Teens With Anorexia May Need Aggressive Feeding Protocol

Findings Challenge Standard 'Start Low, Go Slow' Approach

Joe Barber Jr, PhD

December 19, 2011

December 19, 2011 — More aggressive feeding strategies may be needed for adolescents hospitalized with anorexia nervosa to prevent initial weight loss and to slow weight gain for these patients, according to new findings of a prospective trial.

Andrea K. Garber, PhD, RD, from the University of California, San Francisco, in San Francisco, California, and colleagues published their findings in the January 2012 issue of the Journal of Adolescent Health.

Dr. Garber mentioned the lack of evidence supporting the standard "start low and go slow" strategy for the nutritional rehabilitation of hospitalized adolescents with anorexia nervosa.

"Many have asked how these recommendations could have been in place for so long without evidence to support them," Dr. Garber told Medscape Medical News. "The lag time exemplifies the difficulty of studying and treating anorexia nervosa, which is a relatively rare psychiatric disease with serious medical sequelae."

Faster Rate of Weight Gain

The authors recruited 40 individuals between October 2002 and May 2009 for participation in the study. Although the percent mean body mass index (%MBMI) increased from 80.1 ± 11.5 on day 1 to 84.5 ± 9.6 at discharge, 83% of patients initially exhibited weight loss. %MBMI was significantly lower on day 2 (P < .001) and day 3 (P = .012) than on day 1. Moreover, during the first 3 days of hospitalization, initial fluid loss and initial weight loss were inversely correlated (R = −.356; P = .051).

The study included hospitalized patients aged 9 to 20 years who were diagnosed with anorexia nervosa in accordance with the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Patients were excluded if they had previous admissions for anorexia nervosa; if they were pregnant; or if they had a diagnosis of bulimia nervosa, eating disorder not otherwise specified, or another major mental health diagnosis such as schizophrenia.

In multivariate linear regression models adjusted for %MBMI and the lowest heart rate at baseline, a higher calorie-starting diet predicted a faster rate of weight gain (β = 0.0002, 95% confidence interval [CI], 0.0001 to 0.0005; P = .016) and a shorter hospital stay (β = −0.0092, 95% CI, −0.0152 to −0.0008; P = .013). Each 100-calorie increase in the diet at baseline predicted an increase in %MBMI of 0.02% per day and a decrease in the length of hospital stay of 0.9 days.

Further Research Needed

Despite these findings, Dr. Garber suggested that further investigations are necessary.

"Although this study included a range of diets, the vast majority of study participants started on lower-calorie diets and therefore we were not able to compare clinical outcomes on lower- to higher-calorie diets," she said.

"Thus, although this study suggests that higher-calorie diets are more efficacious than lower-calorie diets, this needs to be tested. In addition, the safety (in terms of refeeding risk) and tolerance of higher- and lower-calorie diets should be compared," Dr. Garber added.

In a linked commentary, Debra K. Katzman, MD, noted that improved feeding protocols would benefit patients.

"Effective, efficient, and safe refeeding protocols that maximize safe weight gain should result in shorter periods of medical instability and briefer hospital stays," Dr. Katzman writes. "Shorter hospitalizations and weight restoration should also minimize disruption to the adolescent's family, education, and social life, and allow for patients and families to engage in outpatient treatments such as family-based treatment that reduce costly inpatient stays."

Dr. Garber and Dr. Katzman have disclosed no relevant financial relationships.

J Adolescent Health. 2012;50:1-2, 24-29.

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