Questioning the nutritional management of anorexia patients

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Even though our understanding and awareness of anorexia has improved, it s still not clear how best to treat anorexic patients when they arrive at the hospital. A severely underweight anorexic, who may be at risk of death, needs to regain that weight as soon as possible. But giving such patients too many calories early on can lead to a dangerous complication called refeeding syndrome, which in some cases can be fatal or lead to cardiac arrhythmia.

Recent coverage of this treatment issue in The New York Times addresses the ongoing debate over how to feed anorexic patients who are hospitalized. The traditional strategy is to start low, advance slow, which involves starting the patient on fewer calories than they need to gain weight typically 1,200 calories and then gradually increasing this number. But some worry that this strategy could be detrimental to the patient. Indeed, a small study published in The Journal of Adolescent Health in August showed that many patients on this start-low regimen actually lost weight at first, and an accompanying editorial noted that feeding anorexic patients too slowly has even caused death in some instances.

Other feeding programs are assessing newer strategies that start patients at a higher caloric intake, closer to 1,900 calories. But some experts remain concerned that this may be too drastic a step, and could raise the risk of refeeding syndrome while also causing psychological damage to the patient. Marjorie Nolan, an eating disorder specialist and spokeswoman for the Academy of Nutrition and Dietetics, explains that a patient s recovery can actually be set back by the traumatizing effect of aggressive feeding. These adolescents are so young they can t process the information, she says, and here they ve gained five pounds in a week and their biggest fear is happening: They re getting fat. Which we know isn t true, but that s how they see it.

ACSH's resident nutrition expert, Dr. Ruth Kava, agrees that too much too soon can lead to a dangerous cycle, in which anorexic patients gain weight through aggressive treatment, but then fall back into their old habits of self-starvation. These people have spent so much time training themselves to think they re fat, she says, that staying underweight becomes almost like an addiction. She adds that trying to change hospital feeding policies could, to a certain extent, be playing with fire. Refeeding syndrome can be fatal, she comments, so there s a fine line between being sure to feed patients enough to maintain their nutrients, and risking the complications of excessive feeding.