Sallaz 2, 1011, Lausanne, Switzerland
| | - Mathea Gjoertz
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Françoise Lier
- Interdisciplinary Division for Adolescent Health (DISA), Lausanne University Hospital (CHUV), Hôpital Nestlé 04-312, Avenue de la Sallaz 2, 1011, Lausanne, Switzerland.,Vaudois Centre for Anorexia and Bulimia (abC), Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Carole Monney Chaubert
- Etablissements Hospitaliers du Nord-Vaudois (eHnv): St. Loup Hospital, Pompaples, Switzerland
| | - Anne-Emmanuelle Ambresin
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland. .,Interdisciplinary Division for Adolescent Health (DISA), Lausanne University Hospital (CHUV), Hôpital Nestlé 04-312, Avenue de la Sallaz 2, 1011, Lausanne, Switzerland.
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Lebow J, Sim L, Crosby RD, Goldschmidt AB, Le Grange D, Accurso EC. Weight gain trajectories during outpatient family-based treatment for adolescents with anorexia nervosa. Int J Eat Disord 2018; 52:10.1002/eat.23000. [PMID: 30578648 PMCID: PMC7463109 DOI: 10.1002/eat.23000] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/16/2018] [Accepted: 11/25/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Given that weight gain patterns in adolescents receiving outpatient Family-Based Treatment (FBT) have not been characterized, the purpose of this study was to examine trajectories of weight gain in a group of adolescent patients with a restrictive eating disorder [e.g., anorexia nervosa (AN) and atypical AN] receiving FBT. This study also examined the association of patient characteristics with weight gain trajectories, including age, diagnosis, weight suppression, presenting BMI-for-age percentile, and eating pathology. METHOD Latent growth mixture modeling was used to identify distinct weight trajectories, as defined by change in BMI-for-age percentile, for 153 adolescents with AN or atypical AN, receiving FBT. RESULTS There were five distinct weight gain trajectory profiles for adolescents receiving FBT for a restrictive eating disorder. Younger age and greater weight suppression were associated with more rapid weight gain trajectories. A pattern of slow and consistent weight gain was associated with older age and less eating pathology. DISCUSSION There was considerable variability in weight gain trajectories in youth receiving outpatient FBT for a restrictive eating disorder. This suggests that patients' presenting information can be used to inform expectations regarding weight gain trajectories.
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Affiliation(s)
- Jocelyn Lebow
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Leslie Sim
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Ross D Crosby
- Department of Psychiatry and Behavioral Science, The University of North Dakota, Fargo, North Dakota
| | - Andrea B Goldschmidt
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Weight Control and Diabetes Research Center/The Miriam Hospital, Providence, Rhode Island
| | - Daniel Le Grange
- Department of Psychiatry, University of California, San Francisco, California
- Department of Psychiatry & Behavioral Neuroscience, The University of Chicago, Chicago, IL (Emeritus)
| | - Erin C Accurso
- Department of Psychiatry, University of California, San Francisco, California
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The Roy Adaptation Model: A Theoretical Framework for Nurses Providing Care to Individuals With Anorexia Nervosa. ANS Adv Nurs Sci 2018; 40:370-383. [PMID: 28825933 DOI: 10.1097/ans.0000000000000175] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Using a nursing theoretical framework to understand, elucidate, and propose nursing research is fundamental to knowledge development. This article presents the Roy Adaptation Model as a theoretical framework to better understand individuals with anorexia nervosa during acute treatment, and the role of nursing assessments and interventions in the promotion of weight restoration. Nursing assessments and interventions situated within the Roy Adaptation Model take into consideration how weight restoration does not occur in isolation but rather reflects an adaptive process within external and internal environments, and has the potential for more holistic care.
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Jennings KM, Gregas M, Wolfe B. Trajectories of Change in Body Weight During Inpatient Treatment for Anorexia Nervosa. J Am Psychiatr Nurses Assoc 2018; 24:306-313. [PMID: 28817991 PMCID: PMC5794613 DOI: 10.1177/1078390317726142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Identifying distinct trajectories of change in body weight during inpatient treatment for anorexia nervosa (AN) may provide knowledge about the process of weight restoration and may help detect optimal body weight response patterns among individuals who are at risk for not achieving weight restoration or leaving treatment prematurely. OBJECTIVE This study explored the extent to which distinct trajectories of change in body weight existed among individuals during inpatient treatment for AN. DESIGN Group-based trajectory modeling was used to identify distinct trajectories of change in body weight among 500 individuals receiving inpatient treatment for AN. RESULTS Four distinct trajectories were identified: weight gain ( n = 197), treatment resistant ( n = 177), weight plateau ( n = 82), and weight fluctuate ( n = 44). CONCLUSION Clinically, it is important to consider the heterogeneity of changes in body weight during inpatient treatment to help guide interventions and outcomes.
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Affiliation(s)
- Karen M Jennings
- 1 Karen M. Jennings, PhD, RN, PMHNP-BC, University of Chicago, Chicago, IL, USA
| | - Matthew Gregas
- 2 Matthew Gregas, PhD, Boston College, Chestnut Hill, MA, USA
| | - Barbara Wolfe
- 3 Barbara Wolfe, PhD, RN, FAAN, University of Rhode Island, Kingston, RI, 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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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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Hart S, Franklin RC, Russell J, Abraham S. A review of feeding methods used in the treatment of anorexia nervosa. J Eat Disord 2013; 1:36. [PMID: 24999415 PMCID: PMC4081821 DOI: 10.1186/2050-2974-1-36] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 07/26/2013] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Clear evidence based guidelines on the best and safest method of achieving and maintaining normal body weight during inpatient treatment of Anorexia Nervosa (AN) are currently not available. Oral feeding with food alone, high-energy liquid supplements, nasogastric feeding and parenteral nutrition all have the potential to achieve weight gain in the treatment of AN but the advantages and disadvantages of each method have not been comprehensively evaluated. A literature search was undertaken to identify papers describing feeding methods used during inpatient treatment of AN. The selection criteria searched for papers that described the feeding method; and reported weight change variables such as admission and discharge weight in kilograms, or Body Mass Index; or weight change over the course of inpatient treatment. RESULTS Twenty-six papers were identified, describing a total of 37 samples with a mean sample size of 58.9 participants, and a range from 6 to 318. The majority (84.6%) of papers were observational cohorts and retrospective chart reviews. The most common feeding method described was nasogastric feeding and food, then high-energy liquid supplements and food. CONCLUSIONS There is limited evidence on the efficacy of feeding methods used in the refeeding and nutritional rehabilitation of AN, therefore no conclusion can be made about the most effective method of achieving weight gain during inpatient treatment. While there are a number of papers exploring this issue there is no consistency in the way the information is reported to enable comparisons between the different methods. There is an urgent need for research in this area to guide decision-making in the inpatient management, refeeding and nutritional rehabilitation of AN.
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Affiliation(s)
- Susan Hart
- Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
- Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Richard C Franklin
- School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, QLD 4811, Australia
| | - Janice Russell
- Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
- Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, The University of Sydney, Camperdown, NSW 2006, Australia
- Northside Clinic Eating Disorder Program, Greenwich, NSW 2065, Australia
| | - Suzanne Abraham
- Northside Clinic Eating Disorder Program, Greenwich, NSW 2065, Australia
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards 2065, NSW, Australia
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Abstract
The rate of adolescents presenting with anorexia nervosa (AN) is increasing. Medically unstable adolescents are admitted to the hospital for nutrition restoration. A lack of global consensus on appropriate refeeding practices of malnourished patients has resulted in inconsistent refeeding practices. Refeeding hypophosphatemia (RH) is the most common complication associated with refeeding the malnourished patient. This review sought to identify the range of refeeding rates adopted globally and the implication that total energy intake and malnutrition may have on RH while refeeding adolescents with anorexia nervosa. Studies were identified by a systematic electronic search of medical databases from 1980 to September 2012. Seventeen publications were identified, including 6 chart reviews, 1 observational study, and 10 case reports, with a total of 1039 subjects. The average refeeding energy intake was 1186 kcal/d, ranging from 125-1900 kcal/d, with a mean percentage median body mass index (% mBMI) of 78%. The average incidence rate of RH was 14%. A significant correlation between malnutrition (% mBMI) and post-refeeding phosphate was identified (R (2) = 0.6, P = .01). This review highlights the disparity in refeeding rates adopted internationally in treating malnourished adolescents with anorexia nervosa. Based on this review, the severity of malnutrition seems to be a marker for the development of RH more so than total energy intake.
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Affiliation(s)
- Graeme O'Connor
- Department of Nutrition and Dietetics, Great Ormond Street Children’s Hospital Foundation Trust, London, UK.
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