Refeeding Regimens for Anorexia Nervosa
Refeeding Protocols for Anorexia Nervosa
Recently, a study published by Andrea Garber, Ph.D., R.D. and colleagues has examined the standard “start low, go slow” nutrition refeeding protocols for patients hospitalized for anorexia nervosa (AN) and have stated that they are inadequate. The American Psychiatric Association recommended the slow-going refeeding protocol as it would avoid refeeding syndrome, a metabolic disturbance resulting from the reinstitution of nutrition to patients who are severely malnourished. Garber and colleagues state that more aggressive approaches may be taken, all while avoiding refeeding syndrome.1
What is Anorexia?
As anorexia nervosa is a rare psychiatric disease, the refeeding protocols were more so based on experience instead of on published evidence—something that is in need of change, according to Garber and colleagues. They conducted an initial study of 35 adolescents who were hospitalized for AN and were moderately malnourished, with bradycardia, hypothermia, and orthostatic hypotension.1 Each patient received a refeeding regimen of three meals a day and three snacks.1 A room-sitter confirmed that the food was consumed to achieve a certain caloric intake.1 Most of the patients were given an average of 1,400 calories per day.1
Garber and colleagues found that while the patients were hypometabolic in their starved state, they became hypermetabolic during their refeeding.1 Although calories were increased by 200 every other day, most of the patients continued to lose weight for the first week.1 Weight gain was only seen around day 8, when the caloric intake reached 1,966.1 Therefore, Garber and colleagues state that a higher caloric intake is associated with faster weight gain and a shorter hospital stay, regardless of illness severity.1 They found that for every 100 calories per day increased, the patient’s body mass index increased by 0.2 percent per day and the length of their hospital stay was reduced by 0.9 days.1
Getting More Aggressive with Anorexia Treatment
Garber and colleagues report that the “start low, go slow” refeeding protocols are too conservative, and more aggressive refeeding schedules are more successful and also avoid refeeding syndrome. Therefore, Garber and colleagues changed their clinical practice from their first study and started to increase the calories for all patients, not certain ones due to certain characteristics.1 In fact, a Great Britain work group reported that cases of current refeeding guidelines resulted in death in some cases due to underfeeding. Garber and colleagues believe future research should focus on the optimal protocols for caloric and nutrient replenishment.1
 Garber AK, Michihata N, Hetnal K, et al. A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol. J Adolesc Health. 2012;50:24-29.
 American Psychiatric Association. Treatment of patients with eating disorders, third edition. American Psychiatric Association. Am J Psychiatry. 2006;163(7 suppl):4-54.
 Katzman DK. Refeeding hospitalized adolescents with anorexia nervosa: is “start low, advance slow” urban legend or evidence based? J Adolesc Health. 2012;50:1-2.
 Whitelaw M, Gilbertson H, Lam PY, Sawyer SM. Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? J Adolesc Health. 2010;46:577-582.
 MARSIPAN: Management of really sick patients with anorexia nervosa. CR162. London: Royal College of Psychiatrists, Royal College of Physicians; October 2010. http://www.rcpsych.ac.uk/publications/collegereports/cr/cr162.aspx. Anorexia.