A review of feeding methods used in the treatment of anorexia nervosa

Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders

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.

Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders

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.

Mapping length of inpatient treatment duration and year-wise relapse rates in eating disordered populations in a well-defined Western-European healthcare region across 1998-2020

OBJECTIVES

Updated international guideline recommendations for AN inpatient care rely on expert opinions/observational evidence and promote extended inpatient stays, warranting investigation using higher-level ecological evidence.

METHODS

The study was conducted according to Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Data encompassing 13,885 ED inpatients (5336 adolescents and 8549 adults) was retrieved from Swedish public health registries. Variables analyzed included (1) ED inpatient care opportunities, (2) unique number of ED inpatients and (3) mean length of ED-related inpatient stays in age groups 15-19 and 20-88+, across 1998-2020.

RESULTS

Mean length of inpatient stays was inversely correlated to relapse to ED-related inpatient care within the same year (p < 0.001, R-squaredadj  = 0.5216 and p < 0.00001, R-squaredadj  = 0.5090, in the 15-19 and 20-88+ age groups, respectively), independent of number of ED inpatients treated within a year in both age groups. Extending mean adolescent inpatient duration from 35 to 45 days was associated with a ∼30% reduction in the year-wise relapse rate.

CONCLUSIONS

Mean length of ED-related inpatient treatment stays was associated with reduced relapses to inpatient care within the same year, which could be interpreted as support for recommendations to include a stabilization phase in inpatient ED treatment.

Advancements in Inpatient Medical Management of Malnutrition in Children and Adolescents with Restrictive Eating Disorders

There is an urgent need to identify best practices for hospital treatment of youth with malnutrition secondary to restrictive eating disorders, including anorexia nervosa (AN) and avoidant/restrictive food intake disorder (ARFID). Certain physical health complications of malnutrition, such as bradycardia, hypotension, and hypothermia, often lead to hospitalization. These acute medical complications improve with refeeding or short-term nutritional rehabilitation and will resolve with ongoing recovery. Historically, refeeding was approached with extreme caution, with lower calorie protocols that advanced slowly and required weeks to restore medical stability.1 –3 Prolonged hospitalizations place eating disorders among the top 6 most common and costly pediatric mental health diagnoses.4 This article reviews the current evidence on refeeding approaches for hospitalized youth with eating disorders. Recent findings suggest that high calorie refeeding (HCR) is a clinically safe method of inpatient management and, more importantly, improves clinical outcomes.

Adding mini meals to a nasogastric refeeding protocol for patients with eating disorders can be achieved on general hospital wards

BACKGROUND

Treatment of medically compromised patients with eating disorders is difficult in general hospital wards. There is currently no consensus on the best feeding method; however, previous research has demonstrated the safety of using enteral feeding. Because an oral diet has benefits on psychological and behavioural pathways, concurrent feeding requires further investigation. The present study aimed to examine acceptability and safety of implementing mini meals to a previously nil-by-mouth 7-day enteral feeding protocol.

METHODS

This was mixed methods research including a retrospective observational study and participant survey. Patients admitted to a tertiary hospital in Brisbane, Australia, between July 2020 and March 2021 were eligible. Eligible participants were provided mini meals from day 5. Type and quantity of meals consumed alongside clinical incident data were collected. The survey examined acceptability of mini meals. Descriptive statistics were used to interpret findings. Content analyses were conducted on survey responses.

RESULTS

Sixty-four participants (95%, n = 57/60 female, 25.2 ± 8.9 years; 75%, n = 45/60 diagnosed with anorexia nervosa) were included. At least half of the participants consumed some or all of the mini meals at each meal period. No clinical incidents were reported. Twenty-six (50%, n = 26/52) surveys were returned. Half (54%, n = 14/26) agreed-strongly agreed that mini meals improved their experience. Eleven participants desired more choice in menu items.

CONCLUSIONS

The present study found that introducing mini meals into an enteral feeding protocol is acceptable and safe for patients with eating disorders. Participants reported benefits in returning to eating; however, some items on the menu require reconsideration to enable increased consumption.

The effect of oral refeeding compared with nasogastric refeeding on the quality of care for patients hospitalised with an eating disorder: A systematic review

AIM

The aim of this systematic review was to compare the benefits and harms of nasogastric and oral-based refeeding on the quality of care, including effectiveness, safety, and patient experience, for patients hospitalised with an eating disorder.

METHODS

A systematic search for studies measuring comparative data between nasogastric and oral refeeding methods was conducted in August 2021. Title and abstracts and remaining full texts were screened by both authors. Risk of bias was evaluated using the PEDro scale, and overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation narrative synthesis.

RESULTS

Seven studies (one randomised controlled trial, five non-randomised studies of interventions, and one qualitative study) with 917 participants were included. There was low certainty evidence that nasogastric refeeding resulted in no difference or a small increase in weekly weight gain, and moderate certainty of greater total weight gain, and very low certainty of increased length of stay compared to oral refeeding. There was no difference or a small increase in discharge weight and body mass index with nasogastric refeeding compared to oral refeeding. No serious adverse events were reported.

CONCLUSION

Patients selected for nasogastric refeeding have a longer duration of illness and lower admission weight, making it difficult to determine which refeeding approach is superior. However, the lack of clear difference in weekly weight gain and the lack of reported harms suggests that other factors such as the normalisation of eating behaviour may be taken into account when choosing the most appropriate refeeding method.

Acceptability of using a nasogastric refeeding protocol with adult patients with medically unstable eating disorders

RATIONALE, AIMS AND OBJECTIVES

Nasogastric feeding is becoming commonly used to support patients with medically compromised eating disorders. Previous research has demonstrated the safety of this approach, however there is limited evidence as to how adult patients and staff perceive this feeding method. This study aimed to describe the acceptability of a nasogastric refeeding protocol with adult patients with medically unstable eating disorders and the staff involved in their treatment.

METHOD

This was a qualitative exploratory study using semi-structured interviews conducted in acute medical wards of a tertiary hospital where nasogastric nutrition is the sole source of nutrition for the first 7 days of the eating disorder admission. Data were analysed using the Framework method.

RESULTS

Eight patients (100% female, median: 22 years old, n = 6 diagnosed with anorexia nervosa) and 12 staff members (medical n = 5, nursing n = 5, dietitians n = 2; median: 8.5 years clinical experience) were interviewed. Patients reported that nasogastric feeding was tolerable, however concerns were raised regarding communication and the desire for concurrent oral feeding. Acceptability from staff was influenced by perceived competence, confidence, tensions around patient-centred care, and working with stigma and ambivalence.

CONCLUSIONS

Consideration needs to be given as to whether a 'nil by mouth' status during nasogastric feeding further impacts recommencing an oral diet to progress treatment. Improvements are required within the current service, including improved communication, additional educational resources for patients, and allowing patients to partake in decision-making as able.

Anorexia Nervosa-What Has Changed in the State of Knowledge about Nutritional Rehabilitation for Patients over the Past 10 Years? A Review of Literature

Anorexia nervosa (AN) is a psycho-metabolic disorder with a high risk of somatic complications such as refeeding syndrome (RFS) and carries the highest mortality rate of all psychiatric illnesses. To date, the consensus on the care for patients with AN has been based on recommendations for a combination of alimentation and psychotherapy. It is important to establish an initial caloric intake that will provide weight gain and minimize the risk of complications in the treatment of undernourished patients. Research over the past few years suggests that current treatment recommendations may be too stringent and should be updated. The aim of this paper is to systematize the current reports on nutritional rehabilitation in AN, to present the results of studies on the safe supplementation of patients and its potential impact on improving prognosis and the healing process. This review of literature, from 2011-2021, describes the changing trend in the nutritional protocols used and the research on their efficacy, safety, and long-term effects. In addition, it presents previous reports on the potential benefits of introducing vitamin, pro-and prebiotic and fatty acid supplementation.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

Treating Eating: A Dynamical Systems Model of Eating Disorders

Mainstream forms of psychiatric talk therapy and cognitive behavioral therapy (CBT) do not reliably generate lasting recovery for eating disorders. We discuss widespread assumptions regarding the nature of eating disorders as fundamentally psychological disorders and highlight the problems that underlie these notions, as well as related practical problems in the implementation of mainstream treatments. We then offer a theoretical and practical alternative: a dynamical systems model of eating disorders in which behavioral interventions are foregrounded as powerful mediators between psychological and physical states. We go on to present empirical evidence for behavioral modification specifically of eating speed in the treatment of eating disorders, and a hypothesis accounting for the etiology and progression, as well as the effective treatment, of the full spectrum of eating problems. A dynamical systems approach mandates that in any dietary and lifestyle change as profound as recovery from an eating disorder, acknowledgment must be made of the full range of pragmatic (psychological, cultural, social, etc.) factors involved. However, normalizing eating speed may be necessary if not sufficient for the development of a reliable treatment for the full spectrum of eating disorders, in its role as a mediator in the complex feedback loops that connect the biology and the psychology with the behaviors of eating.

Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews

Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa.

Development of the "Recovery from Eating Disorders for Life" Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder

BACKGROUND

There is limited evidence to inform nutrition and dietetic interventions for individuals with eating disorders even though it is recommended as an essential part of multidisciplinary management. There is minimal guidance, an absence of standardised nutrition educational material, and no research on how best to educate patients on healthy eating and how to achieve nutrition adequacy. Therefore the REAL Food Guide was developed.

METHODS

The REAL Food Guide is a pyramid with four layers and key nutrition messages beside each layer that was conceived to address gaps in nutrition education and intervention for individuals with eating disorders. Written and verbal consumer feedback was obtained from consumers receiving treatment regarding the acceptability and usefulness of the REAL Food Guide. A unique database was developed to reflect the types of foods and realistic portion sizes that patients are likely to select. This database was used for nutrition modelling to assess the nutrition adequacy of three meal patterns (meat containing, vegetarian and semi-vegan) for both weight maintenance and weight regain. Each meal pattern was compared to the Nutrient Reference Values for Australia and New Zealand.

RESULTS

Nutritional analysis demonstrated nutritional adequacy of meal patterns for energy, macronutrients and most micronutrients when the recommended number of serves from the REAL Food Guide were assessed. All meal patterns were adequate in micronutrients except for the semi-vegan meal pattern that was inadequate in vitamin D. Feedback from individuals with eating disorders demonstrates the nutrition education tool was acceptable to them as they felt it was more helpful for their recovery than general nutrition guidelines.

CONCLUSION

The REAL Food Guide is a comprehensive and user-friendly guide that clinicians can use to educate patients about components of a balanced and healthy diet. The guide can educate all eating disorder clinicians, including those who are new to the field, about the basics of nutrition. Clinicians using the guide can be confident that, if followed, patient's energy and nutritional requirements will be met and important nutrition education messages are reinforced, that are tailored to the beliefs and concerns of individuals with eating disorders.

Homeostasis Meets Motivation in the Battle to Control Food Intake

Signals of energy homeostasis interact closely with neural circuits of motivation to control food intake. An emerging hypothesis is that the transition to maladaptive feeding behavior seen in eating disorders or obesity may arise from dysregulation of these interactions. Focusing on key brain regions involved in the control of food intake (ventral tegmental area, striatum, hypothalamus, and thalamus), we describe how activity of specific cell types embedded within these regions can influence distinct components of motivated feeding behavior. We review how signals of energy homeostasis interact with these regions to influence motivated behavioral output and present evidence that experience-dependent neural adaptations in key feeding circuits may represent cellular correlates of impaired food intake control. Future research into mechanisms that restore the balance of control between signals of homeostasis and motivated feeding behavior may inspire new treatment options for eating disorders and obesity.

Description of an intensive nutrition therapy in hospitalized adolescents with anorexia nervosa

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.

To ingest or rest? Specialized roles of lateral hypothalamic area neurons in coordinating energy balance

Survival depends on an organism’s ability to sense nutrient status and accordingly regulate intake and energy expenditure behaviors. Uncoupling of energy sensing and behavior, however, underlies energy balance disorders such as anorexia or obesity. The hypothalamus regulates energy balance, and in particular the lateral hypothalamic area (LHA) is poised to coordinate peripheral cues of energy status and behaviors that impact weight, such as drinking, locomotor behavior, arousal/sleep and autonomic output. There are several populations of LHA neurons that are defined by their neuropeptide content and contribute to energy balance. LHA neurons that express the neuropeptides melanin-concentrating hormone (MCH) or orexins/hypocretins (OX) are best characterized and these neurons play important roles in regulating ingestion, arousal, locomotor behavior and autonomic function via distinct neuronal circuits. Recently, another population of LHA neurons containing the neuropeptide Neurotensin (Nts) has been implicated in coordinating anorectic stimuli and behavior to regulate hydration and energy balance. Understanding the specific roles of MCH, OX and Nts neurons in harmonizing energy sensing and behavior thus has the potential to inform pharmacological strategies to modify behaviors and treat energy balance disorders.

Who seeks residential treatment? A report of patient characteristics, pathology, and functioning in females at a residential treatment facility

There has been a growth in the availability and use of residential treatment for eating disorders. Yet there is a paucity of information on the individuals who seek this treatment. This study provides data on 259 consecutive patients (116 adults and 143 adolescents) entering residential treatment for their eating disorders. Upon admission all patients provided individual characteristics data and the following measures: the Eating Disorder Inventory-3 (EDI-3), the Beck Depression Inventory-II, the Beck Anxiety Inventory, the Eating Disorder Quality of Life (EDQOL), and the SF-36 Health Survey-Version 2. Findings are presented by diagnosis (anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified) and age (adult and adolescent). Results show that 61% of adolescents and 80% of adults were above the clinical cutoff for depression, and 59% of adolescents and 78% of adults were above the clinical cutoff for anxiety. Scores on the EDI-3 are presented by subscale and diagnosis. Very low quality of life is reported for both adults and adolescents on the EDQOL. For both adolescents and adults the SF-36 showed average population scores for the physical scale but very low mental scores. Implications for these findings and future directions for this work are discussed.