weight changes during inpatient refeeding of underweight eating disorder patients
TRANSCRIPT
RESEARCH ARTICLE
Weight Changes During Inpatient Refeeding ofUnderweight Eating Disorder PatientsSusan Hart1*, Suzanne Abraham2, Richard Franklin3 & Janice Russell4
1
Accredited Practising Dietitian, Department of Obstetrics and Gynaecology, University of Sydney, Royal North Shore Hospital, Australia2Associate Professor, Department of Obstetrics and Gynaecology, University of Sydney, Royal North Shore Hospital, Australia
3Conjoint Senior Research Fellow, School of Medicine-Central Clinical Division, University of Queensland
4Professor, Department of Psychological Medicine, University of Sydney, The Northside Clinic, Australia
Abstract
Aim: To describe patterns of weight change in patients admitted to a specialised eating disorder program with
established protocols for inpatient refeeding.
Methods:Weight records between January 2000 and December 2006 were categorised using BodyMass Index (BMI)
at first admission (BMI ranges < 14.0, 14.1–17.49, 17.5–18.9 kg/m2). Total weight gained, number of days of
inpatient treatment and rate of weekly weight gain were examined.
Results: In total there were 247 patients representing 414 admissions. The rate of weight gain was 0.77, 0.63 and
0.53 kg/week, respectively, for each BMI group. Twenty patients (8.1%) in the refeeding program did not gain
weight.
Conclusion: Weight gain in underweight patients is highly variable. A greater understanding of the processes that
contribute to weight gain, and establishment of best practice in achieving weight gain in patients needs to be
determined. This data provide detailed information about expectations for refeeding without artificial feeding.
Copyright # 2010 John Wiley & Sons, Ltd and Eating Disorders Association.
Keywords
anorexia nervosa; weight; inpatient; refeeding; dietitian
*Correspondence
Susan Hart, Missenden Psychiatric Unit. Dept. of Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW, 2060, 02 8587 0200.
Email: [email protected]
Published online 20 December 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1052
Introduction
The refeeding of underweight patients is currently a
challenge for clinicians and is perhaps more art than
science. There are practice guidelines and position
statements on management of anorexia nervosa
(American Dietetic Association, 2001; Beumont et al.,
2004; Gowers et al., 2004; Wakefield & Williams, 2009;
Winston et al., 2005; Yager et al., 2006) which provide
direction on refeeding but lack robust scientific
390 Eur. Eat. Disorders Rev. 19 (2011)
evidence to support their recommendations. The
National Institute of Clinical Excellence (NICE) guide-
lines comment that the approach to refeeding varies
between centres and countries (Gowers et al., 2004).
Literature highlights that there is a failure in the field
to provide clinical trials that examine the optimal
approach to re-nutrition (Bulik, Berkman, Brownley,
Sedway, & Lohr, 2007) and a lack of understanding of
the complex interplay of biological and psychological
factors in relation to weight gain (Steinhausen,
390–397 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association.
S. Hart et al. Weight Changes During Refeeding
Grigoroiu-Serbanescu, Boyadjieva, Neumarker, &
Winkler Metzke, 2008).
Published recommendations of average weekly weight
gain in inpatient treatment range from 0–0.5 kilograms
per week (kg/week): (Herzog, Zeeck, Hartmann,
& Nickel, 2004; Okamoto et al., 2002); 0.5–1.0 kg/week
(Castro, Gila, Puig, Rodriguez, & Toro, 2004;
Gowers et al., 2004; Lay, Jennen-Steinmetz, Reinhard,
& Schmidt, 2002) and greater than 1.0 kg/week
(Davies & Jaffa, 2005; Treat, Gaskill, McCabe, Ghinassi,
Luczak, & Marcus, 2005). The American Psychiatric
Association (APA) guidelines recommend 0.9–1.4 kg/
week with ‘expected rates of controlled weight gain’
(Yager et al., 2006), however there are only a few
descriptions of actual weight gain in inpatient treat-
ment. The literature is comprised of descriptions of
practice based on clinical treatment in particular
facilities (Okamoto et al., 2002; Zuercher, Cumella,
Woods, Eberly, & Carr, 2003); case studies (Latzer,
Eysen-Eylat, & Tabenkin, 2000; Mehler &Weiner, 2007;
Neiderman, Zarody, Tattersall, & Lask, 2000) or studies
with small sample sizes (Arii, Yamashita, Kinoshita,
Shimizu, Nakamura, & Nakajima, 1996; Silber, Robb,
Orrell-Valente, Ellis, Valadez-Meltzer, & Dadson, 2004)
and there are only a few descriptions of patterns
of weight change in Anorexia Nervosa (AN) subjects
with a sample size greater than 100 (Beumont,
Al-Alami, & Touyz, 1988; Diamanti et al., 2008;
Zuercher et al., 2003). Evidence of how achievable
described weight targets are in clinical settings is
unclear as there is frequently limited detail to aid in
translation of treatment practices into other settings
(Davies & Jaffa, 2005). There may be only one or
two weight points described rather than a series
(Bowers & Ansher, 2008), detail of how mean weight
changes are calculated is omitted (Holtkamp, Hebeb-
rand, Mika, Heer, Heussen, & Herpertz- Dahlmann,
2004) as is detail on length of stay (Solanto, Jacobson,
Heller, Golden, & Hertz, 1994) or what feeding
methods are used to achieve weight outcomes
(Mewes, Tagay, & Senf, 2008). There are only a
few studies that examine longer-term effectiveness of
nutritional rehabilitation (Baran, Weltzin, & Kaye,
1995; Bowers & Ansher, 2008; Castro et al., 2004;
Lay et al., 2002).
It is important to understand factors affecting weight
gain as weight gain is a surface variable for the core
elements of treatment response (Steinhausen et al.,
2008), and ‘The patients’ weight chart under treatment
Eur. Eat. Disorders Rev. 19 (2011) 390–397 � 2010 John Wiley & Sons, Ltd and
conditions is a valuable reflection of her temperament
and conflicts’ (Crisp, Mayer, & Bhat, 1986). Due to the
severe psychological, social and financial impact of AN
and its sequelae there should be interest in factors that
may be helpful in predicting outcome (Lowe, Zipfel,
Buchholz, Dupont, Reas, & Herzog, 2001). Zipfel has
shown that inadequate weight gain during the first
admission predicts a poor outcome (Zipfel, Lowe, Reas,
Deter, & Herzog, 2000). In order to obtain better
clinical outcomes in the process of refeeding, it is
essential that patterns of weight restoration in the
short and long term are examined in greater detail. In a
disorder that is fundamentally about under-nutrition,
its effects and treatment, there is little information to
direct best practice.
Aim
The aim of this paper is to describe weight changes in a
large, well described clinical sample of low weight eating
disorder patients (Body Mass Index (BMI) less than
19.0 kg/m2) who present for treatment to a specialist
inpatient facility in Sydney, Australia with established
protocols for refeeding.
Methods
Consecutive weight records of female patients with
eating disorders admitted for treatment between
1 January 2000 and 31 December 2006 were examined.
The hospital is a private psychiatric hospital experi-
enced in treating eating disorder patients’ older than
14 years. Patients were weighed at admission and then
three times weekly (Monday, Wednesday and Friday)
over the course of admission and detailed weight
records were kept as part of standard care. Weigh-in
was compulsory before breakfast, supervised by
experienced nursing staff on calibrated balance beam
scales with the patient in a hospital gown.
The sample was comprised of patients whose BMI
was less than 19.0 kg/m2 at the first admission for
treatment to the facility in the study period. The
sample was analysed as a total sample, and categorised
into three separate BMI groups to see if there were any
differences in weight change, or patient descriptives
by BMI group. BMI categories were less than or
equal to 14.0 kg/m2 (severely underweight), BMI¼14.01–17.49 kg/m2 (moderately underweight) which
included restricting and purging AN, and BMI¼ 17.5–
Eating Disorders Association. 391
Weight Changes During Refeeding S. Hart et al.
18.99 kg/m2 (slightly underweight) which by definition
included patients with Bulimia Nervosa (BN) and
Eating Disorder Not Otherwise Specified (EDNOS).
BN patients were included if they were underweight,
BMI< 19.0 kg/m2. A cut off of BMI 19.0 kg/m2 rather
than 17.5 kg/m2 was chosen because while these
patients do not meet DSM IV criteria for AN they
are underweight as a consequence of their behaviour
and would benefit from weight gain. The sample
was predominantly Caucasian (93.5%; n¼ 231) and
adult (mean age¼ 20.7 years (SD¼ 7.1)) so this
definition of underweight was considered clinically
appropriate. Patients with a BMI between 17.5 and
19.0 kg/m2 are not frequently reported on, however
they are often admitted for inpatient treatment, so one
research aim was to examine how patterns of weight
gain in this group may differ from AN diagnosed
patients.
All patients were placed on the refeeding program
of the unit aiming for weight gain of 1.0 kg/week to a
minimum BMI of 19.0 kg/m2 and were assessed as
medically stable prior to admission. A refeeding
program of three meals and three snacks without any
form of artificial feeding (nasogastric or parenteral
nutrition) was used. The refeeding regime was designed
to be an age appropriate ‘normal’ diet similar to
what their peers might eat, as judged by the dietitian
with discussion from the team. Food alone was
most commonly used, however, oral liquid supple-
ments (OLS) were sometimes included in underweight
patients in order to meet energy requirements if they
had difficulty achieving weight gain targets or tolerating
the volume of food required for weight gain. The aim
was to achieve a gain of 1.0 kg/week, with or without
OLS. The nutrient composition of the prescribed
refeeding regime for patients feeding on food only
(n¼ 318) was a mean energy intake of 1980 kilocalories
(8285 kilojoules) with 20.5% of energy from protein,
47% from carbohydrate and 32.5% from fat. Between
one to four OLS were added to meal plans for
96 patients the mean energy prescription for an OLS
regime of 2520 kilocalories (10530 kilojoules), 19% of
energy provided from protein, 46.5% from carbo-
hydrate and 34.5% from fat. Three patients required
the addition of four supplements which provided a
maximum refeeding regime of 2810 kilocalories
(11745 kilojoules).
Each patient had an individualised meal plan
reviewed weekly by an experienced dietitian, and
392 Eur. Eat. Disorders Rev. 19 (2011)
registered nurses supervised all meals, usually with
one nurse for 6–8 patients consistent with an earlier
study of Australian eating disorder units (Hart,
Abraham, Luscombe, & Russell, 2008). There were
different levels of meal supervision for patients, with the
highest level of supervision for newly admitted patients
and for those struggling to complete meals, achieve
weight gain targets or comply with aspects of the
program such as cessation of weight losing behaviours.
Once progress was demonstrated including achieving
weight targets, or when patients were preparing for
discharge they were given increased autonomy by
eating without supervision, eating outside of hospital
and being given opportunities to eat at home with their
family.
As the hospital is privately funded, it was necessary to
adopt a strategy that maximised time in hospital for
each patient. Funding generally did not cover patients
for extended admissions longer than 8–10 weeks.
Therefore a policy was adopted where patients were
discharged after 8 weeks, provided with intensive
outpatient support then readmitted within four weeks if
weight trajectory as an outpatient was unsatisfactory.
Total weight gain, rate of weekly weight gain
(kg/week) and days of treatment during each admission
and in total over the 6 year period were calculated. Total
net weight gained over all admissions was calculated
by taking first weight of the first admission (ADM1st)
from the last weight of the final discharge (DCFinal).
Rate of weekly weight gain for the first admission was
calculated by: total weight gain ADM1st/[(length of stay
in days)�7], and rate of weekly gain for all treatment was
calculated by: total net weight gain over all admissions/
[(cumulative treatment days)�7]. The number of
previous inpatient admissions each patient had prior
to their first admission to this treatment facility was
recorded.
Diagnoses were made by the Medical Director of the
program using the Diagnostic and Statistical Manual of
Mental Disorders, version IV (APA, 1994). Abnormal
eating and weight losing behaviours were assessed
at admission by the EEE-C (Eating and Exercise
Examination, Computerised), which measures the
presence of the behaviour in the 28 days preceding
admission (Abraham & Lovell, 1999). ANOVA was
used for analysis of continuous variables and BMI
groups were compared as categorical variables using x2,
using SPSS 15.0, Graduate version (SPSS Inc., 1989–
2006). When running ANOVA or x2 statistics, all three
390–397 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association.
S. Hart et al. Weight Changes During Refeeding
groups were entered into the analyses, i.e. three groups
were compared rather than two.
Results
There were 247 female patients representing 414
admissions admitted for refeeding and who met the
inclusion criteria for this sample. Excluded from the
study were males, as they were small in number (n¼ 13,
20 admissions) and 15 patients with chronic medical
illnesses (30 admissions) such as Type-1 diabetes
and Coeliac Disease. Patients who were discharged
from inpatient treatment with a length of stay less than
10 days did not have any weight data collected and were
excluded.
For 179 (73%) patients, it was their first ever admission
for inpatient treatment for an eating disorder. One
hundred and forty nine patients (60%) had only one
admission during the study period, 92 patients (37%)
had two to four admissions (228 occasions of care),
while six patients (2%) had five or more admissions (37
occasions of care). Tables 1 and 2 show the descriptive
and behavioural data of this sample including the total
weight gained over all inpatient treatment days.
The severely underweight group gained significantly
more weight between first admission and discharge
from their last admission (F¼ 10.8, p� .001), and
significantly more weight, when weight gain at each
occasion of care was totalled (F¼ 10.4, p� .001).
However, a longer admission time was required to
achieve this weight gain; so when the rate of weight gain
in kg/week was calculated between the first and
last admission this result was less significant (F¼ 3.4,
p� .05).
Approximately one third of patients with BMI<¼17.49 kg/m2 voluntarily included OLS to assist in
meeting weight gain targets while only one patient
chose to have OLS in the slightly underweight group
(BMI¼ 17.5–18.9 kg/m2).
In total there were 70 patients who purged in the
sample of 247 patients. There were three patients with
AN purging in the severely underweight group and
42 patients who purged in the moderate underweight
group which was significant (F¼ 5.1, p� .05).
There were four deaths in the sample of patients
representing six occasions of care. These patients were
not currently in any eating disorder treatment when
they died. At their first admission to the current clinic,
all four patients had multiple unsuccessful admissions
Eur. Eat. Disorders Rev. 19 (2011) 390–397 � 2010 John Wiley & Sons, Ltd and
to other facilities. Three patients died from complications
of malnutrition. During treatment they had a mean
admission BMI of 13.7 kg/m2, mean discharge BMI at last
admission was 14.8 kg/m2, mean number of admissions
to the current clinic was 1.7 and total days of current
inpatient treatment was 89.3 days. A fourth patient died
from unknown causes and was in the normal weight
range when discharged from the clinic.
Some patients did not respond to inpatient weight
restoration and lost weight in hospital despite efforts
to improve weight and nutritional status. Nineteen
patients lost weight over all admissions at a rate of
�0.17 kg/week (a total loss of –0.83 kg over 37.3 days)
and 69 patients gained weight minimally between 0
and 0.5 kg/week, at a mean rate of 0.33 kg/week (total
gain of 4.5 kg over 88.9 days). These rates were not
significantly different between the BMI groups.
In each BMI group there were 48%, 78% and 73% of
patients respectively whom it was their first ever
admission for treatment and this was statistically
significant (x2¼ 11.4, p� .01), with lower weight patients
having a greater number of previous admissions.
Discussion
Expert consensus in the management of eating disorder
patients agrees that the initial priority of treatment is
to reverse the effects of under-nutrition and starvation
and aim for a return to normal eating (Beumont et al.,
2004; Gowers et al., 2004; Yager et al., 2006). However,
there are limited descriptions of patterns of weight gain
during inpatient treatment and the best way of
achieving lasting and permanent changes in the weight
of eating disorder patients.
Approximately one-third of patients (n¼ 95) (see
Tables 1 and 2) with a BMI less than 17.5 kg/m2 chose
OLS as a mid meal snack with their meal plan
rather than food alone. A survey of Australian specialist
dietitians recommended OLS as the preferred method
of increasing energy intake for refeeding in preference
to NG feeding or TPN, which were not considered
ideal methods (Hart et al., 2008). In this sample, there
were no differences in the rate of weight gain for
patients with or without OLS (Table 3); however,
patients choosing OLS gained slightly more weight but
took significantly longer to achieve their weight target.
Whether this is a result of increased metabolic difficulty
in gaining weight, difficulty tolerating the volume of
food necessary for weight gain or a marker of
Eating Disorders Association. 393
Table 1 Descriptive information on all underweight patients (BMI<19.0 kg/m2)
Total
M (SD)
Severe
�14.0
M (SD)
Moderate
14.1–17.49
M (SD)
Slightly
17.5–18.9
M (SD)
N 247 33 151 63
All admissions 414 58 266 90
Mean number of admissions 1.7 (1.1) 1.8 (1.1) 1.8 (1.2) 1.43 (0.7) F¼ 5.6, p� . 01
Age at ADM1st (years) 20.7 (7.1) 21.3 (6.4) 20.3 (6.5) 21.4 (8.7) NS
Weight at ADM1st (kg) 43.9 (6.1) 35.2 (3.6) 43.2 (4.3) 50.2 (3.9) F¼149.5, p� . 001
Weight at DCFinal (kg) 48.1 (6.3) 41.9 (6.1) 47.3 (5.4) 53.0 (4.8) F¼ 50.3, p� . 001
BMI at ADM1st 16.1 (1.8) 13.0 (0.9) 15.9 (1.0) 18.2 (0.4) NS
BMI at DCFinal 17.6 (2.0) 15.5 (2.2) 17.4 (1.7) 19.2 (1.1) F¼ 55.9, p� . 001
BMI change (ADM1st to DCFinal) 1.5 (1.5) 2.5 (2.0) 1.5 (1.5) 1.0 (1.1) F¼ 10.9, p� . 001
Total net weight gain (kg) (ADM1st to DCFinal) 4.2 (4.0) 6.7 (5.2) 4.1 (3.9) 2.8 (3.0) F¼ 10.8, p� . 001
Sum of all weight gained each ADM (kg) 5.5 (5.3) 8.1 (5.8) 5.9 (5.6) 3.3 (3.4) F¼ 10.4, p� . 001
Rate gain (kg/week) (ADM1st to DCFinal) 0.62 (0.43) 0.77 (0.36) 0.63 (0.43) 0.53 (0.46) F¼ 3.4, p� .05
Length of treatment ADM1st (days) 40.1 (19.4) 46.5 (17.8) 42.1 (20.6) 31.7 (14.5) F¼9.1, p� .001
Sum of all treatment days 67.4 (62.1) 80.2 (62.0) 73.8 (69.8) 45.4 (29.2) F¼ 5.7, p� .01
Weight Changes During Refeeding S. Hart et al.
differences in motivation in this group is unclear, and
would be worth further research. Use of OLS was not
randomised in this sample, rather they were included
when patients had difficulty meeting their weight targets,
so it is not possible to draw too many conclusions from
this result.
Few studies assess whether weight is retained in
the long term after an inpatient admission or how
Table 2 Behaviours and diagnosis of all underweight patients (BMI<19.0 kg/m2)
Total
M (SD)
Severe
�14.0
M (%)
Moderate¼14.1–17.49
M (%)
Slightly¼17.5–18.9
M (%)
N 247 33 151 63
Purging ADM1st 70 3 (9%) 42 (28%) 25 (40%) x2¼ 10.0, p� .01
Objective Binge Eating ADM1st 28 1 12 15 x2¼13.7, p� .001
Diagnosis ADM1st
AN-R 139 30 (91%) 109 (72%) 0
X2¼ 5.1, p< .05
AN-P 45 3 (9%) 42 (28%) 0
EDNOS 48 0 0 48 (76%)
BN 15 0 0 15 (24%)
OLS (All admissions) n (% yes) 96 (23%) 19 (33%) 76 (29%) 1 (1%) x2¼31.5, p� .001
Is this first ever ADM? n (% yes) 179 (72%) 16 (48%) 117 (78%) 46 (73%) x2¼ 11.4, p� .01
Rate of gain¼ 0 - 0.5 kg/week
(all admissions)
69 7 44 18 NS
Weight loss (all admissions) 19 1 9 9 NS
Deaths 4 2 (7%) 1 (2%) 1 (2%) NS
NS¼Not significant.ADM1st¼weight of first admission 2000-2006.DCFinal¼ last weight of final admission 2000-2006.
394 Eur. Eat. Disorders Rev. 19 (2011) 390–397 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association
initial changes in weight during treatment may predict
longer-term outcome. Rate of weight gain was one of the
variables related to readmission in a study of 101 AN
patients (Castro et al., 2004). Castro-Fornieles et al., 2007
described a sample in whichmean weight gain was 0.9 kg/
week, however 25% failed to maintain weight during
outpatient treatment after being totally weight recovered
with a lower rate of weight increase during treatment
.
Table 3 Comparison of AN patients refeeding with and without OLS
OLS
M (SD)
No
OLS
M (SD)
Total
M (SD)
N 96 318 414
ADM1st BMI (kg/m2) 15.1 (1.4) 16.6 (2.2) 16.3 (2.1) F¼ 39.1, p� .001
DCFinal BMI (kg/m2) 16.9 (1.5) 17.8 (2.1) 17.6 (2.0) F¼9.5, p� .01
Total Gain (ADM 1st) (kg) 3.9 (2.1) 3.2 (2.7) 3.3 (2.6) F¼5.4, p� .05
Rate of weight gain (ADM 1st) (kg/week) 0.60 (0.32) 0.60 (0.50) 0.60 (0.5) NS
Treatment days (all admissions) 48.7 (21.3) 38.0 (20.4) 40.4 (21.1) F¼ 19.9, p� .001
NS¼Not significant
S. Hart et al. Weight Changes During Refeeding
predicting readmission in this sample. It has been
suggested that motivation to change is the variable that
best predicts weight maintenance nine months after
discharge from inpatient care and that patients, own
psychological variables seem to be more relevant to
short term outcome (Castro-Fornieles et al., 2007).
In a study of 41 AN adolescents it was concluded that
response to initial hospitalisation in terms of weight
gain may be an important predictor of longer-term
maintenance of outcome, and this is more important
than initial weight or initial hospital length of stay
(Lock & Litt, 2003). Understanding the dynamics of
weight gain is clearly helpful in providing effective
clinical interventions, and there is a need to change
standard admission treatment programs in patients
who present a higher risk of readmission (Castro et al.,
2004).
There needs to bemore research on identifying patients
who respond best to inpatient weight restoration
because our results show that some patients do not
respond to inpatient weight restoration and lose weight
in hospital or gain weight minimally as in the case of
88 patients. These patients may do equally as well or
poorly in terms of weight gain in outpatient treatment.
As patterns of weight change are not often reported or
only mean weight change of samples are reported, it is
unclear whether this is a peculiar or usual finding
during weight restoration.
Further analysis of patients who retain all weight
gained in treatment versus patients who are unable to
retain this weight may be useful to predict longer-term
recovery from an eating disorder. Research needs to
examine what the differences are between those patients
who do well in terms of nutritional rehabilitation and
weight change and those who do poorly. Characteristics
of patients who respond and do not respond to
Eur. Eat. Disorders Rev. 19 (2011) 390–397 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association. 395
inpatient treatment should be identified prospectively
rather than retrospectively, and different interventions
should be tailored to these patients, rather than a one
size fits all approach to nutritional rehabilitation and
refeeding.
Conclusion
Patterns of weight change in eating disorder patients
are infrequently described. How much weight is gained
(or lost in treatment) or the best way of achieving
nutritional rehabilitation and weight outcomes is
unknown.
Future research should examine these issues looking
at weight gain in the short term and retention of weight
gained over the long term as well as identifying patients
who are responders to inpatient treatment. Patterns
of weight change in treatment and best practice in
achieving weight gain are a forgotten but important
aspect of treatment of the eating disorder patient.
Limitations of this study are that it is a naturalistic
study that examines voluntary presentations for
treatment to a private clinic for nutritional rehabilita-
tion. Due to the fact that all patients were privately
funded to attend treatment and there were no
involuntary admissions, this sample is unlikely to be
representative of eating disorder inpatient treatment
in general. Whether this data on weight change is
transferable to other treatment settings where different
funding arrangements, feeding methods and thera-
peutic milieus are employed is not known.
This study examined presentations to one clinic over
a 6-year period, and attempted to measure all previous
inpatient eating disorder admissions. However, it is
unclear whether the final admission for treatment to
this clinic was the final treatment ever or whether they
Weight Changes During Refeeding S. Hart et al.
had subsequent admissions elsewhere, particularly in
149 patients who presented only once for treatment to
the clinic.
396 Eur. Eat. Disorders Rev. 19 (2011)
The authors of this paper are not making recom-
mendations about feedingmethods but highlighting the
lack of knowledge in this area.
References
Abraham, S., & Lovell, N. (1999). Research and clinical
assessment of eating and exercise behaviour. Hospital
Medicine, 60, 481–485.
ADA. (2001). Position of the American Dietetic Associ-
ation: Nutrition intervention in the treatment of
anorexia nervosa, bulimia nervosa, and eating dis-
orders not otherwise specified (EDNOS): American
Dietetic Association.
APA. (1994). Diagnostic and statistical manual of mental
disorders (4th edition). Washington, DC: American
Psychiatric Association.
Arii, I., Yamashita, T., Kinoshita, M., Shimizu, H., Naka-
mura, M., & Nakajima, T. (1996). Treatment for
inpatients with anorexia nervosa: Comparison of
liquid formula with regular meals for improvement
from emaciation. Psychiatry & Clinical Neurosciences,
50, 55–59.
Baran, S. A., Weltzin, T. E., & Kaye, W. H. (1995). Low
discharge weight and outcome in anorexia nervosa.
American Journal of Psychiatry, 152, 1070–1072.
Beumont, P., Al-Alami, M., & Touyz, S. (1988). Relevance
of a standard measurement of undernutrition to the
diagnosis of anorexia nervosa: Use of Quetelet’s Body
Mass Index (BMI). International Journal of Eating
Disorders, 7, 399–405.
Beumont, P., Hay, P., Beumont, D., Birmingham, L.,
Derham, H., Jordan, A., et al. (2004). Australian
and New Zealand clinical practice guidelines for the
treatment of anorexia nervosa. [see comment][erra-
tum appears in Aust N Z J Psychiatry. 2004Nov.–Dec.;
38 (11–12): 987]. Australian & New Zealand Journal of
Psychiatry, 38, 659–670.
Bowers, W. A., & Ansher, L. S. (2008). The effectiveness
of cognitive behavioral therapy on changing eating
disorder symptoms and psychopathy of 32
anorexia nervosa patients at hospital discharge and
one year follow-up. Annals of Clinical Psychiatry, 20,
79–86.
Bulik, C., Berkman, N., Brownley, K., Sedway, J., & Lohr,
K. (2007). Anorexia nervosa treatment: A systematic
review of randomized controlled trials. International
Journal of Eating Disorders, 40, 310–320.
Castro-Fornieles, J., Casula, V., Saura, B., Martinez, E.,
Lazaro, L., Vila, M., et al. (2007). Predictors of weight
maintenance after hospital discharge in adolescent
anorexia nervosa. International Journal of Eating Dis-
orders, 40, 129–135.
Castro, J., Gila, A., Puig, J., Rodriguez, S., & Toro, J.
(2004). Predictors of rehospitalization after total
weight recovery in adolescents with anorexia nervosa.
International Journal of Eating Disorders, 36, 22–30.
Crisp, A., Mayer, C., & Bhat, A. V. (1986). Patterns of
weight gain in a group of patients treated for anorexia
nervosa. International Journal of Eating Disorders, 5,
1007–1024.
Davies, S., & Jaffa, T. (2005). Patterns of weekly weight
gain during inpatient treatment for adolescents with
anorexia nervosa. European Eating Disorders Review,
13, 273–277 (275).
Diamanti, A., Basso, M. S., Castro, M., Bianco, G., Ciacco,
E., Calce, A., et al. (2008). Clinical efficacy and safety
of parenteral nutrition in adolescent girls with anor-
exia nervosa. [see comment]. Journal of Adolescent
Health 42, 111–118.
Gowers, S., Pilling, S., Treasure, J., Fairburn, C., Palmer,
B., Bell, L., et al. (2004). Eating disorders. Core inter-
ventions in the treatment and management of anor-
exia nevosa, bulimia nervosa and related eating
disorders (No. CG9): National Institute for Clinical
Excellence.
Hart, S., Abraham, S., Luscombe, G., & Russell, J. (2008).
Eating disorder management in hospital patients:
Current practice among dietitians in Australia. Nutri-
tion and Dietetics, 65, 16–22.
Herzog, T., Zeeck, A., Hartmann, A., & Nickel, T. (2004).
Lower targets for weekly weight gain lead to better results
in inpatient treatment of anorexia nervosa: A pilot study.
European Eating Disorders Review, 12, 164–168.
Holtkamp, K., Hebebrand, J., Mika, C., Heer, M., Heus-
sen, N., & Herpertz-Dahlmann, B. (2004). High serum
leptin levels subsequent to weight gain predict
renewed weight loss in patients with anorexia nervosa.
Psychoneuroendocrinology, 29, 791–797.
Latzer, Y., Eysen-Eylat, D., & Tabenkin, H. (2000). A case
report: Treatment of severe anorexia nervosa with
home total parenteral hyperalimentation. Inter-
national Journal of Eating Disorders, 27, 115–118.
Lay, B., Jennen-Steinmetz, C., Reinhard, I., & Schmidt,
M. H. (2002). Characteristics of inpatient weight gain
in adolescent anorexia nervosa: Relation to speed of
relapse and re-admission. European Eating Disorders
Review, 10, 22–40.
390–397 � 2010 John W
Lock, J., & Litt, I. (2003). What predicts maintenance of
weight for adolescents medically hospitalized for anor-
exia nervosa? Eating Disorders. The Journal of Treat-
ment & Prevention, 11, 1–7.
Lowe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas, D. L.,
& Herzog, W. (2001). Long-term outcome of anorexia
nervosa in a prospective 21-year follow-up study. [see
comment]. Psychological Medicine, 31, 881–890.
Mehler, P., &Weiner, K. L. (2007). Use of total parenteral
nutrition in the refeeding of selected patients with
severe anorexia nervosa. International Journal of Eat-
ing Disorders, 40, 285–287.
Mewes, R., Tagay, S., & Senf, W. (2008). Weight curves as
predictors of short-term outcome in anorexia nervosa
inpatients. European Eating Disorders Review, 16, 37–
43.
Neiderman, M., Zarody, M., Tattersall, M., & Lask, B.
(2000). Enteric feeding in severe adolescent anorexia
nervosa: A report of four cases. International Journal of
Eating Disorders, 28, 470–475.
Okamoto, A., Yamashita, T., Nagoshi, Y., Masui, Y.,
Wada, Y., Kashima, A., et al. (2002). A behavior
therapy program combined with liquid nutrition
designed for anorexia nervosa. Psychiatry & Clinical
Neurosciences, 56, 515–520.
Silber, T. J., Robb, A. S., Orrell-Valente, J. K., Ellis, N.,
Valadez-Meltzer, A., & Dadson, M. J. (2004). Noctur-
nal nasogastric refeeding for hospitalized adolescent
boys with anorexia nervosa. Journal of Developmental
& Behavioral Pediatrics, 25, 415–418.
Solanto, M. V., Jacobson, M. S., Heller, L., Golden, N. H.,
& Hertz, S. (1994). Rate of weight gain of inpatients
with anorexia nervosa under two behavioral contracts.
Pediatrics, 93, 989–991.
Steinhausen, H. C., Grigoroiu-Serbanescu, M.,
Boyadjieva, S., Neumarker, K. J., & Winkler Metzke,
C. (2008). Course and predictors of rehospitalization
in adolescent anorexia nervosa in a multisite
study. International Journal of Eating Disorders, 41,
29–36.
Treat, T. A., Gaskill, J. A., McCabe, E. B., Ghinassi, F. A.,
Luczak, A. D., & Marcus, M. D. (2005). Short-term
outcome of psychiatric inpatients with anorexia ner-
vosa in the current care environment. International
Journal of Eating Disorders, 38, 123–133.
Wakefield, A., & Williams, H. (2009). Practice recommen-
dations for the nutritional managment of anorexia
iley & Sons, Ltd and Eating Disorders Association.
S. Hart et al. Weight Changes During Refeeding
nervosa in adults. ACT: Dietitians Association of Aus-
tralia Website; 1–45.
Winston, A. P., Gowers, S., Jackson, A. A., Richardson, K.,
Robinson, P., Shenkin, A., et al. (2005). Guidelines for
the nutritional management of anorexia nervosa (No.
CR130), London: Royal College of Psychiatrists,
London.
Eur. Eat. Disorders Rev. 19 (2011) 390–397 � 2010
Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B.,
Mitchell, J. E., Powers, P., et al. (2006). Practice
guideline for the treatment of patients with eating
disorders (3rd edition). American Psychiatric Associ-
ation; 1–128.
Zipfel, S., Lowe, B., Reas, D. L., Deter, H. C., & Herzog,W.
(2000). Long-term prognosis in anorexia nervosa:
John Wiley & Sons, Ltd and Eating Disorders Associati
Lessons from a 21-year follow-up study. Lancet,
355, 721–722.
Zuercher, J. N., Cumella, E. J., Woods, B. K., Eberly, M., &
Carr, J. K. (2003). Efficacy of voluntary nasogastric
tube feeding in female inpatients with anorexia ner-
vosa. Jpen. Journal of Parenteral & Enteral Nutrition,
27, 268–276.
on. 397