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Brodie E, van Veenendaal N, Platz E, Fleming J, Gunn H, Johnson D, Griffin H, Wittholz K. The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study. Int J Eat Disord 2024; 57:661-670. [PMID: 38288636 DOI: 10.1002/eat.24151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/17/2024] [Accepted: 01/17/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED. METHOD This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change. RESULTS Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission. DISCUSSION The incidence of severe RFS was low in this cohort and was associated with lower admission weight. PUBLIC SIGNIFICANCE This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.
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Affiliation(s)
- Emily Brodie
- Clinical Nutrition Department, The Royal Melbourne Hospital, Melbourne, Australia
| | | | - Emma Platz
- Clinical Nutrition Department, The Royal Melbourne Hospital, Melbourne, Australia
- Eating Disorders Unit, The Royal Melbourne Hospital, Melbourne, Australia
| | - Judith Fleming
- Eating Disorders Unit, The Royal Melbourne Hospital, Melbourne, Australia
| | - Hamish Gunn
- Consultation-Liaison Psychiatry-Inner West Area Mental Health Service, The Royal Melbourne Hospital, Melbourne, Australia
| | - Douglas Johnson
- Department of General Medicine and Infectious Diseases, The Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine and Infectious Diseases, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Hilda Griffin
- Clinical Nutrition Department, The Royal Melbourne Hospital, Melbourne, Australia
| | - Kym Wittholz
- Clinical Nutrition Department, The Royal Melbourne Hospital, Melbourne, Australia
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Landini L, Dadson P, Gallo F, Honka MJ, Cena H. Microbiota in anorexia nervosa: potential for treatment. Nutr Res Rev 2023; 36:372-391. [PMID: 35875979 DOI: 10.1017/s0954422422000130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Anorexia nervosa (AN) is characterised by the restriction of energy intake in relation to energy needs and a significantly lowered body weight than normally expected, coupled with an intense fear of gaining weight. Treatment of AN is currently based on psychological and refeeding approaches, but their efficacy remains limited since 40% of patients after 10 years of medical care still present symptoms of AN. The intestine hosts a large community of microorganisms, called the "microbiota", which live in symbiosis with the human host. The gut microbiota of a healthy human is dominated by bacteria from two phyla: Firmicutes and, majorly, Bacteroidetes. However, the proportion in their representation differs on an individual basis and depends on many external factors including medical treatment, geographical location and hereditary, immunological and lifestyle factors. Drastic changes in dietary intake may profoundly impact the composition of the gut microbiota, and the resulting dysbiosis may play a part in the onset and/or maintenance of comorbidities associated with AN, such as gastrointestinal disorders, anxiety and depression, as well as appetite dysregulation. Furthermore, studies have reported the presence of atypical intestinal microbial composition in patients with AN compared with healthy normal-weight controls. This review addresses the current knowledge about the role of the gut microbiota in the pathogenesis and treatment of AN. The review also focuses on the bidirectional interaction between the gastrointestinal tract and the central nervous system (microbiota-gut-brain axis), considering the potential use of the gut microbiota manipulation in the prevention and treatment of AN.
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Affiliation(s)
- Linda Landini
- S.S.D. Dietetics and Clinical Nutrition ASL 4 Chiavarese Liguria-Sestri Levante Hospital, Sestri Levante, Italy
| | - Prince Dadson
- Turku PET Centre, University of Turku, Turku, Finland
| | - Fabrizio Gallo
- S.S.D. Dietetics and Clinical Nutrition ASL 4 Chiavarese Liguria-Sestri Levante Hospital, Sestri Levante, Italy
| | | | - Hellas Cena
- Dietetics and Clinical Nutrition Laboratory, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, Pavia, Italy
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Lopes HCB, Mazzolani BC, Koritar P, Cordás TA. Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review. Gen Hosp Psychiatry 2023; 85:43-54. [PMID: 37778285 DOI: 10.1016/j.genhosppsych.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN). METHODS This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS). RESULTS Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies. CONCLUSION All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.
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Affiliation(s)
- Helen Cristina Bittencourt Lopes
- Nutrition and Dietetics Service and Interdisciplinary Project for Care, Teaching, and Research on Eating Disorders in Childhood and Adolescence (PROTAD), Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
| | - Bruna Caruso Mazzolani
- Applied Physiology & Nutrition Research Group and Laboratory of Assessment and Conditioning in Rhematology, University of São Paulo, São Paulo, Brazil.
| | - Priscila Koritar
- Nutrition and Dietetics Service, Barueri City Hall, São Paulo, SP, Brazil
| | - Táki Athanássios Cordás
- AMBULIM - Eating Disorders Program, Institute and Department of Psychiatry, University of São Paulo, São Paulo, Brazil.
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Stoody VB, Garber AK, Miller CA, Bravender T. Advancements in Inpatient Medical Management of Malnutrition in Children and Adolescents with Restrictive Eating Disorders. J Pediatr 2023; 260:113482. [PMID: 37196778 DOI: 10.1016/j.jpeds.2023.113482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/10/2023] [Accepted: 04/30/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Vishvanie Bernadene Stoody
- Division of Adolescent/Young Adult and Sports Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI.
| | - Andrea Kay Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, CA
| | - Catherine Anne Miller
- Division of Adolescent/Young Adult and Sports Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Terrill Bravender
- Division of Adolescent/Young Adult and Sports Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
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Morgan K, Cutmore C, Matthews-Rensch K. Adding mini meals to a nasogastric refeeding protocol for patients with eating disorders can be achieved on general hospital wards. J Hum Nutr Diet 2023; 36:1207-1213. [PMID: 36945998 DOI: 10.1111/jhn.13170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/19/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Treatment of medically compromised patients with eating disorders is difficult in general hospital wards. There is currently no consensus on the best feeding method; however, previous research has demonstrated the safety of using enteral feeding. Because an oral diet has benefits on psychological and behavioural pathways, concurrent feeding requires further investigation. The present study aimed to examine acceptability and safety of implementing mini meals to a previously nil-by-mouth 7-day enteral feeding protocol. METHODS This was mixed methods research including a retrospective observational study and participant survey. Patients admitted to a tertiary hospital in Brisbane, Australia, between July 2020 and March 2021 were eligible. Eligible participants were provided mini meals from day 5. Type and quantity of meals consumed alongside clinical incident data were collected. The survey examined acceptability of mini meals. Descriptive statistics were used to interpret findings. Content analyses were conducted on survey responses. RESULTS Sixty-four participants (95%, n = 57/60 female, 25.2 ± 8.9 years; 75%, n = 45/60 diagnosed with anorexia nervosa) were included. At least half of the participants consumed some or all of the mini meals at each meal period. No clinical incidents were reported. Twenty-six (50%, n = 26/52) surveys were returned. Half (54%, n = 14/26) agreed-strongly agreed that mini meals improved their experience. Eleven participants desired more choice in menu items. CONCLUSIONS The present study found that introducing mini meals into an enteral feeding protocol is acceptable and safe for patients with eating disorders. Participants reported benefits in returning to eating; however, some items on the menu require reconsideration to enable increased consumption.
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Affiliation(s)
- Kate Morgan
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Clare Cutmore
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Kylie Matthews-Rensch
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia
- Eating disorders and Nutrition Research Group 'ENRG', Western Sydney University, Sydney, Australia
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Mosuka EM, Murugan A, Thakral A, Ngomo MC, Budhiraja S, St Victor R. Clinical Outcomes of Refeeding Syndrome: A Systematic Review of High vs. Low-Calorie Diets for the Treatment of Anorexia Nervosa and Related Eating Disorders in Children and Adolescents. Cureus 2023; 15:e39313. [PMID: 37351245 PMCID: PMC10281854 DOI: 10.7759/cureus.39313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
Over the years, the standard of care for re-alimentation of patients admitted for the treatment of anorexia nervosa (AN) has been a conservative or cautious approach described as "start low and go slow." These traditional refeeding protocols advocate for a low-calorie diet that restricts carbohydrates, with the primary goal of hypothetically lowering the risk of refeeding syndrome (RFS) and its complication. However, no consensus exists for the optimal inpatient approach to refeeding children and adolescents with AN. There is still some disagreement about what constitutes an ideal pace for nutritional rehabilitation. Varying treatment protocols have emerged across the globe, often reflecting the preferences and biases of individual practitioners and contributing to the lack of a universally accepted protocol for refeeding in AN. Although it is widely accepted that low-caloric refeeding (LCR) is safe for inpatient treatment of AN, this strategy has been shown to have several significant drawbacks, leading to increased criticism of the LCR method. Research from the last decade has led to calls for a more aggressive refeeding protocol, one that suggests a higher caloric intake from the offset. As a result, this research aimed to conduct a systematic review of the existing literature on strategies for refeeding hospitalized pediatric/adolescent patients with AN and related eating disorders. We aimed to compare high-caloric refeeding (HCR) and LCR in terms of weight gain, length of stay, and risk of RFS. We conducted a thorough search of medical databases for abstracts published in English, including Google Scholar, PubMed, and MEDLINE, to find relevant studies published between 2010 and February 2023. Our focus was on articles that evaluated high versus low refeeding protocols in children and adolescents hospitalized for treating AN and related eating disorders. Only articles that reported on at least one of the outcome variables of interest, such as hypophosphatemia, weight gain, RFS, or length of hospital stay, were considered. This review included 20 full-text articles published in the last decade on the HCR protocol in children and adolescents, with a total sample size of 2191 participants. In only one of the 20 studies did researchers find evidence of a true clinical case of RFS. We, therefore, found no evidence that HCR increased the risk of RFS in adolescents, even in those with a very low body mass index (BMI). However, evidence suggests a lower BMI at the time of hospital admission is a better predictor of hypophosphatemia than total caloric intake. In conclusion, based on the evidence from this review, a high-caloric diet or rapid refeeding in children/adolescents suffering from AN may be both safe and effective, with serial laboratory investigations and phosphate supplementation as needed. Hence, more research, particularly, randomized controlled trials, is required to help shape an evidence-based refeeding guideline outlining target calorie intakes and rates of advancement to assist clinicians in the treatment of adolescents with AN and related eating disorders.
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Affiliation(s)
- Emmanuel M Mosuka
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Anushree Murugan
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Abhinav Thakral
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Mbelle C Ngomo
- Medicine, Université de Yaoundé, Faculté de Médecine et des Sciences Biomédicales, Yaoundé, CMR
| | - Sushil Budhiraja
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
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[Nutritional recovery of underweight adolescents with anorexia nervosa: analysis of a hospital protocol]. NUTR HOSP 2023; 40:13-18. [PMID: 36602137 DOI: 10.20960/nh.04201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Background: anorexia nervosa (AN) is a severe psychiatric pathology that has one of the highest mortality rates among mental illnesses, estimated at 5.1 deaths per 1,000 people/year, and is associated with high comorbidity, both psychiatric and somatic. Aim: to characterize hospitalized adolescents and their nutritional rehabilitation using a standardized protocol. Methods: a descriptive-retrospective study of adolescent patients hospitalized at the San Carlos of Apoquindo Clinic with a diagnosis of AN, hemodynamically stable and without refeeding syndrome criteria, between 2015 and 2021. Epidemiological, clinical, and nutritional data of the patients were analyzed. Results: of 46 patients studied, 37 were female; the average length of stay was 45.4 (SD ± 36.1) days; 53.8 % of the patients had mood disorder as psychiatric comorbidity, and the most common personality trait was obsessive-compulsive (36.9 %); the most frequent somatic comorbidity was thyroid pathology (19.2 %). The initial oral caloric intake was 1467 (SD ± 479) kcal, with an average weekly increase of 400 kcal, reaching 2430 (SD ± 457) kcal at discharge. An average body mass index (BMI%) percentage change of 7.8 % (SD ± 6.1) was obtained. Conclusions: this is the first national study that describes the nutritional rehabilitation of adolescents with AN and the length of hospitalization required to achieve it.
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Refeeding Hypophosphatemia in Hospitalized Adolescents With Anorexia Nervosa. J Adolesc Health 2022; 71:517-520. [PMID: 36123000 DOI: 10.1016/j.jadohealth.2022.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 10/14/2022]
Abstract
Refeeding hypophosphatemia in hospitalized adolescents with anorexia nervosa is correlated with degree of malnutrition, with a high index of suspicion for severely malnourished patients (<70% median body mass index). Weight history (greater magnitude or rate of weight loss prior to admission) regardless of presentation weight has also been associated with lower serum phosphate. Higher energy meal-based refeeding starting at 2,000 kcal has not been shown to be associated with higher rates of refeeding hypophosphatemia than the traditional standard of care, lower energy refeeding. Further research is needed to identify risk factors for refeeding hypophosphatemia and develop optimal delivery methods (oral vs. enteral), macronutrient content, and electrolyte replacement strategies to optimize weight gain without increasing the risk for refeeding hypophosphatemia.
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Hambleton A, Pepin G, Le A, Maloney D, Touyz S, Maguire S. Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. J Eat Disord 2022; 10:132. [PMID: 36064606 PMCID: PMC9442924 DOI: 10.1186/s40337-022-00654-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders. METHODS This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised. RESULTS A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED. CONCLUSIONS This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.
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Affiliation(s)
- Ashlea Hambleton
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Charles Perkins Centre (D17), University of Sydney, Camperdown, NSW, 2006, Australia.
| | - Genevieve Pepin
- School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC, 3220, Australia
| | - Anvi Le
- Healthcare Management Advisors, Melbourne, VIC, Australia
| | - Danielle Maloney
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Charles Perkins Centre (D17), University of Sydney, Camperdown, NSW, 2006, Australia.,Sydney Local Health District, Camperdown, NSW, Australia
| | | | - Stephen Touyz
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Charles Perkins Centre (D17), University of Sydney, Camperdown, NSW, 2006, Australia.,Sydney Local Health District, Camperdown, NSW, Australia
| | - Sarah Maguire
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Charles Perkins Centre (D17), University of Sydney, Camperdown, NSW, 2006, Australia.,Sydney Local Health District, Camperdown, NSW, Australia
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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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Schlapfer L, Fujimoto A, Gettis M. Impact of caloric prescriptions and degree of malnutrition on incidence of refeeding syndrome and clinical outcomes in patients with eating disorders: A retrospective review. Nutr Clin Pract 2021; 37:459-469. [PMID: 34751947 DOI: 10.1002/ncp.10792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND For individuals with eating disorders (EDs), medical stabilization is paramount for restoration of body weight. Careful nutritional rehabilitation minimizes risk of refeeding syndrome. Study's purpose: describe clinical outcomes of pediatric/adolescent patients with EDs treated with lower calorie (<1300 kcals/day, n = 137), higher calorie (≥1400 kcals/day, n = 154) diets. METHODS Retrospective chart reviews conducted for patients with known/suspected EDs. Inclusion: patients ages 12-21 years with anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS), atypical anorexia nervosa (AtAN). Exclusion: patients with other EDs, co-morbid medical conditions. Demographic information, length of stay, anthropometrics, prior weight loss were recorded. Malnutrition classifications based on: %mBMI, BMI z-score, prior weight loss percentage. Laboratory data, electrolyte supplementations were collected. Initial calorie intake/calorie intake day 7 were recorded. RESULTS No significant differences in age, admit weight, BMI, BMI z-score, %mBMI at admission, weight gain between the two groups. Six (4.4%) patients in lower calorie group, 4 (2.6%) in higher calorie group met criteria for severe refeeding syndrome based on ASPEN consensus recommendations (P = .52). Higher calorie group length of stay was significantly shorter than lower calorie group (P = .006). Shorter length of stay associated with increased calorie intake (P < .001), greater %mBMI (P < .001). Higher calorie prescriptions were not associated with different rates of hypomagnesia (P = 1) and hypokalemia (P = .34). There was significant increase in rate of hypophosphatemia in the lower calorie group versus the higher calorie group. CONCLUSION Higher calorie diets were associated with decreased length of stay without impacting risk of refeeding syndrome.
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Golden NH, Cheng J, Kapphahn CJ, Buckelew SM, Machen VI, Kreiter A, Accurso EC, Adams SH, Le Grange D, Moscicki AB, Sy AF, Wilson L, Garber AK. Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial. Pediatrics 2021; 147:peds.2020-037135. [PMID: 33753542 PMCID: PMC8015147 DOI: 10.1542/peds.2020-037135] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations. METHODS In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time. RESULTS Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR. CONCLUSIONS The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.
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Affiliation(s)
- Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco, San Francisco, California
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | | | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Daniel Le Grange
- Psychiatry and Behavioral Sciences,,Department of Psychiatry and Behavioral Neuroscience, School of Medicine, The University of Chicago, Chicago, Illinois; and
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Allyson F. Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Leslie Wilson
- Medicine, and Clinical Pharmacy, University of California, San Francisco, San Francisco, California
| | - Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
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13
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Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, Kreiter A, Le Grange D, Machen VI, Moscicki AB, Sy A, Wilson L, Golden NH. Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial. JAMA Pediatr 2021; 175:19-27. [PMID: 33074282 PMCID: PMC7573797 DOI: 10.1001/jamapediatrics.2020.3359] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome. OBJECTIVE To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa. DESIGN, SETTING, AND PARTICIPANTS In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach. INTERVENTIONS Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day. MAIN OUTCOMES AND MEASURES Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay. RESULTS Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant. CONCLUSIONS AND RELEVANCE In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02488109.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco
| | - Erin C. Accurso
- Department of Psychiatry and Behavioral Medicine, University of California, San Francisco
| | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Daniel Le Grange
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco,Department of Psychiatry and Behavioral Medicine, University of California, San Francisco,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois (emeritus)
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles
| | - Allyson Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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14
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Excessive laboratory monitoring to prevent adolescent's refeeding syndrome: opportunities for enhancement. Eat Weight Disord 2020; 25:1021-1027. [PMID: 31168728 DOI: 10.1007/s40519-019-00723-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 05/29/2019] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Anorexia nervosa (AN) is a complex medical condition affecting mainly adolescents and young adults. To monitor and prevent refeeding syndrome, current guidelines recommend daily laboratory testing in the first week of hospitalization and 2-3 times/week for the following 3 weeks. The aims of this study were to determine the proportion of abnormal results of the blood tests done during the first week of nutritional rehabilitation in adolescents with AN, the proportion of test having led to supplementation and the cost of all these tests. METHOD A retrospective chart review of admissions for eating disorders between May 2014 and May 2015 in a tertiary Pediatric University Hospital center was performed. Patients were included if they were younger than 18 years, admitted for protocol-based refeeding and met criteria for AN (DSM 5). RESULTS Among the 99 hospitalizations included in the study, the mean age was 14.6 years (± 1.7), with a female predominance (97%). The mean admission BMI was 15.3 ± 2 kg/m2 (Z-score - 2.6 ± 1.4). The mean length of hospitalization was 40.3 days ± 21.8. Of the 1289 laboratory tests performed, only 1.5% revealed abnormal values and 0.85% led to supplementation. No critical value was identified. The total cost for the tests performed was 148,926.80 CAD$, 1504$/admitted patient, instead of 3890$/admitted patient had we followed the recommendations. CONCLUSION More precise criteria should be developed regarding the frequency of laboratory tests needed to monitor and prevent refeeding syndrome. At present, the recommendations could lead to unnecessary testing and expenses. LEVEL OF EVIDENCE Level IV: Dramatic results in uncontrolled trials.
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15
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Lenherr-Taube N, Trajcevski K, Sochett E, Katzman DK. Low PTH Levels in Adolescents With Anorexia Nervosa. Front Pediatr 2020; 8:99. [PMID: 32219087 PMCID: PMC7078244 DOI: 10.3389/fped.2020.00099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Patients with anorexia nervosa (AN) experience medical complications including impaired bone metabolism, increased fracture rate, kidney stones and chronic renal failure. However, the mechanisms of such complications are not fully understood. Healthy adolescents have been shown to have higher PTH levels when compared with pre-pubertal children and adults. Given the importance of central measures of calcium and vitamin D metabolism in bone and kidney health, 25-hydroxyvitamin D (25OHD) and parathyroid hormone (PTH) have been extensively investigated in patients with AN, however none of the previous studies accounted for age-specific reference ranges for PTH. The aim of this study was to investigate central measures of calcium and vitamin D metabolism in adolescents with newly diagnosed AN using age-specific reference ranges and to determine whether any significant abnormalities required further study. Methods: This was a cross-sectional study of 61 adolescents (mean age = aged 15.2 ± 1.56 years) with newly diagnosed AN, referred to a tertiary center over a period of 2 years. Demographic, auxiological, and nutrient (vitamin D and calcium) intake data was obtained. Central measures of calcium and vitamin D metabolism in blood and urine were investigated. PTH results were compared with age-specific reference ranges from the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER). Descriptive statistics and correlation analysis were performed. Results: Low PTH levels were observed in 35% of the cohort. Overall, serum calcium, phosphate and 25OHD were within the reference range. Using loess curves, PTH had a significant negative and non-linear correlation with 25OHD with an inflection point at a 25OHD level of 100 nmol/l, above which the association was no longer present. Correlation analysis did not show a significant association between PTH and total or corrected serum calcium, urine calcium/creatinine (Ca/Cr) ratio, total dietary calcium intake, magnesium or Tanner staging. Conclusion: PTH levels were reduced in approximately a third of adolescents with AN. This observation has not been reported given the universal usage of reference ranges that covers all ages. This finding may unmask a potential role for reduced PTH levels in the pathogenesis of kidney stones and bone phenotype in patients with AN.
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Affiliation(s)
- Nina Lenherr-Taube
- Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Karin Trajcevski
- Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Etienne Sochett
- Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Debra K Katzman
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Division of Adolescent Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada
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16
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Reber E, Friedli N, Vasiloglou MF, Schuetz P, Stanga Z. Management of Refeeding Syndrome in Medical Inpatients. J Clin Med 2019; 8:jcm8122202. [PMID: 31847205 PMCID: PMC6947262 DOI: 10.3390/jcm8122202] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/05/2019] [Accepted: 12/11/2019] [Indexed: 12/14/2022] Open
Abstract
Refeeding syndrome (RFS) is the metabolic response to the switch from starvation to a fed state in the initial phase of nutritional therapy in patients who are severely malnourished or metabolically stressed due to severe illness. It is characterized by increased serum glucose, electrolyte disturbances (particularly hypophosphatemia, hypokalemia, and hypomagnesemia), vitamin depletion (especially vitamin B1 thiamine), fluid imbalance, and salt retention, with resulting impaired organ function and cardiac arrhythmias. The awareness of the medical and nursing staff is often too low in clinical practice, leading to under-diagnosis of this complication, which often has an unspecific clinical presentation. This review provides important insights into the RFS, practical recommendations for the management of RFS in the medical inpatient population (excluding eating disorders) based on consensus opinion and on current evidence from clinical studies, including risk stratification, prevention, diagnosis, and management and monitoring of nutritional and fluid therapy.
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Affiliation(s)
- Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland;
- Correspondence:
| | - Natalie Friedli
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland; (N.F.); (P.S.)
| | - Maria F. Vasiloglou
- AI in Health and Nutrition Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, 3008 Bern, Switzerland;
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland; (N.F.); (P.S.)
- Medical Faculty of the University of Basel, 4056 Basel, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland;
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17
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Gjoertz M, Wang J, Chatelet S, Monney Chaubert C, Lier F, Ambresin AE. Nutrition Approach for Inpatients With Anorexia Nervosa: Impact of a Clinical Refeeding Guideline. JPEN J Parenter Enteral Nutr 2019; 44:1124-1139. [PMID: 31742725 DOI: 10.1002/jpen.1723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 09/18/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study assesses the impact of a clinical refeeding guideline on weight restoration, length of stay, rate of refeeding complications, and rehospitalizations. METHOD This retrospective study included patient records of 107 participants aged 13-55 years with a diagnosis of AN, admitted for at least 7 days for renutrition before and after introduction of the refeeding guideline. Weight evolution graphs were rated by 2 clinical experts independently. Binary logistic regression models were erected to identify clinical outcomes associated independently with the guideline as well as to control for potential confounding by sociodemographic and clinical characteristics at admission. RESULTS The proportion of patients achieving optimal weight gain after the first 2 weeks increased significantly from 6.3% pre-guideline to 41.8% post guideline (adjusted odds ratio [AOR] = 37.6; 95% confidence interval [CI], 2.77-510.3; P = 0.006). Average length of hospitalization was reduced from 96.7 (SD 48.3) days pre-guideline to 62.2 (SD 45.5) days post guideline (AOR = 0.99; 95% CI, 0.97-1.01; P = 0.18). None of the patients developed a full refeeding syndrome. There was no significant change in the rate of rehospitalization: 48.5% pre-guideline to 43.2% post guideline (OR = 0.81; 95% CI, 0.36-1.84; P = 0.62). DISCUSSION The clinical guideline proved highly effective in bolstering weight gain via intensive refeeding procedures while also being safe. Harmonizing clinical practices improves quality of care for patients with anorexia and, interestingly, may decrease costs by cutting average length of stay by a third without increasing the rehospitalization rate.
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Affiliation(s)
- Mathea Gjoertz
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jen Wang
- Interdisciplinary Division for Adolescent Health (DISA), Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Solène Chatelet
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | | | - Françoise Lier
- Interdisciplinary Division for Adolescent Health (DISA), Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Vaudois Centre for Anorexia and Bulimia (abC), Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Anne-Emmanuelle Ambresin
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland.,Interdisciplinary Division for Adolescent Health (DISA), Lausanne University Hospital (CHUV), Lausanne, Switzerland
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18
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Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa. J Clin Med 2019; 8:jcm8071042. [PMID: 31319585 PMCID: PMC6679071 DOI: 10.3390/jcm8071042] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022] Open
Abstract
Background: Anorexia Nervosa (AN) is a psychiatric disorder characterised by a physical and psychosocial deterioration due to an altered pattern on the intake and weight control. The severity of the disease is based on the degree of malnutrition. The objective of this article is to review the scientific evidence of the refeeding process of malnourished inpatients with AN; focusing on the clinical outcome. Methods: We conducted an extensive search in Medline and Cochrane; on April 22; 2019; using different search terms. After screening all abstracts; we identified 19 papers that corresponded to our inclusion criteria. Results: The article focuses on evidence on the characteristics of malnutrition and changes in body composition; energy and protein requirements; nutritional treatment; physical activity programmes; models of organisation of the nutritional treatment and nutritional support related outcomes in AN patients. Conclusion: Evidence-based standards for clinical practice with clear outcomes are needed to improve the management of these patients and standardise the healthcare process.
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19
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Shadman KA, Coller RJ, Smith W, Kelly MM, Cody P, Taft W, Bodine L, Sklansky DJ. Managing Eating Disorders on a General Pediatrics Unit: A Centralized Video Monitoring Pilot. J Hosp Med 2019; 14:357-360. [PMID: 30986188 PMCID: PMC6625438 DOI: 10.12788/jhm.3176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Adolescents with severe eating disorders require hospitalization for medical stabilization. Supervision best practices for these patients are not established. This study sought to evaluate the cost and feasibility of centralized video monitoring (CVM) supervision on a general pediatric unit of an academic quaternary care center. This was a retrospective cohort study of nursing assistant (NA) versus CVM supervision for girls 12-18 years old admitted for medical stabilization of an eating disorder between September 2013 and March 2017. There were 37 consecutive admissions (NA = 23 and CVM = 14). NA median supervision cost was more expensive than CVM ($4,104/admission vs $1,166/admission, P < .001). Length of stay and days to weight gain were not statistically different. There were no occurances of family refusal of CVM, conversion from CVM to NA, technological failure, or unplanned discontinuation. Video monitoring was feasible and associated with lower supervision costs than one-to-one NA supervision. Larger samples in multiple centers are needed to confirm the safety, acceptability, and efficacy of CVM.
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Affiliation(s)
- Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Corresponding Author: Kristin A Shadman, MD; E-mail: ; Telephone: 608-265-8561
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Windy Smith
- American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Paula Cody
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - William Taft
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Laura Bodine
- American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Daniel J Sklansky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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20
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Kirkpatrick R, Booij L, Vance A, Marshall B, Kanellos-Sutton M, Marchand P, Khalid-Khan S. Eating disorders and substance use in adolescents: How substance users differ from nonsubstance users in an outpatient eating disorders treatment clinic. Int J Eat Disord 2019; 52:175-182. [PMID: 30638270 DOI: 10.1002/eat.23017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 12/16/2018] [Accepted: 12/20/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The relationship between eating disorders (EDs) and substance use (SU) has only been briefly described in literature using mainly adult populations. This study examined the prevalence and characteristics of SU among patients of an adolescent ED outpatient treatment program. METHOD A retrospective chart analysis was conducted to determine and subsequently compare medical status, psychosocial factors, treatment course and outcome between patients with and without SU. RESULTS Over 60% of patients with SU status (n = 203) reported regularly consuming substances. 33.4% of substance users received a diagnosis involving purging behaviors compared to 5.9% of nonusers. Females composed 96.4% and 81.7% of users and nonusers, respectively. Users reported significantly more self-harm (57.7% of users vs. 38.6% of nonusers) but did not differ significantly in terms of trauma (abuse or victimization; 48.3% of users vs. 44.9% of nonusers). The percentage of ideal body weight significantly improved throughout treatment and did not differ by SU with a mean increase of 5.29% (SD = 13.6) among nonusers compared to 5.45% (SD = 7.5) of users. While users and nonusers did not differ before and after treatment in ED severity, users were more likely than nonusers to drop-out of treatment (41.5% of users vs. 25.2% of nonusers). DISCUSSION Adolescents with SU benefit from ED outpatient treatment as much as those without SU, however, users are more likely to drop-out. Therefore, treatment should target these adolescents' emotional dysregulation to improve treatment compliance. Further research is necessary to determine the efficacy of such an approach.
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Affiliation(s)
- Ryan Kirkpatrick
- Division of Child and Youth Psychiatry, Kingston Health Sciences Centre, Hotel Dieu Hospital Site, Kingston, Ontario, Canada.,Department of Psychiatry, Queen's University, Kingston, Ontario, Canada.,Centre for Neuroscience Studies, Queen's University, Botterell Hall, Kingston, Ontario, Canada
| | - Linda Booij
- Department of Psychology, Queen's University, Kingston, Ontario, Canada.,Department of Psychology, Concordia University, Montréal, Québec, Canada.,Sainte-Justine Hospital Research Centre, University of Montréal, Montréal, Québec, Canada
| | - Ashleigh Vance
- Division of Child and Youth Psychiatry, Kingston Health Sciences Centre, Hotel Dieu Hospital Site, Kingston, Ontario, Canada
| | - Brittany Marshall
- Division of Child and Youth Psychiatry, Kingston Health Sciences Centre, Hotel Dieu Hospital Site, Kingston, Ontario, Canada
| | - Marina Kanellos-Sutton
- Division of Child and Youth Psychiatry, Kingston Health Sciences Centre, Hotel Dieu Hospital Site, Kingston, Ontario, Canada.,Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Patricia Marchand
- Division of Child and Youth Psychiatry, Kingston Health Sciences Centre, Hotel Dieu Hospital Site, Kingston, Ontario, Canada.,Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Sarosh Khalid-Khan
- Division of Child and Youth Psychiatry, Kingston Health Sciences Centre, Hotel Dieu Hospital Site, Kingston, Ontario, Canada.,Department of Psychiatry, Queen's University, Kingston, Ontario, Canada.,Centre for Neuroscience Studies, Queen's University, Botterell Hall, Kingston, Ontario, Canada.,Department of Psychology, Queen's University, Kingston, Ontario, Canada
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21
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Rizzo SM, Douglas JW, Lawrence JC. Enteral Nutrition via Nasogastric Tube for Refeeding Patients With Anorexia Nervosa: A Systematic Review. Nutr Clin Pract 2018; 34:359-370. [PMID: 30070730 DOI: 10.1002/ncp.10187] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Weight restoration is an important first step in treating patients with anorexia nervosa (AN), because it is essential for medical stabilization and reversal of long-term complications. Tube feeding may help facilitate weight restoration, but its role in treatment remains unclear. This study aimed to review the literature describing the efficacy, safety, tolerance, and long-term effects of nasogastric (NG) refeeding for patients with AN. Four electronic databases were systematically searched through May 2018. Boolean search terms included "anorexia nervosa," "refeeding," and "nasogastric tube feeding." Ten studies were eligible for inclusion: 8 retrospective chart reviews, 1 prospective cohort, and 1 randomized controlled trial. Nine of the studies were performed in-hospital. In 8 studies, NG nutrition resulted in an average rate of weight gain exceeding 1 kg/wk. In 4 of 5 studies including an oral-only control group, mean weekly weight gain and caloric intake were significantly higher in tube-fed patients. Six studies provided prophylactic phosphate supplementation, all with <1% occurrence rate of refeeding hypophosphatemia. Seven studies reported on other physiological disturbances, 6 evaluated medical and gastrointestinal side effects, 3 considered psychological outcomes, and 4 assessed patients postdischarge. Results indicated that NG feeding was not associated with an increased risk for adverse outcomes. Overall, in these studies, NG nutrition was considered safe and well tolerated, and effectively increased caloric intake and rate of weight gain in patients with AN. However, results are limited by weaknesses in study designs, and more rigorous methods are needed for development of evidence-based, standardized refeeding protocols.
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Affiliation(s)
- Saara M Rizzo
- Department of Human Nutrition and Hospitality Management, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Joy W Douglas
- Department of Human Nutrition and Hospitality Management, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Jeannine C Lawrence
- Department of Human Nutrition and Hospitality Management, The University of Alabama, Tuscaloosa, Alabama, USA
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22
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Kezelman S, Crosby RD, Rhodes P, Hunt C, Anderson G, Clarke S, Touyz S. Anorexia Nervosa, Anxiety, and the Clinical Implications of Rapid Refeeding. Front Psychol 2018; 9:1097. [PMID: 30022961 PMCID: PMC6040228 DOI: 10.3389/fpsyg.2018.01097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/08/2018] [Indexed: 11/13/2022] Open
Abstract
The current study aimed to examine the temporal relationship between anxiety symptoms and weight gain for adolescents with anorexia nervosa over the course of an inpatient admission targeting weight restoration through rapid refeeding. Participants were 31 females presenting to a specialist inpatient unit. Psychometric assessments using standardized procedures were conducted to assess co-morbid anxiety diagnoses, and eating disorder symptom severity at admission and discharge. Study protocols were completed on a weekly basis over the course of their admission and were compared with weekly BMI change. Multiple mixed-effects linear models with random intercepts were used to assess change in weight status and psychological variables. Results indicated a reduction in anxiety over the course of hospitalization; however, there was no evidence to support a relationship between anxiety change and weight restoration. The clinical implications of these results are discussed and directions for future research recommended.
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Affiliation(s)
- Sarah Kezelman
- School of Psychology, University of Sydney, Sydney, NSW, Australia
| | - Ross D. Crosby
- Neuropsychiatric Research Institute, Fargo, ND, United States
- School of Medicine & Health Sciences, University of North Dakota, Fargo, ND, United States
| | - Paul Rhodes
- School of Psychology, University of Sydney, Sydney, NSW, Australia
| | - Caroline Hunt
- School of Psychology, University of Sydney, Sydney, NSW, Australia
| | - Gail Anderson
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Simon Clarke
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Stephen Touyz
- School of Psychology, University of Sydney, Sydney, NSW, Australia
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23
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A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders. J Acad Nutr Diet 2018; 118:1450-1463. [PMID: 29656932 DOI: 10.1016/j.jand.2018.01.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/30/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using "start low, go slow" refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts. OBJECTIVE To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs. DESIGN This was a retrospective pre-test-post-test study. PARTICIPANTS/SETTING One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013. MAIN OUTCOME MEASURES Differences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined. STATISTICAL ANALYSIS PERFORMED χ2 tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols. RESULTS Descriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391). CONCLUSIONS A higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial.
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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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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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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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27
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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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Seitz J, Bühren K, Biemann R, Timmesfeld N, Dempfle A, Winter SM, Egberts K, Fleischhaker C, Wewetzer C, Herpertz-Dahlmann B, Hebebrand J, Föcker M. Leptin levels in patients with anorexia nervosa following day/inpatient treatment do not predict weight 1 year post-referral. Eur Child Adolesc Psychiatry 2016; 25:1019-25. [PMID: 26847072 DOI: 10.1007/s00787-016-0819-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
Elevated serum leptin levels following rapid therapeutically induced weight gain in anorexia nervosa (AN) patients are discussed as a potential biomarker for renewed weight loss as a result of leptin-related suppression of appetite and increased energy expenditure. This study aims to analyze the predictive value of leptin levels at discharge as well as the average rate of weight gain during inpatient or day patient treatment for body weight at 1-year follow-up. 121 patients were recruited from the longitudinal Anorexia Nervosa Day patient versus Inpatient (ANDI) trial. Serum leptin levels were analyzed at referral and discharge. A multiple linear regression analysis to predict age-adjusted body mass index (BMI-SDS) at 1-year follow-up was performed. Leptin levels, the average rate of weight gain, premorbid BMI-SDS, BMI-SDS at referral, age and illness duration were included as independent variables. Neither leptin levels at discharge nor rate of weight gain significantly predicted BMI-SDS at 1-year follow-up explaining only 1.8 and 0.4 % of the variance, respectively. According to our results, leptin levels at discharge and average rate of weight gain did not exhibit any value in predicting weight at 1-year follow-up in our longitudinal observation study of adolescent patients with AN. Thus, research should focus on other potential factors to predict weight at follow-up. As elevated leptin levels and average rate of weight gain did not pose a risk for reduced weight, we found no evidence for the beneficial effect of slow refeeding in patients with acute AN.
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Affiliation(s)
- Jochen Seitz
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital, RWTH University Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany.
| | - Katharina Bühren
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital, RWTH University Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany
| | - Ronald Biemann
- Institute for Clinical Chemistry and Pathochemistry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Nina Timmesfeld
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany
| | - Astrid Dempfle
- Institute of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Christian Albrecht-University, Kiel, Germany
| | - Sibylle Maria Winter
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Charité-Universitätsmedizin, Berlin, Germany
| | - Karin Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg, Würzburg, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Medical Centre Freiburg, Freiburg, Germany
| | - Christoph Wewetzer
- Department of Child and Adolescent Psychiatry and Psychotherapy, Kliniken der Stadt Köln, Cologne, Germany
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital, RWTH University Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany
| | - Johannes Hebebrand
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Duisburg-Essen, Essen, Germany
| | - Manuel Föcker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Duisburg-Essen, Essen, Germany
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Loung RPY, Cooney M, Fallon EM, Langer JC, Katzman DK. Pneumothorax in a young man with anorexia nervosa. Int J Eat Disord 2016; 49:895-8. [PMID: 27196534 DOI: 10.1002/eat.22558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 03/28/2016] [Accepted: 04/03/2016] [Indexed: 11/06/2022]
Abstract
Primary spontaneous pneumothorax (PSP) is defined as a pneumothorax that occurs in the absence of an external cause in an individual without underlying generalized lung disease. A number of factors are important and should be carefully considered in the pathogenesis of PSP. This is the first case report of a PSP in a severely malnourished adolescent male with anorexia nervosa (AN) who was involved in excessive physical activity. Clinicians caring for adolescents with AN and vigorous exercise need to be aware of the risk factors associated with the development of a PSP. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:895-898).
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Affiliation(s)
- Robert P Y Loung
- Department of Pediatrics, The Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada.,The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Megan Cooney
- Department of Pediatrics, The Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada.,The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Erica M Fallon
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada.,Department of General and Thoracic Surgery, Division of General Surgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Jacob C Langer
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada.,Department of General and Thoracic Surgery, Division of General Surgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Debra K Katzman
- Department of Pediatrics, The Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada. .,The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada.
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30
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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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Weissman RS, Becker AE, Bulik CM, Frank GKW, Klump KL, Steiger H, Strober M, Thomas J, Waller G, Walsh BT. Speaking of That: Terms to Avoid or Reconsider in the Eating Disorders Field. Int J Eat Disord 2016; 49:349-53. [PMID: 27084795 DOI: 10.1002/eat.22528] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2016] [Indexed: 01/15/2023]
Abstract
Inspired by an article on 50 terms that, in the interest of clarity in scientific reasoning and communication in psychology, psychiatry, and allied fields, "should be avoided or at most be used sparingly and only with explicit caveats,"(1) we propose a list of terms to avoid or think twice about before using when writing for the International Journal of Eating Disorders (IJED). Drawing upon our experience as reviewers or editors for the IJED, we generated an abridged list of such terms. For each term, we explain why it made our list and what alternatives we recommend. We hope that our list will contribute to improved clarity in scientific thinking about eating disorders, and that it will stimulate discussion of terms that may need to be reconsidered in our field's vocabulary to ensure the use of language that is respectful and sensitive to individuals who experience an eating disorder.
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Affiliation(s)
- Ruth S Weissman
- Department of Psychology, Wesleyan University, Middletown, Connecticut
| | - Anne E Becker
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Eating Disorders Clinical and Research Program, Boston, Massachusetts
| | - Cynthia M Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Guido K W Frank
- Department of Psychiatry, University of Colorado Denver, Colorado.,Department of Neuroscience, University of Colorado Denver, Colorado
| | - Kelly L Klump
- Department of Psychology, Michigan State University, East Lansing, Michigan
| | - Howard Steiger
- Douglas University Institute and Psychiatry Department, Eating Disorders Continuum, McGill University, Montreal, Canada
| | - Michael Strober
- Jane & Terry Semel Institute for Neuroscience & Human Behavior, Stewart & Lynda Resnick Neuropsychiatric Hospital, David Geffen School of Medicine, University of California at Los Angeles Department of Psychiatry and Biobehavioral Sciences, Los Angeles, California
| | - Jennifer Thomas
- Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Eating Disorders Clinical and Research Program, Boston, Massachusetts
| | - Glenn Waller
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - B Timothy Walsh
- New York State Psychiatric Institute and Department of Psychiatry, Columbia University, New York, New York
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Pettersson C, Tubic B, Svedlund A, Magnusson P, Ellegård L, Swolin-Eide D, Forslund HB. Description of an intensive nutrition therapy in hospitalized adolescents with anorexia nervosa. Eat Behav 2016; 21:172-8. [PMID: 26970731 DOI: 10.1016/j.eatbeh.2016.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe an intensive nutrition therapy for hospitalized adolescents and young adults with anorexia nervosa (AN) in terms of body weight, body composition, energy balance and food related anxiety. METHOD Twenty-six young females, 16-24years of age, with AN were invited to participate at admission to a specialized eating disorder unit in Göteborg, Sweden. Intensive nutrition therapy comprised 12weeks on a structured meal plan. Six meals were served daily, in combination with high-energy liquid nutritional supplements from start. Energy and nutrient intakes, energy expenditure, body composition and food related anxiety were measured during the study. A 3-month follow-up of body weight and food related anxiety was conducted. RESULTS Twenty-one patients participated. The total daily energy intake was, during the first week of treatment, (mean±SD) 3264±196kcal (74kcal/kg), and decreased gradually during treatment to 2622±331kcal (49kcal/kg). Total daily energy expenditure was initially 1568±149kcal and increased gradually to 2034±194kcal. Patients gained on average 9.8±2.1kg and body mass index increased from 15.5±0.9 to 19.0±0.9kg/m(2). Body fat increased from 13±6% to 26±6%. Fat free mass remained unchanged, but skeletal muscle mass increased from 16.7±2.0 to 17.6±2.4kg, p=0.009. Patients' food related anxiety decreased significantly during treatment and was still unchanged 3months later. CONCLUSION The presented intensive nutrition therapy with initially high energy and nutrient intakes produced substantial weight gain, increased fat and muscle mass and decreased food related anxiety in AN patients, without any clinical side effects.
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Affiliation(s)
- Cecilia Pettersson
- Anorexia-Bulimia Unit, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Göteborg, Sweden.
| | - Bojan Tubic
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden
| | - Anna Svedlund
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden
| | - Per Magnusson
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University, Linkoping, Sweden
| | - Lars Ellegård
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden
| | - Diana Swolin-Eide
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden
| | - Heléne Bertéus Forslund
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden
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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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Golden NH, Katzman DK, Sawyer SM, Ornstein RM, Rome ES, Garber AK, Kohn M, Kreipe RE. Update on the medical management of eating disorders in adolescents. J Adolesc Health 2015; 56:370-5. [PMID: 25659201 DOI: 10.1016/j.jadohealth.2014.11.020] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/14/2014] [Accepted: 11/23/2014] [Indexed: 12/21/2022]
Abstract
The medical practitioner has an important role to play in the management of adolescents with eating disorders, usually as part of a multidisciplinary team. This article reviews the role of the medical practitioner in the diagnosis and treatment of eating disorders, updating the reader on the changing epidemiology of eating disorders, revised diagnostic criteria, newer methods of assessing degree of malnutrition, more aggressive approaches to refeeding, and current approaches to managing low bone mass.
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Affiliation(s)
- Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California.
| | - Debra K Katzman
- Department of Pediatrics, Division of Adolescent Medicine, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Susan M Sawyer
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Royal Children's Hospital, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Rollyn M Ornstein
- Division of Adolescent Medicine and Eating Disorders, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Ellen S Rome
- Center for Adolescent Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio; Department of Pediatrics, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Andrea K Garber
- Division of Adolescent Medicine, University of California Benioff Children's Hospital, San Francisco, California
| | - Michael Kohn
- Department of Adolescent Medicine, The Sydney Children's Hospital Network, Westmead, New South Wales, Australia; Faculty of Medicine, The University of Sydney, Westmead, New South Wales, Australia
| | - Richard E Kreipe
- Department of Pediatrics, Division of Adolescent Medicine, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York; New York State ACT for Youth Center of Excellence, Western New York Comprehensive Care Center for Eating Disorders, Rochester, New York
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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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Sachs K, Andersen D, Sommer J, Winkelman A, Mehler PS. Avoiding medical complications during the refeeding of patients with anorexia nervosa. Eat Disord 2015; 23:411-21. [PMID: 25751129 DOI: 10.1080/10640266.2014.1000111] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nutritional rehabilitation and weight restoration are key underpinnings of the treatment protocol for patients with anorexia nervosa. While their inherent state of malnutrition and weight loss is certainly not a healthy one, ironically, the very essence of the refeeding process, if done injudiciously, can also be unsafe for patients with anorexia nervosa. In this article we will provide a review of the major complications that may arise during refeeding, how best to avoid them, and how to treat them.
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Affiliation(s)
- Katherine Sachs
- a Department of Medicine , Denver Health Medical Center , Denver , Colorado , USA
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Katzman DK, Garber AK, Kohn M, Golden NH. Refeeding hypophosphatemia in hospitalized adolescents with anorexia nervosa: a position statement of the Society for Adolescent Health and Medicine. J Adolesc Health 2014; 55:455-7. [PMID: 25151056 PMCID: PMC6159900 DOI: 10.1016/j.jadohealth.2014.06.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 11/28/2022]
Abstract
Refeeding hypophosphatemia in hospitalized adolescents with anorexia nervosa is correlated with degree of malnutrition. Therefore, when initiating nutritional rehabilitation, clinicians should have a heightened awareness of the possibility of refeeding hypophosphatemia in severely malnourished patients (<70% median body mass index).
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Affiliation(s)
- Debra K. Katzman
- Professor of Pediatrics, Division of Adolescent Medicine, Department of Pediatrics, Hospital for Sick Children, 555 University Avenue, Toronto, ON Canada M5G 1X8, , Tel: 416-813-5084, Fax: 416-813-5392
| | - Andrea K. Garber
- Associate Professor of Pediatrics, Division of Adolescent Medicine, University of California San Francisco, 3333 California Street, Suite 245, Box 0503, San Francisco, CA 94143-0503, , Tel: 415-514-2180, Fax: 415-476-6106
| | - Michael Kohn
- Senior Staff Specialist, Department of Adolescent Medicine, Clinical Associate Professor, Faculty of Medicine Sydney University, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead NSW 2145 Australia, , Tel: (02) 9845 2446, Fax: (02) 9845 2517
| | - Neville H. Golden
- The Marron and Mary Elizabeth Kendrick Professor in Pediatrics, Chief, Division of Adolescent Medicine, Stanford University School of Medicine, 770 Welch Road, Suite 433, Palo Alto, CA 94304, , Tel: 650-736-9557,Fax: 650-736-7706
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Rocks T, Pelly F, Wilkinson P. Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a systematic review of the evidence. J Acad Nutr Diet 2014; 114:897-907. [PMID: 24512952 DOI: 10.1016/j.jand.2013.11.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 11/20/2013] [Indexed: 01/08/2023]
Abstract
Restoration of weight and nutritional rehabilitation are recognized as fundamental steps in the therapeutic treatment of children and adolescent inpatients with anorexia nervosa (AN). However, current recommendations on initial energy requirements for this population are inconsistent, with a clear lack of empirical evidence. Thus, the aim of our study was to systematically review, assess, and summarize the available evidence on the effect of differing nutrition therapies prescribed during refeeding on weight restoration in hospitalized children and adolescents (aged 19 years and younger) with diagnosed AN. Searches were conducted in Scopus, Web of Science, Global Health (CABI), PubMed, and the Cochrane database for articles published in English up to May 2012, and complemented by a search of the reference lists of key publications. Seven observational studies investigating a total of 403 inpatients satisfied the inclusion criteria. The range of prescribed energy intakes varied from 1,000 kcal to >1,900 kcal/day with a progressive increase during the course of hospitalization. It appeared that additional tube feeding increased the maximum energy intake and led to greater interim or discharge weight; however, this was also associated with a higher incidence of adverse effects. Overall, the level of available evidence was poor, and therefore consensus on the most effective and safe treatment for weight restoration in inpatient children and adolescents with AN is not currently feasible. Further research on refeeding methods is crucial to establish the best practice approach to treatment of this population.
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Le Grange D. Examining refeeding protocols for adolescents with anorexia nervosa (again): challenges to current practices. J Adolesc Health 2013; 53:555-6. [PMID: 24138761 DOI: 10.1016/j.jadohealth.2013.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 08/24/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel Le Grange
- Section of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois
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