Extra-high-calorie refeeding was successful in a randomized trial for inpatient treatment of anorexia nervosa.
When compared with a standard feeding regimen, an accelerated and higher calorie refeeding schedule in an inpatient eating disorder program restored medical stability significantly faster (hazard ratio 1.67, 95% CI 1.10-2.53, P=0.01), reported Andrea Garber, PhD, RD, of the University of California, San Francisco, and colleagues.
This equated to an average of 3 days sooner to medical stability (7 vs 10 days), the group wrote in the study online in JAMA Pediatrics.
Medical stability was defined according to six factors:
- 24-hour heart rate of 45 beats/min or more
- Systolic blood pressure of 90 mmHg or more
- Temperature of 96.1° F or more
- Orthostatic increase in heart rate of 35 beats/min or less
- Orthostatic decrease in systolic blood pressure of 20 mmHg or less
- 75% or more of median body mass index for age and sex
The high calorie approach was associated with a 4-day shorter overall hospital stay as well (8 days vs 12 days), which equated to an average estimated savings of $5,518 (95% CI -$8,266 to -$2,770) per patient’s stay in cost, as well as a savings of $19,056 (95% CI -$28,819 to -$9,293) per patient’s stay in hospital charges.
And for patients who were admitted with bradycardia, the high calorie refeeding approach led to a restored heart rate 4 days sooner (4.5 vs 8 days).
Weight gain overall was slightly higher in the high calorie group as well, at about 1.74 lb more (0.79 kg) vs the low calorie refeeding approach.
Between the refeeding approaches, there were no significant differences in the incidence of electrolyte disturbances or the number of patients who needed supplementation. Electrolyte nadirs for phosphorus and magnesium did occur earlier for the high calorie group, but not for potassium.
The high calorie group saw a gain in body weight by only day 2 of treatment, while the low calorie group initially lost weight on treatment.
Neither group experienced any cases of clinical refeeding syndrome and there were no differences in adverse events.
“In the past, these patients stayed in the hospital for weeks on end and usually lost weight initially,” Garber explained in a statement. “We wanted to see if increased calories would improve these outcomes and still maintain safety.”
“Our inpatient programs are operating at maximum capacity; the isolation, uncertainty, and anxiety of COVID-19 is amplified for our patients,” she underscored. “We believe that this faster and more efficacious approach will reduce the upheaval of hospitalization during an already stressful time.”
The researchers noted that current clinical guidelines, including from the American Psychiatric Association Work Group on Eating Disorders, American Psychiatric Association, and American Dietetic Association, still recommend a low calorie refeeding approach, which typically starts at 1,200 kcal/d.
“Over the decades that [lower-calorie refeeding] has endured as the standard of care for [anorexia nervosa], only a small number of cases documenting cardiac arrest, delirium, and death during refeeding were reported,” the group wrote. “Although [lower-calorie refeeding] was generally considered safe, preliminary studies showed that it was associated with initial weight loss, slow weight gain, and protracted hospital stay.”
This multicenter trial included a total of 111 adolescents and young adults between the ages of 12 and 24, 93% of whom were female. All were hospitalized with anorexia nervous or atypical anorexia nervosa with 60% or more of median body mass index.
Half of the patients were randomized to the standard lower-calorie refeeding regimen, which began with 1,400 kcal/d and increased by 200 kcal every other day — slightly higher than the 1,200 kcal recommended in current guidelines.
These participants were compared with the higher-calorie refeeding regimen, which began at 2,000 kcal/d and increased by 200 kcal/d.
Both refeeding approaches included three meals paired with two to three snacks each day comprised of approximately 30-40% fat, 15-25% protein, and 35-55% carbohydrates. There was a supervisor present during all meals to monitor the patient, and stayed for up to 45 minutes after the meal was complete.
The researchers noted that they are continuing to follow the patients and currently assessing 12-month clinical remission of the two groups — the primary endpoint of this trial.
“We are eager to find out if the benefits in hospital are sustained over time,” Garber noted. “We want to avoid a situation in which shorter stays create a revolving door of more frequent readmissions, undoing early good outcomes and hospital cost savings.”
Kristen Monaco is a staff writer, focusing on endocrinology, psychiatry, and dermatology news. Based out of the New York City office, she’s worked at the company for nearly five years.
The study was supported by a grant from the National Institutes of Health, and Garber was also supported in part by a grant from the Health Resources and Services Administration, Leadership Training in Adolescent Health.
The researchers reported grants from the National Institutes of Health during the study, and relationships with the Training Institute of Child and Adolescent Eating Disorders, Guilford Press, and Routledge; no other disclosures were reported.