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Study: Higher caloric diets are safe and reduce length of stay in hospitalized teens with anorexia

Patients hospitalized for anorexia nervosa need more than a balanced diet. They require nutrients so their body can halt weight loss and reverse the harmful effects of malnutrition. But once starving patents resumes eating, they can suffer from a deadly imbalance of electrolytes known as refeeding syndrome.

Refeeding syndrome was first described by doctors treating the multitudes of starving and malnourished patients created by World War II. Today, refeeding syndrome is a concern for people with severe anorexia nervosa, and other malnourished patients such as those with kwashiokor, end stage cancer, or inflammatory bowel disease.

When a person is starving, sugar and electrolytes, such as potassium, magnesium, and phosphate, are in short supply. Refeeding causes the few electrolytes the patient has to move from the bloodstream into their body’s cells. This electrolyte imbalance can cause cardiac arrest, pulmonary edema, seizures, coma, and death.

To avoid the risk of refeeding syndrome, doctors often err on the side of caution by prescribing lower-calorie diets for malnourished patients as recommended by international guidelines. But, according to new Stanford research, the fastest road to recovery for teens hospitalized with anorexia nervosa may be to start treatment with higher - not lower - calorie diets. This research is important because it confirms the findings of a recent smaller-scale study, and upends the long-held belief that high-calorie diets are a shock to the system for anorexic patients. 

I recently spoke with lead author Neville Golden, MD, chief of adolescent medicine and a Lucile Packard Children's Hospital pediatrician, to learn the story behind the study that he and his team describe in this month's Journal of Adolescent Health. Golden explained that the causes of refeeding syndrome are not as well understood as its symptoms. A popular perception is that refeeding syndrome is simply the result of feeding a patient too much too fast, but Golden and his team think otherwise.

"We agree that’s its extremely important to monitor for refeeding syndrome and to treat it early. The issue is the predictors of refeeding syndrome are the degree of malnutrition, and not the amount of calories prescribed," he said.

For the study, Golden and his team reviewed the medical records from 310 anorexia nervosa patients between the ages of ten and twenty. Of these patients, 222 were given higher-calorie diets as soon as they were hospitalized for treatment, while 88 patients were given lower-calorie diets as recommended by international guidelines. None of the patients developed refeeding syndrome, and the researchers found no evidence of an association between higher-calorie intake and the syndrome.

"What we [also] found is that by starting patients on a higher amount of calories, their length of stay was shorter, allowing patients to get back home to their families where they can get back into treatment," says Golden.

"For adolescents, family based treatment - where the parents take control of the refeeding - is the most effective kind of treatment. So it makes sense to get the patient home as soon a possible," says Golden. "...Even reducing the length of stay for three days would be a tremendous benefit for patients and would reduce health care costs."

This is significant because according to the Agency for Healthcare and Research Quality, hospitalizations for eating disorders may be on the rise. For the study period of 1999-2000 and 2005-2006, the agency found that the number of hospitalizations related to eating disorders, and anorexia nervosa increased 18 and 17 percent respectively.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Examining the benefits of estrogen therapy for girls with anorexiaEating-disorder hospitalizations declineExploring the connection between food and brain functionHow anorexia is striking what many consider to be an unlikely group: boys and young men and What a teenager wishes her parents knew about eating disorders.

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