Anorexia patients can safely regain weight faster than US standards recommend, if they are hospitalized and closely monitored, new research shows.
“We were able to get patients with anorexia to safely gain around 4 pounds a week. That’s twice the national average,” says psychiatrist Graham Redgrave, an expert in eating disorders and leader of the study at Johns Hopkins University.
The results, published online by the International Journal of Eating Disorders, challenge longstanding “refeeding” guidelines set by the American Psychiatric Association, the American Dietetic Association and other groups. Those recommendations, aimed at reversing starvation and stabilizing dangerously underweight patients, call for weight gain of about 1 to 3 pounds per week.
Faster but safe refeeding makes an important difference, Redgrave says. It allowed most patients in his study to leave the hospital at a normal weight.
“Patients who gain more weight in treatment are less likely to relapse in the first two years after treatment, when they’re most vulnerable,” Redgrave says. Relapse after intensive hospital treatment for anorexia is now a common, challenging problem, he says.
Getting patients to a healthy weight is critical for therapy to work, Redgrave adds. “Patients at a very low weight don’t think clearly,” he says. “Their judgment becomes impaired; they’re more obsessional, anxious, and depressed. Weight restoration reverses that.”
Why slower may not be safer
Redgrave and fellow researchers collected data over eight years from 361 patients with anorexia nervosa and related disorders; each patient spent a week or more on an inpatient weight gain regimen.
At issue is refeeding syndrome, a metabolic disturbance that can affect severely underweight cancer patients and starved war survivors as well as patients with anorexia nervosa when they return too quickly to high-calorie meals. During starvation, a malnourished body falls into a metabolic holding pattern that drains available glucose, phosphate, and mineral reserves.
When eating is rapidly restored, 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,” says senior researcher Angela Guarda, director of the Johns Hopkins Eating Disorders Program. Other effects can include confusion, convulsions and coma.
“So ‘slower is safer’ has been the clinical view. But at what price?” Guarda asks. “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.”
Close monitoring is key
The Johns Hopkins study suggests that careful monitoring of patients in an inpatient treatment program can sidestep refeeding syndrome. 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. The 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 no one developed refeeding syndrome.
At the end of the Johns Hopkins program, more than 70 percent of adult patients reached a normal BMI of 19 or higher, and 80 percent of adolescents were within 5 pounds of their target weight.
The study included patients ranging in age from 11 to 78 and suffering from both major types of anorexia nervosa—food-restricting or binging and purging—with varying severity. Many had additional psychiatric diagnoses.
Redgrave thinks his results can be explained by the highly structured nature of the Johns Hopkins program, which relies on behavior-focused therapy to change patients’ thinking and to motivate them. “Our study shows what’s actually possible. Now we’d like national guidelines and practices to reflect that,” he says.
The Steven and Jeanne Robinson Fund for Eating Disorders and Johns Hopkins funded the study.
Source: Johns Hopkins University