Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome

Refeeding syndrome very rarely develops during pregnancy. A 35-year-old primiparous woman pregnant with twins complained of severe fatigue at 19 weeks’ gestation. She was admitted to our hospital in a malnourished condition because of repeated self-induced vomiting due to anorexia nervosa. Just after hospitalization, she voluntarily increased her caloric intake significantly above the recommended prescribed diet, without medical permission. Nine days later, she developed refeeding syndrome. Electrolyte replacement and calorie restriction were started and her condition gradually improved. The healthy twin babies were born by cesarean section at 36 weeks’ gestation. Acute increases in caloric intake by previously malnourished pregnant women with anorexia nervosa may induce refeeding syndrome. Women with the binge eating/purging subtype of anorexia nervosa may be at additional risk due to alternating phases of starvation and overeating.

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

Nutrients ◽

10.3390/nu13113819 ◽

2021 ◽

Vol 13 (11) ◽

pp. 3819

Author(s):

Katarzyna Jowik ◽

Marta Tyszkiewicz-Nwafor ◽

Agnieszka Słopień

Keyword(s):

Anorexia Nervosa ◽

Healing Process ◽

Caloric Intake ◽

Current Treatment ◽

Review Of Literature ◽

Nutritional Rehabilitation ◽

Long Term Effects ◽

Refeeding Syndrome ◽

The Past ◽

Potential Benefits

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.

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To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Nutrients ◽

10.3390/nu14010229 ◽

2022 ◽

Vol 14 (1) ◽

pp. 229

Author(s):

Stephanie Proulx-Cabana ◽

Marie-Elaine Metras ◽

Danielle Taddeo ◽

Olivier Jamoulle ◽

Jean-Yves Frappier ◽

...

Keyword(s):

Anorexia Nervosa ◽

Caloric Intake ◽

Tube Feeding ◽

Narrative Review ◽

Cardiac Monitoring ◽

Current Evidence ◽

Cardiac Complications ◽

Nutritional Rehabilitation ◽

Refeeding Syndrome ◽

Pubmed Search

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

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Metabolic and Nutritional Needs to Normalize Body Mass Index by Doubling the Admission Body Weight in Severe Anorexia Nervosa

Clinical Medicine Insights Case Reports ◽

10.4137/ccrep.s11471 ◽

2013 ◽

Vol 6 ◽

pp. CCRep.S11471 ◽

Cited By ~ 4

Author(s):

Maria Gabriella Gentile ◽

Chiara Lessa ◽

Marina Cattaneo

Keyword(s):

Body Weight ◽

Anorexia Nervosa ◽

Clinical Laboratory ◽

Psychiatric Patients ◽

Caloric Intake ◽

Tube Feeding ◽

Young Female ◽

Refeeding Syndrome ◽

Nutritional Needs ◽

Electrolyte Abnormalities

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/m2) 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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Avoiding Refeeding Syndrome in Anorexia Nervosa

10.26226/morressier.588f064ed462b8028d891148 ◽

2017 ◽

Author(s):

Diana Brigadeiro

Keyword(s):

Anorexia Nervosa ◽

Refeeding Syndrome

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Higher Caloric Refeeding Is Safe in Hospitalised Adolescent Patients with Restrictive Eating Disorders

Journal of Nutrition and Metabolism ◽

10.1155/2016/5168978 ◽

2016 ◽

Vol 2016 ◽

pp. 1-9 ◽

Cited By ~ 12

Author(s):

Elizabeth K. Parker ◽

Sahrish S. Faruquie ◽

Gail Anderson ◽

Linette Gomes ◽

Andrew Kennedy ◽

...

Keyword(s):

Eating Disorders ◽

Weight Gain ◽

Statistical Significance ◽

Caloric Intake ◽

Tube Feeding ◽

Retrospective Chart Review ◽

Refeeding Syndrome ◽

Restrictive Eating ◽

Weight Restoration ◽

The Mean

Introduction. This study examines weight gain and assesses complications associated with refeeding hospitalised adolescents with restrictive eating disorders (EDs) prescribed initial calories above current recommendations.Methods. Patients admitted to an adolescent ED structured “rapid refeeding” program for >48 hours and receiving ≥2400 kcal/day were included in a 3-year retrospective chart review.Results. The mean (SD) age of the 162 adolescents was 16.7 years (0.9), admission % median BMI was 80.1% (10.2), and discharge % median BMI was 93.1% (7.0). The mean (SD) starting caloric intake was 2611.7 kcal/day (261.5) equating to 58.4 kcal/kg (10.2). Most patients (92.6%) were treated with nasogastric tube feeding. The mean (SD) length of stay was 3.6 weeks (1.9), and average weekly weight gain was 2.1 kg (0.8). No patients developed cardiac signs of RFS or delirium; complications included 4% peripheral oedema, 1% hypophosphatemia (<0.75 mmol/L), 7% hypomagnesaemia (<0.70 mmol/L), and 2% hypokalaemia (<3.2 mmol/L). Caloric prescription on admission was associated with developing oedema (95% CI 1.001 to 1.047;p=0.039). No statistical significance was found between electrolytes and calories provided during refeeding.Conclusion. A rapid refeeding protocol with the inclusion of phosphate supplementation can safely achieve rapid weight restoration without increased complications associated with refeeding syndrome.

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OP004 MYOCARDIAL DYSFUNCTION ASSOCIATED WITH REFEEDING SYNDROME (RS) IN SEVERELY MALNOURISHED ANOREXIA NERVOSA (AN) PATIENTS

Clinical Nutrition Supplements ◽

10.1016/s1744-1161(11)70005-9 ◽

2011 ◽

Vol 6 (1) ◽

pp. 2

Author(s):

M.G. Hanachi-Guidoum ◽

A. Kimmoun ◽

A. Fayssoil ◽

M. Antona ◽

J.C. Melchior ◽

...

Keyword(s):

Anorexia Nervosa ◽

Myocardial Dysfunction ◽

Refeeding Syndrome

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Caloric intake necessary for weight maintenance in anorexia nervosa: nonbulimics require greater caloric intake than bulimics

American Journal of Clinical Nutrition ◽

10.1093/ajcn/44.4.435 ◽

1986 ◽

Vol 44 (4) ◽

pp. 435-443 ◽

Cited By ~ 38

Author(s):

W H Kaye ◽

H E Gwirtsman ◽

E Obarzanek ◽

T George ◽

D C Jimerson ◽

...

Keyword(s):

Anorexia Nervosa ◽

Weight Maintenance ◽

Caloric Intake

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Unexpected Association of Desacyl-Ghrelin with Physical Activity and Chronic Food Restriction: A Translational Study on Anorexia Nervosa

Journal of Clinical Medicine ◽

10.3390/jcm9092782 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2782 ◽

Cited By ~ 1

Author(s):

Philibert Duriez ◽

Lauralee Robichon ◽

Roland Dardennes ◽

Guillaume Lavoisy ◽

Dominique Grouselle ◽

...

Keyword(s):

Physical Activity ◽

Anorexia Nervosa ◽

Food Restriction ◽

Plasma Concentrations ◽

Caloric Intake ◽

Positive Association ◽

Recovery Process ◽

Post Discharge ◽

Ad Libitum ◽

Energy Deprivation

Anorexia nervosa (AN) is a severe metabopsychiatric disorder characterised by caloric intake restriction and often excessive physical exercise. Our aim is to assess in female AN patients and in a rodent model, the co-evolution of physical activity and potential dysregulation of acyl—(AG) and desacyl—(DAG) ghrelin plasma concentrations during denutrition and weight recovery. AN inpatients were evaluated at inclusion (T0, n = 29), half—(T1) and total (T2) weight recovery, and one month after discharge (T3, n = 13). C57/Bl6 mice with access to a running wheel, were fed ad libitum or submitted to short—(15 days) or long—(50 days) term quantitative food restriction, followed by refeeding (20 days). In AN patients, AG and DAG rapidly decreased during weight recovery (T0 to T2), AG increased significantly one-month post discharge (T3), but only DAG plasma concentrations at T3 correlated negatively with BMI and positively with physical activity. In mice, AG and DAG both increased during short- and long-term food restriction. After 20 days of ad libitum feeding, DAG was associated to persistence of exercise alteration. The positive association of DAG with physical activity during caloric restriction and after weight recovery questions its role in the adaptation mechanisms to energy deprivation that need to be considered in recovery process in AN.

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