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Fonseca NKO, Curtarelli VD, Bertoletti J, Azevedo K, Cardinal TM, Moreira JD, Antunes LC. Avoidant restrictive food intake disorder: recent advances in neurobiology and treatment. J Eat Disord 2024; 12:74. [PMID: 38849953 PMCID: PMC11157884 DOI: 10.1186/s40337-024-01021-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 05/14/2024] [Indexed: 06/09/2024] Open
Abstract
Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by persistent insufficient nutritional and/or energy intake. ARFID, before referred to as "selective eating disorder", was introduced recently in the DSM-5 as a replacement for and expansion of the previous diagnosis. Individuals with ARFID may limit food variety and intake due to avoidance based on the sensory characteristics of the food or related to any adverse consequences of eating without the intention of losing weight and concerns of body image. The limited understanding of avoidant and restrictive eating poses challenges to effective treatment and management, impacting directly on the growth and development of children and adolescents. The ARFID neurobiological concept has not yet been clearly defined to clinical practice for nutritionists, thereby hindering screening and impeding the development of treatment recommendations. This narrative review provide useful practical information to consult the pathophysiology, the neurobiology, the clinical features, the assessment and the treatment for healthcare professionals seeking to enhance their clinical knowledge and management of this disorder.
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Affiliation(s)
- Natasha K O Fonseca
- Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil.
| | | | | | - Karla Azevedo
- Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
- Translational Nutritional Neuroscience Working Group, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Tiago M Cardinal
- Laboratory of Neuroscience and Eating Behavior, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Júlia D Moreira
- Department of Nutrition, Health Sciences Center, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
- Translational Nutritional Neuroscience Working Group, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Luciana C Antunes
- Laboratory of Neuroscience and Eating Behavior, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
- Department of Nutrition, Health Sciences Center, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
- Translational Nutritional Neuroscience Working Group, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
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Matsunaga H, Riku K, Shimizu K, Fujimi S. Severe hypoglycemia with reduced liver volume as an indicator of end-stage malnutrition in patients with anorexia nervosa: a retrospective observational study. J Eat Disord 2024; 12:55. [PMID: 38702806 PMCID: PMC11069231 DOI: 10.1186/s40337-024-01011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/24/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Hypophosphatemia due to excessive carbohydrate administration is considered the primary pathogenesis of refeeding syndrome. However, its association with liver injury and hypoglycemia, often seen in severe malnutrition before re-nutrition, remains unclear. Autophagy reportedly occurs in the liver of patients with severe malnutrition. This study aimed to clarify the pathophysiology of liver injury and hypoglycemia by focusing on liver volume. METHODS Forty-eight patients with anorexia nervosa with a body mass index (BMI) of < 13 kg/m2 were included (median BMI: 10.51 kg/m2 on admission). Liver volume was measured in 36 patients who underwent abdominal computed tomography (CT), and the "estimated liver weight/ideal body weight" was used as the liver volume index. Seventeen blood test items were analyzed during the first 60 days. RESULTS Liver volume significantly decreased when abdominal CTs were conducted shortly before or after hypoglycemia compared to when the scans were performed during periods without hypoglycemia. Five patients with severe hypoglycemia on days 13-18 after admission had a very low nutritional intake; of them, four showed a marked decrease in liver volume. Severe hypoglycemia was accompanied by low serum triglycerides and liver dysfunction. Patients experiencing hypoglycemia of blood glucose levels < 55 mg/dL (< 3.05 mmol/L) (32 patients; median lowest BMI: 9.45 kg/m2) exhibited significantly poorer blood findings for most of the 17 items, except serum phosphorus and potassium, than did those not experiencing hypoglycemia (16 patients; median lowest BMI: 11.2 kg/m2). All patients with a poor prognosis belonged to the hypoglycemia group. Empirically, initiating re-nutrition at 500 kcal/day (20-25 kcal/kg/day), increasing to 700-800 kcal/day after a week, and then gradually escalating can reduce serious complications following severe hypoglycemia. CONCLUSIONS Liver volume reduction accompanied by hypoglycemia, low serum triglyceride levels, and liver dysfunction occurs when the body's stored energy sources are depleted and external nutritional intake is inadequate, suggesting that the liver was consumed as a last resort to obtain energy essential for daily survival. This pathophysiology, distinct from refeeding syndrome, indicates the terminal stage of malnutrition and is a risk factor for complications and poor prognosis. In treatment, extremely low nutrient levels should be avoided.
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Affiliation(s)
- Hidenori Matsunaga
- Department of Psychiatry, Osaka General Medical Center, Bandai-Higashi 3-1-56, Sumiyoshi-ku, Osaka, 558-8558, Japan.
- Department of Psychiatry, Osaka University Graduate School of Medicine, Yamada-Oka 2-2, Suita-City, Osaka, 565-0871, Japan.
- Department of Pharmacotherapeutics II, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, Nasahara 4-20-1, Takatsuki-City, Osaka, 569-1094, Japan.
| | - Keisen Riku
- Rikusato Kenko Clinic, Andoji-Machi, 2-6-3-102, Chuo-ku, Osaka, 542-0061, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Yamada-Oka 2-2, Suita-City, Osaka, 565-0871, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Bandai-Higashi 3-1-56, Sumiyoshi-ku, Osaka, 558-8558, Japan
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3
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Suzuki Y, Itagaki S, Nodera M, Suyama K, Yabe H, Hosoya M. Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders. Fukushima J Med Sci 2024; 70:75-85. [PMID: 38599829 PMCID: PMC11140198 DOI: 10.5387/fms.2023-02] [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] [Received: 01/17/2023] [Accepted: 01/19/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND This study investigated changes of lipid parameters in children with severe eating disorders during refeeding in order to explore the optimal timing for lipid preparation administration. METHODS We prospectively assessed the physical conditions of patients with eating disorders after the start of nutrition therapy. The assessments were performed at admission and at 2 and 4 weeks. Lipid metabolism was assessed based on triglyceride (TG), total cholesterol (TC), and free carnitine (FC) levels, as well as acylcarnitine/free carnitine (AC/FC) ratio. RESULTS A total of 18 patients were included. Of these, 12 and 6 received an oral diet (OD group) and total parenteral nutrition (TPN group), respectively. The mean body mass indexes at hospital admission were 12.8 kg/m2 in the OD group and 12.7 kg/m2 in the TPN group. At 2 weeks after the start of refeeding, TC, TG, and AC/FC levels were significantly lower in the TPN group than in the OD group. Other blood test results did not show any significant differences between the two groups. CONCLUSIONS Fat-free glucose-based nutrition promoted lipid metabolism over a 2-week period after the start of refeeding, suggesting that balanced energy and lipid intake are essential, even in TPN.
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Affiliation(s)
- Yuichi Suzuki
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Shuntaro Itagaki
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine
| | - Maki Nodera
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine
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4
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Suzuki Y, Itagaki S, Nodera M, Suyama K, Yabe H, Hosoya M. Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders. Fukushima J Med Sci 2024:2023_02. [PMID: 38522893 DOI: 10.5387/fms.2023_02] [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: 03/26/2024] Open
Abstract
BACKGROUND This study investigated changes of lipid parameters in children with severe eating disorders during refeeding in order to explore the optimal timing for lipid preparation administration. METHODS We prospectively assessed the physical conditions of patients with eating disorders after the start of nutrition therapy. The assessments were performed at admission and at 2 and 4 weeks. Lipid metabolism was assessed based on triglyceride (TG), total cholesterol (TC), and free carnitine (FC) levels, as well as acylcarnitine/free carnitine (AC/FC) ratio. RESULTS A total of 18 patients were included. Of these, 12 and 6 received an oral diet (OD group) and total parenteral nutrition (TPN group), respectively. The mean body mass indexes at hospital admission were 12.8 kg/m2 in the OD group and 12.7 kg/m2 in the TPN group. At 2 weeks after the start of refeeding, TC, TG, and AC/FC levels were significantly lower in the TPN group than in the OD group. Other blood test results did not show any significant differences between the two groups. CONCLUSIONS Fat-free glucose-based nutrition promoted lipid metabolism over a 2-week period after the start of refeeding, suggesting that balanced energy and lipid intake are essential, even in TPN.
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Affiliation(s)
- Yuichi Suzuki
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Shuntaro Itagaki
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine
| | - Maki Nodera
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine
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Tsutsumi M, Okamoto N, Tesen H, Kijima R, Yoshimura R. Choosing Appropriate Nutritional Therapy for Patients With Anorexia Nervosa Exhibiting Liver Dysfunction: A Case Report. Cureus 2024; 16:e54332. [PMID: 38500915 PMCID: PMC10945030 DOI: 10.7759/cureus.54332] [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: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
Anorexia nervosa (AN) presents with a variety of physical complications such as hypoglycemia, electrolyte abnormalities, and dehydration associated with starvation, requiring rapid weight gain through nutritional therapy. However, despite nutritional therapy, patients are at risk of many serious medical complications, including hypoglycemia, hypophosphatemia, edema, and liver damage. Starvation has been found to cause hepatocyte injury with mild-to-severe increases in liver enzyme levels, and distinguishing between autophagy and refeeding syndrome is important for treatment strategies. Herein, we report a rare case of sudden liver injury after the initiation of nutritional therapy in a patient with AN. A 35-year-old woman was admitted to our hospital for the treatment of weight loss due to AN. Nutritional therapy was initiated at 600 kcal/day and increased to 1500 kcal/day on the 21st day of admission. On the 22nd day after admission, rapid liver injury was observed, with an aspartate aminotransferase level of 141 U/L and an alanine aminotransferase level of 221 U/L. After the exclusion of refeeding syndrome, since there was no evidence of hypokalemia, hypophosphatemia, or fatty liver disease based on blood tests and abdominal echography, we diagnosed starvation-induced hepatocyte autophagy, and she was treated with the same calories. Her liver dysfunction gradually improved thereafter. This case report highlights the clinical utility of identifying the etiology of hepatic dysfunction in patients with AN. Clinicians must make appropriate decisions regarding continuing or reducing nutritional therapy based on relevant tests when patients with AN develop liver dysfunction after the initiation of nutritional therapy.
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Affiliation(s)
- Motoharu Tsutsumi
- Psychiatry, University of Occupational and Environmental Health, Kitakyushu, JPN
| | - Naomichi Okamoto
- Psychiatry, University of Occupational and Environmental Health, Kitakyushu, JPN
| | - Hirofumi Tesen
- Psychiatry, University of Occupational and Environmental Health, Kitakyushu, JPN
| | - Reoto Kijima
- Psychiatry, University of Occupational and Environmental Health, Kitakyushu, JPN
| | - Reiji Yoshimura
- Psychiatry, University of Occupational and Environmental Health, Kitakyushu, JPN
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Chen L, Liu Z, Zheng Y. Acute liver failure and aplastic crisis due to anorexia nervosa in an adolescent girl: a case report. J Int Med Res 2023; 51:3000605231214922. [PMID: 38017360 PMCID: PMC10686022 DOI: 10.1177/03000605231214922] [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] [Received: 07/16/2023] [Accepted: 10/17/2023] [Indexed: 11/30/2023] Open
Abstract
Anorexia nervosa (AN) has a high mortality rate due to the widespread organ dysfunction caused by the underlying severe malnutrition. Malnutrition-induced hepatitis is common among individuals with AN especially as body mass index decreases, while acute liver failure and aplastic crisis related to coagulation disease and encephalopathy rarely occur in AN patients. The supervised increase of caloric intake can quickly improve the elevated aminotransferases caused by starvation and aplastic crisis. This current case report describes a 12-year-old adolescent girl who was admitted with a 3-month history of weight loss. Within 3 months, she had lost 10 kg of weight. The girl was diagnosed with AN, acute liver failure, severe malnutrition with emaciation, electrolyte disorder, bradycardia and aplastic crisis. She was gradually supplemented with vitamins and enteral nutrition to avoid refeeding syndrome. After treatment, her liver function and haematopoietic function returned to normal. In conclusion, acute liver failure and aplastic crisis are rare but potentially life-threatening complications of AN, which could be improved by supervised feeding and timely rehydration. AN should be considered as the potential aetiology of acute liver failure and aplastic crisis.
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Affiliation(s)
- Leilei Chen
- Department of Paediatrics, Yancheng No.1 People’s Hospital, Affiliated Hospital of Medical School, Nanjing University, Yancheng, Jiangsu Province, China
| | - Zhifeng Liu
- Department of Gastroenterology, Nanjing Children’s Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yucan Zheng
- Department of Gastroenterology, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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Puga FM, Baptista P, Oliveira A, França M. Refeeding syndrome: What to expect when you're not expecting. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 3:71-73. [PMID: 37640475 DOI: 10.1016/j.endien.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/20/2022] [Indexed: 08/31/2023]
Affiliation(s)
| | - Patrícia Baptista
- Department of Internal Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Oliveira
- Department of Internal Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Margarida França
- Department of Internal Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
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8
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Wani M, Chakole S, Agrawal S, Gupta A, Chavada J, Pathade AG, Yelne S. Unveiling Skin Manifestations: Exploring Cutaneous Signs of Malnutrition in Eating Disorders. Cureus 2023; 15:e44759. [PMID: 37809242 PMCID: PMC10556793 DOI: 10.7759/cureus.44759] [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] [Received: 08/12/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
The intricate interplay between eating disorders, malnutrition, and their cutaneous manifestations is the focal point of this comprehensive review. The review delves into the clinical significance of recognising and understanding these visible signs in the context of eating disorders. It highlights the vital role of nutrition in maintaining healthy skin and addresses the challenges associated with relying solely on cutaneous signs for diagnosis. Emphasising a multidisciplinary approach involving dermatologists, psychiatrists, and nutritionists, the review underscores the holistic nature of the treatment. Addressing psychological aspects alongside nutritional rehabilitation is underscored with a forward-looking perspective on future research avenues. This review is valuable for healthcare professionals by synthesising existing knowledge and identifying research gaps. It aims to improve the diagnosis, treatment, and preventative strategies for individuals dealing with the complex challenges of eating disorders and malnutrition.
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Affiliation(s)
- Mohit Wani
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swarupa Chakole
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Suyash Agrawal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anannya Gupta
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Jay Chavada
- Medical Student, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Aniket G Pathade
- Research and Development, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Seema Yelne
- Nursing, Shalinitai Meghe College of Nursing, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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9
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Hirata T, Yasuda K, Iwata Y, Uemura T, Aruga Y, Shioe R, Uchinuma N, Tamaoki T, Suzuki T. Catheter-related bloodstream infection in patients With severe anorexia nervosa. Perspect Psychiatr Care 2022; 58:2224-2227. [PMID: 35152427 DOI: 10.1111/ppc.13050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Anorexia nervosa (AN) may be treated with intravenous hyperalimentation (IVH) that may be associated with catheter-related bloodstream infection (CRBSI). DESIGN AND METHODS Retrospective chart review was conducted to compare those who developed CRBSI were compared with those who did not. FINDINGS Of 34 patients, 17 episodes of AN treated with IVH were identified, of which five resulted in CRBSI. The average body mass index at admission was low at 12.2. Patients who needed physical restraint during IVH had a higher (albeit statistically nonsignificant) risk. Also, those with purging had numerically lower risk. PRACTICE IMPLICATIONS CRBSI complicated IVH in 29.4% instances of severe life-threatening AN in our sample. Whether physical restraints and no purging constitute a risk factor of CRBSI needs to be further investigated.
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Affiliation(s)
- Takashi Hirata
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Kazuyuki Yasuda
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Yusuke Iwata
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Takuji Uemura
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Yu Aruga
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Risa Shioe
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Niina Uchinuma
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Toshio Tamaoki
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Takefumi Suzuki
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan.,Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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10
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Sakata M, Takaki A, Oyama A, Adachi T, Wada N, Takeuchi Y, Yasunaka T, Onishi H, Shiraha H, Okada H. Pathogenesis of Severe Liver Injury in Patients with Anorexia Nervosa: A Report of Two Cases and a Literature Review. Kurume Med J 2022; 67:121-129. [PMID: 36130885 DOI: 10.2739/kurumemedj.ms6723011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Anorexia nervosa (AN) can cause severe protein energy malnutrition and the consequent development of various organ disorders. AN is known to cause hepatic complications. We report two cases of starvation and refeeding-induced liver injury in patients with AN, and review the literature on the hepatic complications of AN. Acute liver injury can be induced by both starvation and refeeding, although the underlying pathomechanisms and management of liver injury differ between these two conditions. Clinicians should carefully identify the clinical features to ensure an accurate diagnosis and appropriate management of these conditions.
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Affiliation(s)
- Masahiro Sakata
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Atsushi Oyama
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takuya Adachi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Nozomu Wada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Yasuto Takeuchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Tetsuya Yasunaka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hideki Onishi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hidenori Shiraha
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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11
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Refeeding syndrome: What to expect when you’re not expecting. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Taylor S, Chan DL, Villaverde C, Ryan L, Peron F, Quimby J, O’Brien C, Chalhoub S. 2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat. J Feline Med Surg 2022; 24:614-640. [PMID: 35775307 PMCID: PMC11107985 DOI: 10.1177/1098612x221106353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PRACTICAL RELEVANCE Inappetence may have many origins and, as a presenting sign or observation in the hospitalised patient, is common in feline practice. Nutritional assessment of every patient is encouraged, to identify the need for, and appropriate type of, intervention indicated. The impact of malnutrition may be significant on the feline patient, perpetuating illness, delaying recovery, slowing wound healing and negatively impacting gut health and immunity. Delayed intervention may result in the cat's deterioration; hence prompt control of contributing factors such as the underlying illness, pain, nausea, ileus and stress is vital to optimise voluntary food intake. Management is multimodal, comprising reduction of stress, medications and assisted nutrition in the form of tube feeding or parenteral nutrition. Use of antiemetic, analgesic, prokinetic and appetite stimulant medications may restore appetite, but placement of feeding tubes should not be delayed. Feeding tubes are generally well tolerated and allow provision of food, water and medication with minimal stress, although clinicians must be aware of complications such as stoma site infections and refeeding syndrome. CLINICAL CHALLENGES Cats are vulnerable to malnutrition owing to their unique metabolism and specific nutritional requirements. Moreover, their nature as a species means they are susceptible to stress in the hospital environment, which may result in reduced food intake; previous negative experiences may compound the problem. In particular, an inappropriate clinic environment and/or handling may cause or exacerbate inappetence in hospitalised patients, with negative impacts on recovery. Postponing interventions such as feeding tube placement to await improvement, owing to clinician or caregiver apprehension, may hinder recovery and worsen nutritional deficits. EVIDENCE BASE The 2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat have been created by a panel of experts brought together by the International Society of Feline Medicine (ISFM). Information is based on the available literature, expert opinion and the panel members' experience.
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Affiliation(s)
- Samantha Taylor
- International Society of Feline Medicine, Tisbury, Wiltshire, UK
| | - Daniel L Chan
- Department of Clinical Science and Services, Royal Veterinary College, North Mymms, Hertfordshire, UK
| | | | - Linda Ryan
- Inspiring Pet Teaching, Fordingbridge, Hampshire, UK
| | | | - Jessica Quimby
- Department of Veterinary Clinical Sciences, Ohio State University, Columbus, OH, USA
| | - Carolyn O’Brien
- Melbourne Cat Vets, 157 Westgarth Street, Fitzroy, Australia
| | - Serge Chalhoub
- Faculty of Veterinary Medicine, University of Calgary, Alberta, Canada
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13
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Freizinger M, Recto M, Jhe G, Lin J. Atypical Anorexia in Youth: Cautiously Bridging the Treatment Gap. CHILDREN 2022; 9:children9060837. [PMID: 35740774 PMCID: PMC9221982 DOI: 10.3390/children9060837] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022]
Abstract
Atypical anorexia nervosa (AAN) is a restrictive eating disorder (ED) that describes individuals who may be normal weighted or overweight; many have a premorbid history of obesity. Pediatric care providers are trained to identify and provide best practices for youth with pediatric obesity; however, most pediatric care providers are not trained to assess and treat restrictive EDs which typically present in youth aged 10 and 14 years. Although individuals with AAN may appear to be within a ‘healthy weight’, many experience malnutrition, psychological symptoms, and severe physiological complications after weight loss. These individuals are presenting to pediatric services at an increasing rate and exhibit acute medical instability along with severe ED psychopathology. One complicating factor is youth with AAN may take longer to be identified by pediatric providers and may be reluctant to engage in treatment. Delayed treatment for AAN, along with all EDs often results in poorer treatment outcomes. A greater understanding of this complex illness is essential to inform medical decisions, such as labs, vitals, hospital admissions, and psychological therapy. Currently, there are no standardized guidelines for treating AAN in youths. This review is designed to present evidence-based treatment to inform and guide best treatment practices.
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Affiliation(s)
- Melissa Freizinger
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (G.J.); (J.L.)
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
- Correspondence:
| | - Michelle Recto
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Grace Jhe
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (G.J.); (J.L.)
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Jessica Lin
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (G.J.); (J.L.)
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45229, USA
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14
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Rynkiewicz A, Dembiński Ł, Koletzko B, Michaud PA, Hadjipanayis A, Grossman Z, Korslund K, King BH, Treasure J, Peregud-Pogorzelski J, Del Torso S, Valiulis A, Mazur A. Adolescents With Eating Disorders in Pediatric Practice - The European Academy of Paediatrics Recommendations. Front Pediatr 2022; 10:806399. [PMID: 35558369 PMCID: PMC9086960 DOI: 10.3389/fped.2022.806399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
In the face of the growing number of adolescents suffering from eating disorders (EDs) and access to psychiatric care limited by the epidemiological and demographic situation, the primary care pediatrician's role in diagnosing and treating EDs is growing. The European Academy of Paediatrics (EAP) decided to summarize knowledge about EDs and formulate recommendations to support European pediatricians and improve care for adolescents with EDs.
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Affiliation(s)
- Agnieszka Rynkiewicz
- Department of Psychiatry, College of Medical Sciences, Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland.,Center for Diagnosis, Therapy and Education SPECTRUM ASC-MED, Gdańsk, Poland
| | - Łukasz Dembiński
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
| | - Berthold Koletzko
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,Department of Paediatrics, Dr. von Hauner Children's Hospital, University of Munich Medical Centre, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Pierre-André Michaud
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,Faculté de Biologie et de Médecine, Université de Lausanne, Lausanne, Switzerland
| | - Adamos Hadjipanayis
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,School of Medicine, European University Cyprus, Nicosia, Cyprus.,Department of Paediatrics, Larnaca General Hospital, Larnaca, Cyprus
| | - Zachi Grossman
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,Adelson School of Medicine, Ariel University, Ariel, Israel.,Maccabi Health Services, Tel Aviv, Israel
| | | | - Bryan H King
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Janet Treasure
- Eating Disorder Unit, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Jarosław Peregud-Pogorzelski
- Department of Pediatrics, Pediatric Oncology and Immunology, Pomeranian Medical University, Szczecin, Poland.,Polish Society of Paediatrics, Warsaw, Poland
| | - Stefano Del Torso
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,ChildCare WorldWide-CCWWItalia OdV, Padova, Italy
| | - Arunas Valiulis
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,Clinic of Children's Diseases, Institute of Clinical Medicine, Vilnius University Medical Faculty, Vilnius, Lithuania.,Department of Public Health, Institute of Health Sciences, Vilnius University Medical Faculty, Vilnius, Lithuania
| | - Artur Mazur
- The European Academy of Paediatrics (EAP), Brussels, Belgium.,Department of Paediatrics, College of Medical Sciences, Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
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15
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Brynes N, Tarchichi T, McCormick AA, Downey A. Restrictive Eating Disorders: Accelerating Treatment Outcomes in the Medical Hospital. Hosp Pediatr 2021; 11:751-759. [PMID: 34103401 DOI: 10.1542/hpeds.2020-005389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children's hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.
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Affiliation(s)
- Nicole Brynes
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tony Tarchichi
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew A McCormick
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amanda Downey
- Departments of Pediatrics and Psychiatry and Behavioral Sciences, University of California, San Francisco, California
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16
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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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17
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Chukwuma B, Mujtaba B, Ibikunle A, Taiwo A, Ogunsanya A. Nutritional status and anemia in persons with cancrum oris. NIGERIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4103/njm.njm_146_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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18
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Yamazaki T, Inada S, Sawada M, Sekine R, Kubota N, Fukatsu K, Yoshiuchi K. Diets with high carbohydrate contents were associated with refeeding hypophosphatemia: A retrospective study in Japanese inpatients with anorexia nervosa. Int J Eat Disord 2021; 54:88-94. [PMID: 33236366 DOI: 10.1002/eat.23416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Refeeding hypophosphatemia (RH) is a potentially fatal complication in patients with anorexia nervosa (AN), and its dietary preventive strategy is not well established. We aimed to examine the association between carbohydrate content in the diet and the occurrence of RH in inpatients with AN via retrospective medical chart review. METHOD We performed a chart review to collect data of patients with AN hospitalized at the Department of Psychosomatic Medicine of the University of Tokyo Hospital between April 1, 2012, and February 29, 2020. Receiver operating characteristic (ROC) analysis was performed to determine the cutoff point of the percentage of carbohydrate content in the diet for the occurrence of RH. Multivariate logistic regression analysis was performed with occurrence of RH as the dependent variable and the carbohydrate content of more than the identified cutoff point as the independent variable adjusting for the risk factors for RH. RESULTS The percentage of carbohydrate content that is higher than the cutoff point obtained from the ROC analysis (58.4%) was significantly associated with the occurrence of RH, even after adjusting for variables associated with RH in univariate logistic regression analysis (age and body mass index) as well as the average daily calorie intake (odds ratio, 5.37; 95% confidence interval, 1.60-18.1; p = .0066). DISCUSSION We identified that diets with higher carbohydrate contents were associated with RH in inpatients with AN, even after adjusting for known risk factors. Our findings may promote the development of dietary preventive strategies against RH in inpatients with AN.
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Affiliation(s)
- Tadahiro Yamazaki
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Inada
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mika Sawada
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Rie Sekine
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoto Kubota
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Fukatsu
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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19
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VĂDUVA N, PUSKAS L, RĂCHIȘAN AL, TOMȘA AM, ALDEA AA, PERNE MG. Skeletal effects and refeeding syndrome in anorexia nervosa. BALNEO RESEARCH JOURNAL 2020. [DOI: 10.12680/balneo.2020.410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose Anorexia nervosa (AN) is a psychiatric disorder which can lead to numerous medical complications. In the clinical practice, during weight restoration, it is relatively common to observe potentially fatal complications, such as refeeding syndrome (RS). The objective of this case report is to highlight some key factors regarding nutritional support and the therapeutic approach in AN to avoid life-threatening complications, for example severe hypophosphatemia.
Methods We present the case of a 14-year-old girl suffering from AN, who was admitted to our hospital with lethargy, emaciation with bitemporal wasting, hirsutism and pitting lower extremity edema.
Results Based on the laboratory findings, the concerning condition of the patient was attributed to hypophosphatemia (1,64 mg/dl) caused by RS.
Conclusions Refeeding syndrome is a potentially lethal condition in the case of AN patients. Hypophosphatemia, which is a result of the refeeding syndrome, is a relatively common complication of overly aggressive nutritional rehabilitation. Physicians who are involved in treating this condition, should be aware of this potentially life-threatening syndrome, and assess their therapeutic approach accordingly
Keywords: anorexia nervosa, hypophosphatemia, refeeding syndrome, nutritional support,
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Affiliation(s)
- Naomi VĂDUVA
- 1 Department 9 – Mother & Child, 2nd Clinic of Pediatrics, „Iuliu Haţieganu” University of Medicine & Pharmacy Cluj-Napoca, Romania
| | - Lehel PUSKAS
- 1 Department 9 – Mother & Child, 2nd Clinic of Pediatrics, „Iuliu Haţieganu” University of Medicine & Pharmacy Cluj-Napoca, Romania
| | - Andreea-Liana RĂCHIȘAN
- 1 Department 9 – Mother & Child, 2nd Clinic of Pediatrics, „Iuliu Haţieganu” University of Medicine & Pharmacy Cluj-Napoca, Romania
| | - Anamaria Magdalena TOMȘA
- 1 Department 9 – Mother & Child, 2nd Clinic of Pediatrics, „Iuliu Haţieganu” University of Medicine & Pharmacy Cluj-Napoca, Romania
| | - Andreea Alexandra ALDEA
- 1 Department 9 – Mother & Child, 2nd Clinic of Pediatrics, „Iuliu Haţieganu” University of Medicine & Pharmacy Cluj-Napoca, Romania
| | - Mirela-Georgiana PERNE
- 2 Department 5 – Internal Medicine, “Iuliu Hatieganu” University of Medicine & Pharmacy Cluj-Napoca, Romania
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20
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Pacei F, Tesone A, Laudi N, Laudi E, Cretti A, Pnini S, Varesco F, Colombo C. The Relevance of Thiamine Evaluation in a Practical Setting. Nutrients 2020; 12:nu12092810. [PMID: 32933220 PMCID: PMC7551939 DOI: 10.3390/nu12092810] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/03/2020] [Accepted: 09/05/2020] [Indexed: 02/07/2023] Open
Abstract
Thiamine is a crucial cofactor involved in the maintenance of carbohydrate metabolism and participates in multiple cellular metabolic processes. Although thiamine can be obtained from various food sources, some common food groups are deficient in thiamine, and it can be denatured by high temperature and pH. Additionally, different drugs can alter thiamine metabolism. In addition, the half-life of thiamine in the body is between 1 and 3 weeks. All these factors could provide an explanation for the relatively short period needed to develop thiamine deficiency and observe the consequent clinical symptoms. Thiamine deficiency could lead to neurological and cardiological problems. These clinical conditions could be severe or even fatal. Marginal deficiency too may promote weaker symptoms that might be overlooked. Patients undergoing upper gastrointestinal or pancreatic surgery could have or develop thiamine deficiency for many different reasons. To achieve the best outcome for these patients, we strongly recommend the execution of both an adequate preoperative nutritional assessment, which includes thiamine evaluation, and a close nutritional follow up to avoid a nutrient deficit in the postoperative period.
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Affiliation(s)
- Federico Pacei
- ASST Nord Milano, UOC Neurologia, Ospedale Bassini, 20092 Cinisello Balsamo, Italy
- Department of Physical Rehabilitation, Casa di Cura Bonvicini, Via Michael Pacher 12, 39100 Bolzano, Italy; (A.T.); (E.L.); (A.C.); (S.P.); (F.V.)
- Correspondence:
| | - Antonella Tesone
- Department of Physical Rehabilitation, Casa di Cura Bonvicini, Via Michael Pacher 12, 39100 Bolzano, Italy; (A.T.); (E.L.); (A.C.); (S.P.); (F.V.)
| | - Nazzareno Laudi
- Faculty of Medicine and Surgery, Medizinische Universitat Innsbruck, Christoph-Probst-Platz 1, Innrain 52 A, 6020 Innsbruck, Austria;
| | - Emanuele Laudi
- Department of Physical Rehabilitation, Casa di Cura Bonvicini, Via Michael Pacher 12, 39100 Bolzano, Italy; (A.T.); (E.L.); (A.C.); (S.P.); (F.V.)
| | - Anna Cretti
- Department of Physical Rehabilitation, Casa di Cura Bonvicini, Via Michael Pacher 12, 39100 Bolzano, Italy; (A.T.); (E.L.); (A.C.); (S.P.); (F.V.)
| | - Shira Pnini
- Department of Physical Rehabilitation, Casa di Cura Bonvicini, Via Michael Pacher 12, 39100 Bolzano, Italy; (A.T.); (E.L.); (A.C.); (S.P.); (F.V.)
| | - Fabio Varesco
- Department of Physical Rehabilitation, Casa di Cura Bonvicini, Via Michael Pacher 12, 39100 Bolzano, Italy; (A.T.); (E.L.); (A.C.); (S.P.); (F.V.)
| | - Chiara Colombo
- Lombardy Regional Course for General Practitioner, PoliS-Lombardia, Via Taramelli 12/F, 20100 Milano, Italy;
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21
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Abstract
A 5-mo-old severely malnourished 3.5 kg boy was brought to the emergency department with hypoglycemia, bradycardia, bradypnea, and hypothermia. His findings were likely due to severe malnutrition secondary to parental neglect. Resuscitation with dextrose containing intravenous fluids was promptly started. On day 2 of admission, refeeding was initiated. From that time, he had multiple hypoglycemic episodes along with hypophosphatemia, hypomagnesemia, and hypokalemia. Hypoglycemia was associated with the initiation of enteral feeding and an increase in calories and amounts of enteral feeding. Hypoglycemia associated with refeeding syndrome in infant has not been previously reported.
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22
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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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23
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Abstract
Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/"underfeeding syndrome" and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients. What is Known: • Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice. • The risk of a refeeding syndrome is well known and well managed in severely malnourished patients ("conservative approaches"). What is New: • There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness. • The risks of "underfeeding syndrome" and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Graphical abstract.
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24
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Vicinanza A, De Laet C, Rooze S, Willems A, Beretta-Piccoli X, Vens D, Voglet C, Jacquemart C, Massin M, Biarent D. Shoshin Beriberi and Severe Accidental Hypothermia as Causes of Heart Failure in a 6-Year-Old Child: A Case Report and Brief Review of Literature. Front Pediatr 2019; 7:119. [PMID: 30984730 PMCID: PMC6449648 DOI: 10.3389/fped.2019.00119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/11/2019] [Indexed: 01/01/2023] Open
Abstract
Severe accidental hypothermia has been demonstrated to affect ventricular systolic and diastolic functions, and rewarming might be responsible of cardiovascular collapse. Until now, there have been only a few reports on severe accidental hypothermia, none of which involved children. Herein, we describe here a rare case of heart failure in a 6-year-old boy admitted to the emergency unit owing to severe hypothermia and malnutrition. After he was warmed up (core temperature of 27.2°C at admission), he developed cardiac arrest, requiring vasoactive amines administration, and veno-arterial extracorporeal membrane oxygenation. Malnutrition and refeeding syndrome might have caused the thiamine deficiency, commonly known as beriberi, which contributed to heart failure as well. He showed remarkable improvement in heart failure symptoms after thiamine supplementation. High-dose supplementation per os (500 mg/day) after reconstitution of an adequate electrolyte balance enabled the patient to recover completely within 2 weeks, even if a mild diastolic cardiac dysfunction persisted longer. In conclusion, we describe an original pediatric case of heart failure due to overlap of severe accidental hypothermia with rewarming, malnutrition, and refeeding syndrome with thiamine deficiency, which are rare independent causes of cardiac dysfunction. The possibility of beriberi as a cause of heart failure and adequate thiamine supplementation should be considered in all high-risk patients, especially those with malnutrition. Refeeding syndrome requires careful management, including gradual electrolyte imbalance correction and administration of a thiamine loading dose to prevent or correct refeeding-induced thiamine deficiency.
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Affiliation(s)
- Alfredo Vicinanza
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Corinne De Laet
- Nutrition and Metabolic Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Shancy Rooze
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Ariane Willems
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Xavier Beretta-Piccoli
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Daphné Vens
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Cédric Voglet
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Jacquemart
- Division of Pediatric Cardiology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Martial Massin
- Division of Pediatric Cardiology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Dominique Biarent
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
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25
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Milos G, Wolf M, Robetin L, Sprenger M, Monteverde S, Schaer D. [Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich]. PRAXIS 2019; 108:923-930. [PMID: 31662109 DOI: 10.1024/1661-8157/a003356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich Abstract. The serious physical mental and psychosocial morbidity due to anorexia nervosa is often perceived by sufferers as less serious than from their environment. Doctors and other healthcare professionals are therefore confronted with the difficulty that urgent medical treatment is considered as unnecessary or even threatening by those affected. Although patients with anorexia nervosa usually wish to improve their condition, they are usually only able to tolerate treatment aimed at normalizing eating behavior and gaining weight in response to high external pressure. In view of this situation, an interdisciplinary team with experience in these treatments is required to treat these patients. Close cooperation is necessary to ensure a supporting treatment framework.
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Affiliation(s)
- Gabriella Milos
- Universitätsspital Zürich, Klinik für Konsiliarpsychiatrie und Psychosomatik, Zentrum für Essstörungen, Zürich
| | - Maria Wolf
- Universitätsspital Zürich, Klinik für Konsiliarpsychiatrie und Psychosomatik, Zentrum für Essstörungen, Zürich
- Universitätsspital Zürich, Klinik und Poliklinik für Innere Medizin, Zürich
| | - Lara Robetin
- Universitätsspital Zürich, Klinik und Poliklinik für Innere Medizin, Zürich
| | - Melanie Sprenger
- Universitätsspital Zürich, Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Ernährungsberatung, Zürich
| | | | - Dominik Schaer
- Universitätsspital Zürich, Klinik und Poliklinik für Innere Medizin, Zürich
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26
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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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Aubry E, Friedli N, Schuetz P, Stanga Z. Refeeding syndrome in the frail elderly population: prevention, diagnosis and management. Clin Exp Gastroenterol 2018; 11:255-264. [PMID: 30022846 PMCID: PMC6045900 DOI: 10.2147/ceg.s136429] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aging is linked to physiological and pathophysiological changes. In this context, elderly patients often are frail, which strongly correlates with negative health outcomes and disability. Elderly patients are often malnourished, which again is an independent risk factor for both frailty and adverse clinical outcomes. Malnutrition and resulting frailty can be prevented by adequate nutritional interventions. Yet, use of nutritional therapy can also have negative consequences, including a potentially life-threatening metabolic alteration called refeeding syndrome (RFS) in high-risk patients. RFS is characterized by severe electrolyte shifts (mainly hypophosphatemia, hypomagnesemia and hypokalemia), vitamin deficiency (mainly thiamine), fluid overload and salt retention leading to organ dysfunction and cardiac arrhythmias. Although the awareness of malnutrition among elderly people is well established, the risk of RFS is often neglected, especially in the frail elderly population. This partly relates to the unspecific clinical presentation and laboratory changes in the geriatric population. The aim of this review is to summarize recently published recommendations for the management of RFS based on current evidence from clinical studies adapted with a focus on elderly patients.
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Affiliation(s)
- Emilie Aubry
- Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland,
| | - Natalie Friedli
- Medical University Department, Clinic for Endocrinology, Diabetes, Metabolism and Clinical Nutrition, Kantonsspital Aarau, and Medical Faculty of the University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology, Diabetes, Metabolism and Clinical Nutrition, Kantonsspital Aarau, and Medical Faculty of the University of Basel, Basel, Switzerland
| | - Zeno Stanga
- Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland,
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Brown TA, Cusack A, Anderson LK, Trim J, Nakamura T, Trunko ME, Kaye WH. Efficacy of a partial hospital programme for adults with eating disorders. EUROPEAN EATING DISORDERS REVIEW 2018. [DOI: 10.1002/erv.2589] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tiffany A. Brown
- Department of Psychiatry; University of California San Diego; San Diego CA USA
| | - Anne Cusack
- Department of Psychiatry; University of California San Diego; San Diego CA USA
| | - Leslie K. Anderson
- Department of Psychiatry; University of California San Diego; San Diego CA USA
| | - Julie Trim
- Department of Psychiatry; University of California San Diego; San Diego CA USA
| | - Tiffany Nakamura
- Department of Psychiatry; University of California San Diego; San Diego CA USA
| | - Mary Ellen Trunko
- Department of Psychiatry; University of California San Diego; San Diego CA USA
| | - Walter H. Kaye
- Department of Psychiatry; University of California San Diego; San Diego CA USA
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Abstract
SummaryThe MARSIPAN (MAnagement of Really SIck Patients with Anorexia Nervosa) project was established in response to reports of patients admitted to medical wards and proving refractory to treatment, sometimes dying on the ward. Psychiatrists, physicians and other clinicians in nutrition and eating disorders were brought together to discuss key issues in the assessment and management of such patients. The resulting guidance report, which applies to adult patients over 18, addresses: assessment of risk, where to treat the patient, specialist support for medical teams, key elements of treatment, namely (a) safe refeeding to avoid refeeding syndrome and underfeeding syndrome, (b) management of problematic behaviours, (c) support for the family, and (d) transfer to a specialist eating disorder unit when appropriate and possible.
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Kawamura H, Tanaka S, Uenami Y, Tani M, Ishitani M, Morii S, Sakaue M, Ito M. Hypophosphatemia occurs with insulin administration during refeeding by total parenteral nutrition in rats. THE JOURNAL OF MEDICAL INVESTIGATION 2018; 65:50-55. [DOI: 10.2152/jmi.65.50] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Sarasa Tanaka
- School of Human Science and Environment, University of Hyogo
| | - Yuri Uenami
- School of Human Science and Environment, University of Hyogo
| | - Mariko Tani
- Graduate school of Human Science and Environment
| | | | - Saeko Morii
- School of Human Science and Environment, University of Hyogo
| | | | - Mikiko Ito
- Graduate school of Human Science and Environment
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Jennings KM, Gregas M, Wolfe B. Trajectories of Change in Body Weight During Inpatient Treatment for Anorexia Nervosa. J Am Psychiatr Nurses Assoc 2018; 24:306-313. [PMID: 28817991 PMCID: PMC5794613 DOI: 10.1177/1078390317726142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Identifying distinct trajectories of change in body weight during inpatient treatment for anorexia nervosa (AN) may provide knowledge about the process of weight restoration and may help detect optimal body weight response patterns among individuals who are at risk for not achieving weight restoration or leaving treatment prematurely. OBJECTIVE This study explored the extent to which distinct trajectories of change in body weight existed among individuals during inpatient treatment for AN. DESIGN Group-based trajectory modeling was used to identify distinct trajectories of change in body weight among 500 individuals receiving inpatient treatment for AN. RESULTS Four distinct trajectories were identified: weight gain ( n = 197), treatment resistant ( n = 177), weight plateau ( n = 82), and weight fluctuate ( n = 44). CONCLUSION Clinically, it is important to consider the heterogeneity of changes in body weight during inpatient treatment to help guide interventions and outcomes.
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Affiliation(s)
- Karen M Jennings
- 1 Karen M. Jennings, PhD, RN, PMHNP-BC, University of Chicago, Chicago, IL, USA
| | - Matthew Gregas
- 2 Matthew Gregas, PhD, Boston College, Chestnut Hill, MA, USA
| | - Barbara Wolfe
- 3 Barbara Wolfe, PhD, RN, FAAN, University of Rhode Island, Kingston, RI, USA
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Rylander M, Brinton JT, Sabel AL, Mehler PS, Gaudiani JL. A comparison of the metabolic complications and hospital course of severe anorexia nervosa by binge-purge and restricting subtypes. Eat Disord 2017; 25:345-357. [PMID: 28060579 DOI: 10.1080/10640266.2016.1269555] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study examines adult patients with severe, life-threatening anorexia nervosa who were admitted to an inpatient, medical stabilization unit between October 1, 2008 and December 31, 2014. Specifically, the study compares anorexia nervosa, binge purge subtype (AN-BP) and anorexia nervosa, restricting subtype (AN-R) on admission measures, hospital course, and outcomes. Of the 232 patients, 46% (N = 108) had AN-BP. Patients with AN-R manifested a higher frequency of underweight-mediated medical complications, including bone marrow dysfunction, hepatic dysfunction, and hypoglycemia. Understanding the pathophysiologic differences between severe AN-R and AN-BP is essential to understanding the abnormalities seen on clinical presentation, guiding appropriate clinical treatment, and predicting medical complications during refeeding.
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Affiliation(s)
- Melanie Rylander
- a Department of Medicine , University of Colorado , Denver , Colorado , USA.,b ACUTE Center for Eating Disorders at Denver Health , Denver , Colorado , USA.,c Department of Psychiatry , University of Colorado , Denver , Colorado , USA
| | - John T Brinton
- d Department of Biostatistics and Informatics, Colorado School of Public Health , University of Colorado , Denver , Colorado , USA
| | - Allison L Sabel
- d Department of Biostatistics and Informatics, Colorado School of Public Health , University of Colorado , Denver , Colorado , USA.,e Department of Patient Safety and Quality , Denver Health , Denver , Colorado , USA
| | - Philip S Mehler
- a Department of Medicine , University of Colorado , Denver , Colorado , USA.,b ACUTE Center for Eating Disorders at Denver Health , Denver , Colorado , USA.,f Eating Recovery Center , Denver , Colorado , USA
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33
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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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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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35
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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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36
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Kells M, Kelly-Weeder S. Nasogastric Tube Feeding for Individuals With Anorexia Nervosa: An Integrative Review. J Am Psychiatr Nurses Assoc 2016; 22:449-468. [PMID: 27519612 DOI: 10.1177/1078390316657872] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of nasogastric (NG) feeding in individuals with anorexia nervosa (AN) is endorsed by national professional organizations; however, no guidelines currently exist. OBJECTIVES The objectives of this review were to identify and evaluate outcomes of NG feedings for individuals with AN and to develop recommendations for future research, policy, and practice. DESIGN An integrative review of the research literature was conducted. RESULTS Of the 19 studies reviewed, all indicated short-term weight gain following NG feeding. Four studies examined adherence; nearly 30% of subjects were nonadherent as evidenced by tube manipulation. Seven studies reported psychiatric outcomes, suggesting NG feeding reduces eating disorder behaviors but not overall symptomology. CONCLUSIONS NG feeding promotes short-term weight gain; however, long-term outcomes are poorly understood. Future research, using rigorous methods, is still needed to inform practice.
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Affiliation(s)
- Meredith Kells
- Meredith Kells, MSN, RN, CPNP, Boston College, Chestnut Hill, MA, USA; Boston Children's Hospital, Boston MA, USA
| | - Susan Kelly-Weeder
- Susan Kelly-Weeder, PhD, FNP-BC, FAANP, Boston College, Chestnut Hill, MA, USA
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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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Imaeda M, Tanaka S, Fujishiro H, Kato S, Ishigami M, Kawano N, Katayama H, Kohmura K, Ando M, Nishioka K, Ozaki N. Risk factors for elevated liver enzymes during refeeding of severely malnourished patients with eating disorders: a retrospective cohort study. J Eat Disord 2016; 4:37. [PMID: 27980772 PMCID: PMC5142434 DOI: 10.1186/s40337-016-0127-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/04/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There are few previous reports regarding the cause and evolution of liver injury in patients with anorexia nervosa (AN) during the refeeding process, and its management remains controversial. This study aimed to determine the risk factors for elevated liver enzymes during refeeding and their effect on the therapeutic process in severely malnourished patients with eating disorders. METHODS In a retrospective cohort study of 167 female inpatients in a single hospital from January 2004 to March 2015, 67 who had normal alanine aminotransferase (ALT) levels on admission were divided into two groups according to the presence or absence of elevated ALT levels during refeeding, and then compared. RESULTS The median age and body mass index (BMI) of the patients on admission were 22 [interquartile range (IQR), 16-33] years and 12.2 (IQR, 11.1-13.0) kg/m2, respectively. Compared with their cohorts, significantly more patients in the early onset age group (<15 years old) had elevated ALT levels during refeeding (67% vs. 33%, p = 0.033), as did patients with longer median time to nadir BMI (3.0 vs. 0 days, p = 0.03). In addition, onset age [odds ratio (OR): 0.274; 95% confidence interval (CI): 0.077-0.981; p = 0.047] and time to nadir BMI (OR: 1.271; 95% CI: 1.035-1.56; p = 0.022) were significantly associated with the odds of elevated ALT levels during refeeding. CONCLUSIONS The results of this study suggest that early age at onset may be a potential risk factor for elevated ALT levels during refeeding in severely malnourished patients with eating disorders. Furthermore, elevated ALT levels during refeeding were significantly associated with delay in the start of weight gain. No significant relationship was found between the amount of initial prescribed calories and elevated ALT levels during refeeding. The median time to maximum ALT was 27 (IQR, 21-38) days after the refeeding process started.
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Affiliation(s)
- Miho Imaeda
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan ; Sakura Clinic, 5-6 Dankeidori, Showa, Nagoya, Aichi 466-0842 Japan
| | - Satoshi Tanaka
- Department of Psychiatry, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan
| | - Hiroshige Fujishiro
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan
| | - Saki Kato
- Saku Central Hospital, 197 Usuda, Saku, Nagano 384-0301 Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan
| | - Naoko Kawano
- Institute of Innovation for Future Society, Nagoya University, Furocho, Chikusa, Nagoya, Aichi 464-8601 Japan
| | - Hiroto Katayama
- Department of Neuropsychiatry, Faculty of Medical Sciences, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji, Yoshida, Fukui 910-1104 Japan
| | - Kunihiro Kohmura
- Seichiryo Hospital, 16-27 Tsurumai 4, Showa, Nagoya, Aichi 466-0064 Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan
| | - Kazuo Nishioka
- National Hospital Organization Higashi Owari National Hospital, 1301 Omorikita 2, Moriyama, Nagoya, Aichi 463-0802 Japan
| | - Norio Ozaki
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan
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39
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Mayr M, Imgart H, Skala K, Karwautz A. [Quality management in weight restitution in Anorexia nervosa--pathophysiology, evidence-based practice and prevention of the refeeding syndrome]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2015; 29:200-211. [PMID: 26596577 DOI: 10.1007/s40211-015-0165-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/16/2015] [Indexed: 06/05/2023]
Abstract
During refeeding syndrome-a well-known and dreaded complication of weight-restauration in anorexia nervosa-a shift of electrolytes and fluid can occur in malnourished patients and might therefore lead to-potentially fatal-cardiovascular, respiratory and neurological symptoms. Causes of this are metabolic and hormonal changes during re-establishment of a carbohydrate-rich diet. This syndrome is most commonly associated with hypophosphatemia, which can however be accompanied by other chemical laboratory abnormalities. Standardized guidelines for the prevention and management of the refeeding syndrome have not yet been established. In case and cohort studies different low- and high-calorie diet protocols led to comparable results with similar complication rates. A focus should be placed on prevention of serious complications by careful monitoring. The pathophysiology, the main constituents in the development of the refeeding syndrome, recommendations for risk assessment and treatment, and current evidence are discussed.
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Affiliation(s)
- Michael Mayr
- Eating Disorders Unit, Universitätsklinik für Kinder- und Jugendpsychiatrie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Hartmut Imgart
- Kompetenzzentrum für Essstörungen und Adipositas, Parklandklinik, Bad Wildungen, Deutschland.
| | - Katrin Skala
- Eating Disorders Unit, Universitätsklinik für Kinder- und Jugendpsychiatrie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Andreas Karwautz
- Eating Disorders Unit, Universitätsklinik für Kinder- und Jugendpsychiatrie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, Verdi AM, Pletch A, Guarda AS. Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines. Int J Eat Disord 2015; 48:866-73. [PMID: 25625572 DOI: 10.1002/eat.22390] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 12/16/2014] [Accepted: 01/02/2015] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Cohort study from February 2003 through May 2011 to determine weight restoration and refeeding complication outcomes for patients with anorexia nervosa (AN) treated in an integrated inpatient-partial hospital eating disorder program designed to produce rapid weight gain and weight restoration in the majority. METHOD Consecutive admissions (females and males, adolescents and adults; N = 361 patients, 461 admissions) at least 1.8 kg below target weight with AN or subthreshold variants were included. Main outcome measures were rates of hypophosphatemia, transfer to medicine, or death; rates of weight gain and percent achieving weight restoration. RESULTS Hypophosphatemia was present in 7.9% of cases at admission and in 18.5% at some point during treatment. Hypophosphatemia was mild to moderate. Lower admission body mass index (BMI), but not rate of weight gain, predicted hypophosphatemia [OR = 0.65; p < .00001 (95% CI 0.57-0.76)]. Five patients (1.1%) were transferred to medicine or surgery, none because of refeeding. There were no deaths. Mean inpatient weight gain was 1.98 kg/week; mean partial hospital weight gain was 1.36 kg/week. By program discharge, 71.8% of adults reached a BMI of 19, 58.5% a BMI of 20. For adolescents, 80.4% came within 2 kg of their target weight; 76.1% came within 1 kg. DISCUSSION Refeeding patients with AN using a hospital-based, behavioral protocol may be accomplished safely and more rapidly than generally recognized, weight restoring most patients by discharge. Helpful elements may include the program's integrated, step-down structure; multidisciplinary team approach emphasizing group therapy to effect behavior change; and close medical monitoring for those with BMI < 15.
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Affiliation(s)
- Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lindsay M Martin
- Department of Psychology, Drexel University, Philadelphia, Pennsylvania
| | - Anne K Leonpacher
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Margaret Seide
- Department of Psychiatry, Staten Island University Hospital, New York
| | - Antonia M Verdi
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allisyn Pletch
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Vootla VR, Daniel M. Abnormal Liver Function Tests in an Anorexia Nervosa Patient and an Atypical Manifestation of Refeeding Syndrome. Case Rep Gastroenterol 2015; 9:261-5. [PMID: 26351414 PMCID: PMC4560322 DOI: 10.1159/000437321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Refeeding syndrome is defined as electrolyte and fluid abnormalities that occur in significantly malnourished patients when they are refed orally, enterally, or parenterally. The principal manifestations include hypophosphatemia, hypokalemia, vitamin deficiencies, volume overload and edema. This can affect multiple organ systems, such as the cardiovascular, pulmonary, or neurological systems, secondary to the above-mentioned abnormalities. Rarely, patients may develop gastrointestinal symptoms and show abnormal liver function test results. We report the case of a 52-year-old woman with anorexia nervosa who developed refeeding syndrome and simultaneous elevations of liver function test results, which normalized upon the resolution of the refeeding syndrome.
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Affiliation(s)
- Vamshidhar R Vootla
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, N.Y., USA
| | - Myrta Daniel
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, N.Y., USA
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Oxlade O, Huang CC, Murray M. Estimating the Impact of Reducing Under-Nutrition on the Tuberculosis Epidemic in the Central Eastern States of India: A Dynamic Modeling Study. PLoS One 2015; 10:e0128187. [PMID: 26046649 PMCID: PMC4457886 DOI: 10.1371/journal.pone.0128187] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 04/23/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) and under-nutrition are widespread in many low and middle-income countries. Momentum to prioritize under-nutrition has been growing at an international level, as demonstrated by the "Scaling Up Nutrition" movement. Low body mass index is an important risk factor for developing TB disease. The objective of this study was to project future trends in TB related outcomes under different scenarios for reducing under-nutrition in the adult population in the Central Eastern states of India. METHODS A compartmental TB transmission model stratified by body mass index was parameterized using national and regional data from India. We compared TB related mortality and incidence under several scenarios that represented a range of policies and programs designed to reduce the prevalence of under-nutrition, based on the experience and observed trends in similar countries. RESULTS The modeled nutrition intervention scenarios brought about reductions in TB incidence and TB related mortality in the Central Eastern Indian states ranging from 43% to 71% and 40% to 68% respectively, relative to the scenario of no nutritional intervention. Modest reductions in under-nutrition averted 4.8 (95% UR 0.5, 17.1) million TB cases and 1.6 (95% UR 0.5, 5.2) million TB related deaths over a period of 20 years of intervention, relative to the scenario of no nutritional intervention. Complete elimination of under-nutrition in the Central Eastern states averted 9.4 (95% UR 1.5, 30.6) million TB cases and 3.2 (95% UR 0.7-, 10.1) million TB related deaths, relative to the scenario of no nutritional intervention. CONCLUSION Our study suggests that intervening on under-nutrition could have a substantial impact on TB incidence and mortality in areas with high prevalence of under-nutrition, even if only small gains in under-nutrition can be achieved. Focusing on under-nutrition may be an effective way to reduce both rates of TB and other diseases associated with under-nutrition.
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Affiliation(s)
- Olivia Oxlade
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Chuan-Chin Huang
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Megan Murray
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Infectious Disease Unit, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, Touyz S, Ward W. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry 2014; 48:977-1008. [PMID: 25351912 DOI: 10.1177/0004867414555814] [Citation(s) in RCA: 329] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014. METHODS The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified. RESULTS In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice. CONCLUSIONS Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management. EXPERT REVIEWERS Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.
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Affiliation(s)
- Phillipa Hay
- Members of the CPG Working Group School of Medicine and Centre for Health Research, University of Western Sydney, Australia School of Medicine, James Cook University, Townsville, Australia
| | - David Chinn
- Members of the CPG Working Group Capital and Coast District Health Board, Wellington, New Zealand
| | - David Forbes
- Members of the CPG Working Group School of Pediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Sloane Madden
- Members of the CPG Working Group Eating Disorders Service, Sydney Children's Hospital Network, Westmead, Australia; School of Psychiatry, University of Sydney, Australia
| | - Richard Newton
- Members of the CPG Working Group Mental Health CSU, Austin Health, Australia; University of Melbourne, Australia
| | - Lois Sugenor
- Members of the CPG Working Group Department of Psychological Medicine, University of Otago at Christchurch, New Zealand
| | - Stephen Touyz
- Members of the CPG Working Group School of Psychology and Centre for Eating and Dieting Disorders, University of Sydney, Australia
| | - Warren Ward
- Members of the CPG Working Group Eating Disorders Service Royal Brisbane and Women's Hospital; University of Queensland, Brisbane, Australia
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Nakamura M, Yasunaga H, Shimada T, Horiguchi H, Matsuda S, Fushimi K. Body mass index and in-hospital mortality in anorexia nervosa: data from the Japanese Diagnosis Procedure Combination database. Eat Weight Disord 2013; 18:437-9. [PMID: 23929026 DOI: 10.1007/s40519-013-0051-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 07/18/2013] [Indexed: 11/25/2022] Open
Abstract
One of the main purposes of admission for anorexia nervosa is to manage acute medical conditions related to this condition. Factors associated with in-hospital mortality in anorexia nervosa remain unclear. This study describes the clinical features of anorexia nervosa patients requiring hospitalization in Japan. We analyzed the association between in-hospital mortality and body mass index upon admission using a currently available, nationwide hospital-based database. We identified 669 eligible patients with anorexia nervosa (BMI ≤ 16.5) from 229 hospitals between July and December, 2010. More than 90 % of the patients were female and 100 patients were admitted involuntarily. The average body mass index was 13.1, and the in-hospital mortality rate was 0.7 %. Five patients who died had a BMI under 11, indicating that patients with an extremely low BMI may be likely to die, despite admission.
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Affiliation(s)
- Mitsuhiro Nakamura
- Department of Psychiatry, Yokohama Camellia Hospital, 920 Shiranecyo, Asahiku, Yokohama, Kanagawa, 241-0003, Japan,
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Marzola E, Nasser JA, Hashim SA, Shih PAB, Kaye WH. Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment. BMC Psychiatry 2013; 13:290. [PMID: 24200367 PMCID: PMC3829207 DOI: 10.1186/1471-244x-13-290] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/08/2013] [Indexed: 02/08/2023] Open
Abstract
Restoration of weight and nutritional status are key elements in the treatment of anorexia nervosa (AN). This review aims to describe issues related to the caloric requirements needed to gain and maintain weight for short and long-term recovery for AN inpatients and outpatients.We reviewed the literature in PubMed pertaining to nutritional restoration in AN between 1960-2012. Based on this search, several themes emerged: 1. AN eating behavior; 2. Weight restoration in AN; 3. Role of exercise and metabolism in resistance to weight gain; 3. Medical consequences of weight restoration; 4. Rate of weight gain; 5. Weight maintenance; and 6. Nutrient intake.A fair amount is known about overall caloric requirements for weight restoration and maintenance for AN. For example, starting at 30-40 kilocalories per kilogram per day (kcal/kg/day) with increases up to 70-100 kcal/kg/day can achieve a weight gain of 1-1.5 kg/week for inpatients. However, little is known about the effects of nutritional deficits on weight gain, or how to meet nutrient requirements for restoration of nutritional status.This review seeks to draw attention to the need for the development of a foundation of basic nutritional knowledge about AN so that future treatment can be evidenced-based.
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Affiliation(s)
- Enrica Marzola
- Department of Neuroscience, Section of Psychiatry, University of Turin, Turin, Italy
| | - Jennifer A Nasser
- Department of Nutrition Sciences, Drexel University, 19102 Philadelphia, PA, USA
| | - Sami A Hashim
- Department of Medicine, St. Luke's/Roosevelt Hospital Center, 10025 New York, NY, USA
| | - Pei-an Betty Shih
- UCSD Department of Psychiatry, University of California, San Diego, 8950 Villa La Jolla Drive, Suite C – 207 La Jolla, 92037 San Diego, CA, USA
| | - Walter H Kaye
- UCSD Department of Psychiatry, University of California, San Diego, 8950 Villa La Jolla Drive, Suite C – 207 La Jolla, 92037 San Diego, CA, USA
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Gentile MG, Lessa C, Cattaneo M. Metabolic and nutritional needs to normalize body mass index by doubling the admission body weight in severe anorexia nervosa. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2013; 6:51-6. [PMID: 23645991 PMCID: PMC3623609 DOI: 10.4137/ccrep.s11471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anorexia nervosa exhibits one of the highest death rates among psychiatric patients and a relevant fraction of it is derived from undernutrition. Nutritional and medical treatment of extreme undernutrition present two very complex and conflicting tasks: (1) to avoid "refeeding syndrome" caused by a too fast correction of malnutrition; and (2) to avoid "underfeeding" caused by a too cautious refeeding. To obtain optimal treatment results, the caloric intake should be planned starting with indirect calorimetry measurements and electrolyte abnormalities accurately controlled and treated. This article reports the case of an anorexia nervosa young female affected by extreme undernutrition (BMI 9.6 kg/m(2)) who doubled her admission body weight (from 22.5 kg to 44 kg) in a reasonable time with the use of enteral tube feeding for gradual correction of undernutrition. Refeeding syndrome was avoided through a specialized and flexible program according to clinical, laboratory, and physiological findings.
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Affiliation(s)
| | - Chiara Lessa
- Eating Disorders Unit, Niguarda Hospital, Milan Italy
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Hanachi M, Melchior JC, Crenn P. Hypertransaminasemia in severely malnourished adult anorexia nervosa patients: risk factors and evolution under enteral nutrition. Clin Nutr 2012; 32:391-5. [PMID: 22986227 DOI: 10.1016/j.clnu.2012.08.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/14/2012] [Accepted: 08/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND & AIMS Aminotransferase abnormalities have been reported in malnourished patients with anorexia nervosa (AN). The aim of this study was to identify prevalence and risk factors of hyperaminotransferasemia in an adult cohort of AN patients and to describe evolution during nutritional rehabilitation with enteral nutrition for a period of 4 weeks. METHODS Retrospective study of all consecutive malnourished (BMI <16) AN adult patients, without previous liver diseases or hepatotoxic drugs or alcohol consumption, hospitalized for enteral nutrition in a single center between 1998 and 2008. Hypertransaminasemia was defined by an increase in AST and (or) ALT >2N. RESULTS In all, 126 AN patients (117 W, 9 M), age 30 ± 10.8 years, were included. At admission, 54 (43%) patients presented hypertransaminasemia. In univariate analysis, risk factors for hypertransaminasemia were: lower BMI (11.2 ± 2 vs. 13 ± 2, p < 0.0001) and age (28 ± 9 vs. 32 ± 12, p < 0.05), male sex (p < 0.05) and the pure restrictive form (p = 0.07). In multivariate analysis only BMI, at a threshold of 12, remained significant [OR 3.7, CI: 95% 2.24-5.2]. Normalization of aminotransferases at the end of week 4 of enteral nutrition was obtained in 96%. Only 2/54 patients (4%) presented a worsening of aminotransferases during the refeeding period, including one that died of liver failure. None of the patients without hypertransaminasemia admission presented a subsequent elevation. At the end of the 4-week refeeding period, the increase in BMI was greater in patients without hypertransaminasemia than in those with it (2.0 ± 0.8 vs. 1.5 ± 1.0, p < 0.0001). CONCLUSION Elevated transaminases is common in severe malnourished AN patients. Four risk factors were identified: young age, low BMI (the only independent factor in multivariate analysis), the pure restrictive form of the disease and male sex. After 4 weeks of enteral nutrition the evolution is in most cases favourable, albeit with a lower increase in BMI, but can be severe. The long-term evolution remains to be determined.
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Affiliation(s)
- Mouna Hanachi
- Université de Versailles Saint-Quentin-en-Yvelines, EA 4497, Faculté de Médecine, PIFO, France
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Bouquegneau A, Dubois BE, Krzesinski JM, Delanaye P. Anorexia nervosa and the kidney. Am J Kidney Dis 2012; 60:299-307. [PMID: 22609034 DOI: 10.1053/j.ajkd.2012.03.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 03/05/2012] [Indexed: 12/17/2022]
Abstract
Anorexia nervosa is a common psychiatric disorder that disproportionately affects adolescents and young adults and is associated with high rates of morbidity and mortality. Anorexia nervosa can affect the kidney in numerous ways, including increased rates of acute kidney injury and chronic kidney disease, electrolyte abnormalities, and nephrolithiasis. Additionally, the diagnosis and treatment of anorexia nervosa-associated kidney diseases are challenging, reflecting complications such as refeeding syndrome, as well as the limitations of serum creatinine level in this population to estimate kidney function and the psychosocial challenges inherent with treating systemic manifestations of psychiatric conditions. In this review, we discuss kidney diseases and kidney-associated conditions that occur in individuals with anorexia nervosa, summarizing many of the challenges in treating patients with this disease.
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Affiliation(s)
- Antoine Bouquegneau
- Department of Nephrology, Dialysis, Transplantation, University of Liège, CHU Sart Tilman, 4000 Liège, Belgium
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Dubois F, Sudre E, Porte A, Bédry R, Gromb S. Évolution et surveillance des patients grévistes de la faim : expérience d’une unité hospitalière sécurisée interrégionale. Rev Med Interne 2011; 32:669-77. [DOI: 10.1016/j.revmed.2011.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 05/01/2011] [Accepted: 05/17/2011] [Indexed: 10/18/2022]
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Resting Energy Expenditure in Anorexia Nervosa: Measured versus Estimated. J Nutr Metab 2011; 2012:652932. [PMID: 21941638 PMCID: PMC3175729 DOI: 10.1155/2012/652932] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 04/07/2011] [Accepted: 07/20/2011] [Indexed: 11/18/2022] Open
Abstract
Introduction. Aim of this study was to compare the resting energy expenditure (REE) measured by the Douglas bag method with the REE estimated with the FitMate method, the Harris-Benedict equation, and the Müller et al. equation for individuals with BMI < 18.5 kg/m(2) in a severe group of underweight patients with anorexia nervosa (AN). Methods. 15 subjects with AN participated in the study. The Douglas bag method and the FitMate method were used to measure REE and the dual energy X-ray absorptiometry to assess body composition after one day of refeeding. Results. FitMate method and the Müller et al. equation gave an accurate REE estimation, while the Harris-Benedict equation overestimated the REE when compared with the Douglas bag method. Conclusion. The data support the use of the FitMate method and the Müller et al. equation, but not the Harris-Benedict equation, to estimate REE in AN patients after short-term refeeding.
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