Rapid refeeding in anorexia nervosa: A dialectic balance

Abstract

Objective To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion. Method This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m2 and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant. Results Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol. Discussion This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life. Public Significance This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost‐savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life.

The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study

“…Any occurrences of electrolyte abnormalities in this study were able to be corrected with oral or intravenous replacement without any other changes to patient care or provision of energy. This suggests that even though RFS may be present, the consequences are not substantial enough within the acute hospital setting to require a delay to the provision of energy, which enables a more rapid rehabilitation for patients with EDs (Drysdale et al, 2021; Golden et al, 2013; Staab et al, 2022; Whitelaw et al, 2010).…”

“…The incidence of RFS among patients with EDs admitted to acute care facilities for treatment remains uncertain due to various diagnostic criteria used (Dalenbrook et al, 2022; Parker et al, 2016; Staab et al, 2022; Whitelaw et al, 2010). In 2020, the American Society for Enteral and Parenteral Nutrition (ASPEN) defined RFS as “a measurable reduction in levels of one or any combination of phosphorus, potassium, and/or magnesium, or the manifestation of thiamine deficiency, developing shortly (hours to days) after initiation of calorie provision to an individual who has been exposed to a substantial period of undernourishment,” that may manifest in a variety of severities (da Silva et al, 2020).…”

“…In another observational study of 25 patients with AN admitted to an acute hospital, 45% were diagnosed with RFS based on hypophosphatemia, with a mean initial energy provision of 990 (±309) kcal/day (Gaudiani et al, 2012). These findings suggest that during the reintroduction of nutrition, electrolyte derangement may still occur despite energy restriction, therefore making a clear association between energy provision and the development of RFS difficult (Maginot et al, 2017; O'Connor et al, 2016; Staab et al, 2022).…”

“…For malnourished inpatients with EDs, safe weight restoration targets also vary in range from 0.5 to 2 kg per week (Hay et al, 2014; MARSIPAN, 2022; NICE, 2017). The benefits of rapid weight gain during inpatient treatment include faster medical stabilization, greater reduction in ED cognitions, and improved engagement in therapy beyond the inpatient admission (Accurso et al, 2014; Bargiacchi et al, 2019; Parker et al, 2016; Redgrave et al, 2015; Staab et al, 2022; Wales et al, 2016). More rapid weight gain during an inpatient hospital admission has also been demonstrated to reduce the length of stay, reduce readmission rates, and optimize long‐term recovery outcomes for patients with EDs (Garber et al, 2012; Golden et al, 2021; Redgrave et al, 2015; Whitelaw et al, 2010).…”

Vitamin D and Hypophosphatemia in Patients with Anorexia Nervosa and Avoidant/Restrictive Food Intake Disorder: A Case Control Study

“…7 Concerningly, studies have identi ed that protocols aimed at reducing risk through conservative nutrition restoration may be of little utility and lead to poorer weight gain. [8][9][10] Therefore, understanding who is most at risk is crucial to providing proper treatment to patients with AN and ARFID. [11][12][13] One key etiological factor for the development of refeeding syndrome, and a main target of clinical monitoring, is low serum phosphorus level, known as refeeding hypophosphatemia (RH).…”