Research — 13 July 2015

Those hospitalized with anorexia nervosa can gain weight at a faster rate than national guidelines currently recommend as long as the patients are monitored very closely, according to researchers at Johns Hopkins Medicine.

The study challenges long-held guidelines set by the American Psychiatric Association, the American Dietetic Association and other major international organizations for “refeeding” and stabilizing eating and nutrition for dangerously underweight anorexia patients. Currently, the guidelines recommend a weight gain of about one to three pounds per week.

Many treatment programs have low rates of weight gain, in part because of safety concerns about faster refeeding. The problem is the risk of a condition known as refeeding syndrome, a metabolic disturbance that can affect severely underweight patients with cancer, starved war survivors, and patients with anorexia nervosa who return too quickly to high calorie meals.

A starved, malnourished body falls into a metabolic holding pattern that drains available glucose, phosphate, and other mineral reserves. When eating is restored too quickly, some of the body’s major organs draw on these same reserves to resume normal functioning, depleting them even more.

“The initial drop in available phosphate puts patients at risk of a lethal heart arrhythmia and failure, the most serious aspect of refeeding syndrome,” said senior author Angela Guarda, M.D., director of the Johns Hopkins Eating Disorders Program. Other effects can include confusion, convulsions and coma.hospital-484848_1280

“So ‘slower is safer’ has been the clinical view. But at what price?” Guarda said. “If a patient is severely ill and needs to gain 50 pounds, but only gains 10 pounds in the hospital, you achieve little other than a temporary improvement. Worse still, recent research actually shows that under traditional protocols, people can lose weight in the hospital.”

For the study, the researchers collected data over eight years from 361 patients with anorexia nervosa and related disorders, each of whom spent a week or more on an inpatient weight gain regimen.

The patients ranged in age from 11 to 78 and were suffering from both major types of anorexia nervosa — food-restricting or bingeing and purging — with varying severity. Many had additional psychiatric diagnoses.

“We were able to get patients with anorexia to safely gain around four pounds a week. That’s twice the national average,” said psychiatrist Graham Redgrave, M.D., the study’s first author and an expert in eating disorders at Johns Hopkins Medicine.

“The higher rate is important, because it means that most patients left the hospital at a normal weight. Studies show that patients who gain more weight in treatment are less likely to relapse in the first two years after treatment, when they’re most vulnerable.”

The researchers suggest that careful monitoring of patients in an inpatient treatment program can lower the risk of refeeding syndrome. During the study period, those who entered the program with a dangerously low body mass index — a measure that shows whether a person’s weight and height are within healthy proportions — were tested daily for levels of phosphate and glucose in their blood.

This careful monitoring continued until nutritional treatments restored normal levels, Guarda says. Less than one-fifth of patients had a drop in phosphates during more rapid refeeding, and none of the patients developed refeeding syndrome.

“Abnormal phosphate levels were more closely tied to how underweight patients were when entering the hospital than to the rate of weight gain,” Redgrave said.

At the end of the program, more than 70 percent of adult patients reached a normal BMI of 19 or higher, and 80 percent of adolescents were within five pounds of their target weight.

“Reversing starvation and reaching a healthy weight is critical for therapy to work,” Redgrave said. “Patients at a very low weight don’t think clearly. Their judgment becomes impaired; they’re more obsessional, anxious and depressed. Weight restoration reverses that.”

Redgrave believes the study’s positive results are due to the program’s behavior-focused therapy which is designed to motivate patients and change their thinking.

“Our study shows what’s actually possible. Now we’d like national guidelines and practices to reflect that,” he said.

The findings are published online in the International Journal of Eating Disorders.

This article first appeared on ‘Psych Central’ on 12 July 2015.

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