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A growing consensus for revamping anorexia nervosa treatment

For decades the standard of care for anorexia nervosa has been to increase the undernourished patient’s caloric intake with caution, for fear that too sudden an increase would throw the body’s electrolytes out of balance, making a bad situation worse.

That cautious approach, which has been previously been discussed here, stemmed from experiences with malnourished survivors of World War II, when doctors observed that some patients responded to a sudden increase in food consumption by developing severe liver or heart problems, sometimes resulting in death.

Doctors discovered that the main cause of the counterintuitive response was a sudden crash in the levels of certain electrolytes, in particular phosphorus, that was triggered by the abruptly increased amount of food they consumed. The phenomenon became known as “refeeding syndrome” and gave rise to the guiding dictum of “start low and go slow” when it came to increasing a patient’s caloric intake.

That concern is not without validity, but a growing number of researchers are beginning to question just how cautious doctors need to be about the rate at which they feed an anorexic patient.

I talked with Neville Golden, MD, chief of adolescent medicine and a Lucile Packard Children’s Hospital pediatrician, about that question. In the November issue of the Journal of Adolescent Health, Golden and some colleagues report on a retrospective study of the caloric intake of anorexic adolescents hospitalized at Packard.

The prevailing recommendation for beginning refeeding has long been to not exceed 1400 calories a day, but Golden’s team compared the records of patients who received care under that guideline with those that were given between 1,400 and 2,000 calories daily.

The upshot: The patients who received the greater number of calories gained weight more quickly and spent less time in the hospital.

“The development of refeeding syndrome really depends on the degree of malnutrition, not the amount of calories you give them,” Golden told me.

In addition to Golden’s study, three others published in the same issue lend support to the idea that most anorexia patients can benefit from more than 1,400 calories a day. An accompanying editorial suggests that it may be time to alter the old dictum to “start high(er), advance fast(er)”.

The editorial, by Daniel Le Grange, PhD of the University of Chicago, cautions that more rapid discharge from the hospital will increase the importance of proper aftercare, or the gains from faster refeeding could be negated.

Previously: Higher caloric diets are safe and reduce length of stay in hospitalized teens with anorexiaExamining 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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