Refeeding Protocol Research Articles

The Road to Standardizing Refeeding Protocols: Dietitian-led Education to Critical Care Staff to Improve Electrolyte Management in Preventing and Treating Refeeding Syndrome in High Risk, Critically Ill Patients

The Road to Standardizing Refeeding Protocols: Dietitian-led Education to Critical Care Staff to Improve Electrolyte Management in Preventing and Treating Refeeding Syndrome in High Risk, Critically Ill Patients

55 Establishing grain-based modified protocols for re-feeding malnourished horses

Abstract Increased feed costs, forage availability, and the increasing number of malnourished horses present major challenges to the equine industry. The goal of this project was to test an adapted refeeding protocol using Bermuda hay and two commercial grain products in severely malnourished horses. So, an 8-wk study from January to March 2023 was conducted to evaluate the effects of Total Equine in the refeeding of 10 emaciated horses. Horses were previously destined for slaughter and purchased from an auction with an average body condition score (BCS) of 2.01 (S.D. ± 0.69), then quarantined for 30 d before starting the study following recommended biosecurity protocols. During quarantine, horses were evaluated by a veterinarian and received treatment as needed, vaccinations, deworming, and mares were pregnancy checked. All horses were provided with ad libitum Bermuda hay and water. Upon completion of the quarantine period, horses were blocked into two groups based on age, BCS, pregnancy status, and gender and randomly assigned to a diet. The Control (Ctrl) diet consisted of a commercial grain diet recommended and used by five local West Texas horse rescue groups and the Treatment (Trt) diet consisted of Total Equine. Both diets included ad libitum access to water and Bermuda hay (TDN 56.5) offered twice daily in port-a-grazer tubs to control waste and the amount was adjusted daily to maintain a 3% refusal rate. Grain was offered at a rate of 0.005% BW + 227 kg per the manufacturer’s suggestion, divided into 2 equal feedings with amounts adjusted weekly. Individual horses were weighed weekly using an electronic scale and BCS was evaluated at wk 0, 4, and 8. All horses were allowed a 1-h turnout in a dry-pen per day for 6 d each week. Blood samples were collected at wk 0, 4, and 8 for analysis. Health parameters were measured weekly throughout the study. Samples (grain, hay, hay orts) were collected twice weekly for DM, NDF, ADF, EE, CP, and Ash analysis. Data was analyzed using Proc Mixed in SAS. Overall, there was no significant difference between DMI by diet (Ctrl 8.74 kg/d and Trt 9.44 kg/d). However, a tendency for increased ADG (P = 0.06) for the Trt diet (Ctrl 0.20 kg/d & Trt 1.34 kg/d) was noted. Efficiency calculated as (ADG/DMI) was significantly improved (P = 0.04) indicating an improvement in the efficiency of BW gain for the Trt diet compared with the Ctrl. Improved BW gain and efficiency of gain are of interest when rehabilitating malnourished horses. The establishment of accessible modified feeding protocols may improve efficiency and reduce the cost involved in the rehabilitation of malnourished horses and would be a step forward for the equine industry.

Malnutrition drives infection susceptibility and dysregulated myelopoiesis that persists after refeeding intervention.

Undernutrition is one of the largest persistent global health crises, with nearly 1 billion people facing severe food insecurity. Infectious disease represents the main underlying cause of morbidity and mortality for malnourished individuals, with infection during malnutrition representing the leading cause of childhood mortality worldwide. In the face of this complex challenge, simple refeeding protocols have remained the primary treatment strategy. Although an association between undernutrition and infection susceptibility has been appreciated for over a century, the underlying mechanisms remain poorly understood and the extent to which refeeding intervention is sufficient to reverse nutritionally acquired immunodeficiency is unclear. Here we investigate how malnutrition leads to immune dysfunction and the ability of refeeding to repair it. We find that chronic malnutrition severely impairs the ability of animals to control a sub-lethal bacterial infection. Malnourished animals exhibit blunted immune cell expansion, impaired immune function, and accelerated contraction prior to pathogen clearance. While this defect is global, we find that myelopoiesis is uniquely impacted, resulting in in reduced neutrophil and monocyte numbers prior to and post-infection. Upon refeeding, we observe that animals recover body mass, size, cellularity across all major immune organs, the capacity to undergo normal immune cell expansion in response to infection, and a restoration in T cell responses. Despite this broad improvement, refed animals remain susceptible to bacterial infection, uncoupling global lymphoid atrophy from immunodeficiency. Mechanistically, we find peripheral neutrophil and monocyte numbers fail to fully recover and refed animals are unable to undergo normal emergency myelopoiesis. Altogether, this work identifies a novel cellular link between prior nutritional state and immunocompetency, highlighting dysregulated myelopoiesis as a major driver. We believe these findings illustrate how exposure to food scarcity is an immunologic variable, even post-recovery, which should be accounted for in patient medical history and current global public health policy.

The Inpatient Management of Adolescents with Eating Disorders.

Eating disorders affect individuals of all ages, genders, sexual orientations, ethnicities, races, and socioeconomic statuses. They can lead to serious medical complications that require inpatient treatment. The eating disorders that are most likely to lead to medical complications requiring medical inpatient stabilization include anorexia nervosa, atypical anorexia nervosa, avoidant-restrictive food intake disorder, bulimia nervosa, and purging disorder. There are criteria that can help determine if a patient requires inpatient stabilization. Nearly all body systems may be affected. Patients are often treated by following a refeeding protocol that reduces the risk of developing refeeding syndrome, a dangerous and life-threatening state of metabolic derangements that can arise when a malnourished individual begins a renourishment process. Following stabilization, patients should receive further care through a number of different treatment options directed at their underlying eating disorder and by working with a multidisciplinary team. [Pediatr Ann. 2024;53(8):e283-e287.].

Sex differences in electrolyte abnormalities indicating refeeding syndrome risk among hospitalized adolescents and young adults with eating disorders

BackgroundRefeeding syndrome is the gravest possible medical complication in malnourished patients undergoing refeeding in the hospital. We previously reported that males with malnutrition secondary to eating disorders required more calories and had longer hospital stays than females; however, sex differences in electrolyte abnormalities indicating refeeding syndrome risk remain unknown. The objective of this study was to assess differences in electrolyte abnormalities indicating refeeding syndrome risk among male and female adolescents and young adults with eating disorders hospitalized for medical instability.MethodsWe retrospectively reviewed the electronic medical records of 558 patients aged 9–25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability between May 2012 and August 2020. Serum was drawn per standard of care between 5 and 7 am each morning and electrolyte abnormalities indicating refeeding syndrome risk were defined as: hypophosphatemia (< 3.0 mg/dL), hypokalemia (< 3.5 mEq/L), and hypomagnesemia (< 1.8 mg/dL). Logistic regression was used to assess factors associated with electrolyte abnormalities indicating refeeding syndrome risk.ResultsParticipants included 86 (15.4%) males and 472 (84.6%) females, mean (SD) age 15.5 (2.8) years. Rates of refeeding hypophosphatemia (3.5%), hypokalemia (8.1%), and hypomagnesemia (11.6%) in males hospitalized with eating disorders were low, with no statistically significant differences from females. Older age was associated with higher odds of refeeding hypophosphatemia and hypomagnesemia. Lower percent median body mass index and greater weight suppression at admission were associated with higher odds of refeeding hypophosphatemia.ConclusionsRates of electrolyte abnormalities indicating refeeding syndrome risk were low in males hospitalized for eating disorders and rates did not significantly differ from females. Together with our finding that males have higher caloric requirements and longer hospital length of stay, the finding that electrolyte abnormalities indicating refeeding syndrome risk were not greater in males than females supports future research to evaluate the safety and efficacy of higher calorie and/or faster advancing refeeding protocols for males.

A prospective observational study examining weight and psychosocial change in adolescent and adult eating disorder inpatients admitted for nutritional rehabilitation using a high-energy re-feeding protocol

BackgroundHigh-energy re-feeding protocols are increasingly utilised for nutritional rehabilitation in adolescents with anorexia nervosa (AN), however, concern persists that adults with AN may be at greater risk of developing complications. In addition, research on psychological outcomes of eating disorder (ED) inpatient treatment programs, and outcomes of high-energy protocols in avoidant restrictive food intake disorder (ARFID) and bulimia nervosa (BN), is limited. This study of an ED inpatient program using a high-energy protocol, compared changes in weight and psychosocial outcomes between adolescents and adults, and identified medical risk factors associated with deviation from the protocol.MethodThis prospective observational study took place in a voluntary ED treatment program in a private hospital. Weight, height, and psychosocial questionnaires (ED Examination-Questionnaire, Depression Anxiety Stress Score, Clinical Impairment Assessment and AN/BN Stage of Change) were collected from consenting adolescents (16–20 years) and adults (> 20 years) on admission and discharge. Medical tolerance to the high-energy protocol was assessed daily. Independent samples t-tests and paired samples t-tests were applied to normally distributed data, and Mann–Whitney U tests and Wilcoxon signed-rank tests to skewed data. P-values < 0.05 were considered significant statistically.ResultsNinety-seven participants were recruited. The majority (n = 91, 94%) were female and most (n = 80, 83%) had AN. Forty-two (43%) were adolescents and 55 (57%) were adults. In participants with AN, weight change (Δ) was significant [median Δ 8.0 (interquartile range (IQR) 4.3) kg]. There was no difference in rate of weight change between adolescents and adults with AN [mean Δ 1.8 (standard deviation (SD) 0.5) kg/week vs. Δ 1.8 (SD 0.6) kg/week; p = 0.841, respectively]. One (1%) participant with AN did not tolerate the high-energy protocol due to oedema. Participants achieved positive change in psychosocial questionnaire scores (p < 0.001) after the the specialist ED program, with no difference between adolescents and adults (p > 0.05).ConclusionsThis voluntary ED treatment program using a high energy re-feeding protocol was effective in achieving positive weight and psychological change for adolescents and adults with minimal adverse events. This indicates that the specialist ED program has both nutritional and psychological benefits.

A Systematic Review to Manage Avoidant/Restrictive Food Intake Disorders in Pediatric Gastroenterological Practice.

Avoidant/Restrictive food intake disorder (ARFID) is a feeding disorder characterized by persistent difficulty eating, such as limited choices of preferred foods, avoidance or restriction of certain foods or food groups, and negative emotions related to eating or meals. Although ARFID mainly affects children, it can also occur in adolescents and adults. ARFID can have serious physical and mental health consequences, including stunted growth, nutritional deficiencies, anxiety, and other psychiatric comorbidities. Despite its increasing importance, ARFID is relatively underrecognized and undertreated in clinical practice. Treatment consists of a multidisciplinary approach involving pediatric gastroenterologists, nutritionists, neuropsychiatrists, and psychologists. However, there are several gaps in the therapeutic approach for this condition, mainly due to the lack of interventional trials and the methodological variability of existing studies. Few studies have explored the nutritional management of ARFID, and no standardized guidelines exist to date. We performed a systematic literature review to describe the different nutritional interventions for children and adolescents diagnosed with ARFID and to assess their efficacy and tolerability. We identified seven retrospective cohort studies where patients with various eating and feeding disorders, including ARFID, underwent nutritional rehabilitation in hospital settings. In all studies, similar outcomes emerged in terms of efficacy and tolerability. According to our findings, the oral route should be the preferred way to start the refeeding protocol, and the enteral route should be generally considered a last resort for non-compliant patients or in cases of clinical instability. The initial caloric intake may be adapted to the initial nutritional status, but more aggressive refeeding regimens appear to be well tolerated and not associated with an increased risk of clinical refeeding syndrome (RS). In severely malnourished patients, however, phosphorus or magnesium supplementation may be considered to prevent the risk of electrolyte imbalance, or RS.

Clinical Outcomes of Refeeding Syndrome: A Systematic Review of High vs. Low-Calorie Diets for the Treatment of Anorexia Nervosa and Related Eating Disorders in Children and Adolescents.

Over the years, the standard of care for re-alimentation of patients admitted for the treatment of anorexia nervosa (AN) has been a conservative or cautious approach described as "start low and go slow." These traditional refeeding protocols advocate for a low-calorie diet that restricts carbohydrates, with the primary goal of hypothetically lowering the risk of refeeding syndrome (RFS) and its complication. However, no consensus exists for the optimal inpatient approach to refeeding children and adolescents with AN. There is still some disagreement about what constitutes an ideal pace for nutritional rehabilitation. Varying treatment protocols have emerged across the globe, often reflecting the preferences and biases of individual practitioners and contributing to the lack of a universally accepted protocol for refeeding in AN. Although it is widely accepted that low-caloric refeeding (LCR) is safe for inpatient treatment of AN, this strategy has been shown to have several significant drawbacks, leading to increased criticism of the LCR method. Research from the last decade has led to calls for a more aggressive refeeding protocol, one that suggests a higher caloric intake from the offset. As a result, this research aimed to conduct a systematic review of the existing literature on strategies for refeeding hospitalized pediatric/adolescent patients with AN and related eating disorders. We aimed to compare high-caloric refeeding (HCR) and LCR in terms of weight gain, length of stay, and risk of RFS. We conducted a thorough search of medical databases for abstracts published in English, including Google Scholar, PubMed, and MEDLINE, to find relevant studies published between 2010 and February 2023. Our focus was on articles that evaluated high versus low refeeding protocols in children and adolescents hospitalized for treating AN and related eating disorders. Only articles that reported on at least one of the outcome variables of interest, such as hypophosphatemia, weight gain, RFS, or length of hospital stay, were considered. This review included 20 full-text articles published in the last decade on the HCR protocol in children and adolescents, with a total sample size of 2191 participants. In only one of the 20 studies did researchers find evidence of a true clinical case of RFS. We, therefore, found no evidence that HCR increased the risk of RFS in adolescents, even in those with a very low body mass index (BMI). However, evidence suggests a lower BMI at the time of hospital admission is a better predictor of hypophosphatemia than total caloric intake.In conclusion, based on the evidence from this review, a high-caloric diet or rapid refeeding in children/adolescents suffering from AN may be both safe and effective, with serial laboratory investigations and phosphate supplementation as needed. Hence, more research, particularly, randomized controlled trials, is required to help shape an evidence-based refeeding guidelineoutlining target calorie intakes and rates of advancement to assist clinicians in the treatment of adolescents with AN and related eating disorders.

95 Health parameter variation in emaciated stock-type horses going through two refeeding protocols

Equine health and welfare are a concern in the equine industry and veterinary medicine. Clinical health parameters such as Body Condition Scores (BCS), weight, body temperature (T°C), respiratory (RR), heart rate (HR) and hematological evaluation assist the veterinarian in the diagnosis of emaciation due to abuse or neglect. Yet, clinical parameters through the recovery process of emaciated horses are not well studied. Our goal is to establish recovery profiles in emaciated horses going through 2 modified refeeding protocols. We acquired 11 stock-type horses (Geldings = 3, Mares = 8) aged between late-teens and early 20s, with a BCS ≤3, of unknown health history. Animals were quarantined for 30 d at the Sul Ross Horse Unit upon arrival and offered free-choice grass hay, with health care provided as needed and pregnancy checks performed by trained veterinarians. Vaccinations (Equi-Jec 7, Boehringer Ingelheim) and deworming (Ivermectin 2%) were conducted during the quarantine. Clinical parameters of T°C, RR and HR, as well as BCS were collected a week after arrival (Quarantine), during Adaptation and then weekly into the refeeding protocol (Week 1 and 2) by trained veterinarians and animal scientists (n = 4). Hematological analysis including complete blood count (CBC) and blood chemistry (BC) were performed before the adaptation to the refeeding protocol, with a mid-point (Week 4) and post (end of Week 8) analysis scheduled (Texas A&M VMDL). Preliminary analysis show significant differences in RR [F(6,36) = 4.34, P = 0.0022] and T°C [F(6,36) = 2.71, P = 0.0284] during recovery. While thisstudy is ongoing, preliminary data demonstrates improvement in clinical health parameters of the studied horses (Table 1). Better understanding of the changes throughout recovery in starved horses will support decision-making for the equine industry. Data originating from this study will support standards for the care of neglected and malnourished horses.

63 Influence of diet and body condition on blood chemistry and body composition during the refeeding process

Starved horses with low body condition scores (BCS, < 3 out of 9) continues to be a prominent welfare concern, yet limited nutritional studies on the reconditioning process exist. The aim of this study was to determine how alternative diets affected blood chemistry panels and body composition in mature, starved (initial BCS 1 or 2) light breed horses during the refeeding process (final BCS 4, UTK IACUC 2811–1220). Horses (n = 10, 18.8 ± 2.5 y (mean ± SD), BCS 1.4 ± 0.5, 3 geldings and 6 mares, light breeds) were placed on a control diet (C; 100% digestible energy, DE, from grass hay and Purina Free Balance) or a concentrate diet (S; 50 % DE from grass hay and 50% DE from Purina Equine Senior). Diets were formulated to increase caloric intake in accordance with previously established refeeding recommendations and the NRC (2007), where horses were increased from 50% DE to 100% DE over 10 d to prevent refeeding syndrome, and then were increased up to 145% DE as needed based on weekly body weight (BW) until a BCS of 4 was reached. Weekly BW and BCS were assessed by 3 independent reviewers and plasma samples collected at each BCS increase based on reviewer average and an increase in of 16–20 kg in BW. Diet and BCS effects on blood chemistry and body composition were analyzed using generalized linear mixed models in SAS, with breed and individual animals as random effects, and mean separation using Tukey's adjustment.Significance was detected at P < 0.05 (SAS 9.4, Cary, NC). Non-normally distributed data were rank transformed as determined by Shapiro-Wilk. Of the 10 horses in the study, 3 were euthanized within 10d of enrollment due to infectious disease or colic unassociated with dietary treatment, 1 was disenrolled due to pneumonia, and the remaining 6 horses were fully reconditioned (C: n = 3, S: n = 3). Horses were recovered similarly between diet groups (change in BW: C = 46.15 ± 9.9 kg, S = 41.8 ± 14.9 kg, mean ± SD, P > 0.05). Plasma creatine kinase differed by BCS (P = 0.0007), whereas creatinine differed by both diet (P = 0.006) and BCS (P < 0.0001); however, all values were within normal limits. Lactose was lower in BCS 4 horses compared with all other scores, yet all values were also within normal ranges (P = 0.0007). Rib fat thickness was greater in BCS 4 horses (C = 0.35(0.08)mm, S = 0.38(0.20)mm, median(IQR)) than all other BCS (P = 0.001). Rump fat thickness was highest in BCS 4 horses (S = 0.36 (0.13), C = 0.30 (0.05)). Based on our findings, grass hay and complete feed concentrates can be used to successfully recover emaciated horses. Further studies would be helpful in determining optimal refeeding protocols.

Adding mini meals to a nasogastric refeeding protocol for patients with eating disorders can be achieved on general hospital wards.

Treatment of medically compromised patients with eating disorders is difficult in general hospital wards. There is currently no consensus on the best feeding method; however, previous research has demonstrated the safety of using enteral feeding. Because an oral diet has benefits on psychological and behavioural pathways, concurrent feeding requires further investigation. The present study aimed to examine acceptability and safety of implementing mini meals to a previously nil-by-mouth 7-day enteral feeding protocol. This was mixed methods research including a retrospective observational study and participant survey. Patients admitted to a tertiary hospital in Brisbane, Australia, between July 2020 and March 2021 were eligible. Eligible participants were provided mini meals from day 5. Type and quantity of meals consumed alongside clinical incident data were collected. The survey examined acceptability of mini meals. Descriptive statistics were used to interpret findings. Content analyses were conducted on survey responses. Sixty-four participants (95%, n = 57/60 female, 25.2 ± 8.9 years; 75%, n = 45/60 diagnosed with anorexia nervosa) were included. At least half of the participants consumed some or all of the mini meals at each meal period. No clinical incidents were reported. Twenty-six (50%, n = 26/52) surveys were returned. Half (54%, n = 14/26) agreed-strongly agreed that mini meals improved their experience. Eleven participants desired more choice in menu items. The present study found that introducing mini meals into an enteral feeding protocol is acceptable and safe for patients with eating disorders. Participants reported benefits in returning to eating; however, some items on the menu require reconsideration to enable increased consumption.

Acceptability of using a nasogastric refeeding protocol with adult patients with medically unstable eating disorders.

Nasogastric feeding is becoming commonly used to support patients with medically compromised eating disorders. Previous research has demonstrated the safety of this approach, however there is limited evidence as to how adult patients and staff perceive this feeding method. This study aimed to describe the acceptability of a nasogastric refeeding protocol with adult patients with medically unstable eating disorders and the staff involved in their treatment. This was a qualitative exploratory study using semi-structured interviews conducted in acute medical wards of a tertiary hospital where nasogastric nutrition is the sole source of nutrition for the first 7days of the eating disorder admission. Data wereanalysed using the Framework method. Eight patients (100% female, median: 22 years old, n = 6 diagnosed with anorexia nervosa) and 12 staff members (medical n = 5, nursing n = 5, dietitians n = 2; median: 8.5 years clinical experience) were interviewed. Patients reported that nasogastric feeding was tolerable, however concerns were raised regarding communication and the desire for concurrent oral feeding. Acceptability from staff was influenced by perceived competence, confidence, tensions around patient-centred care,and working with stigma and ambivalence. Consideration needs to be given as to whether a 'nil by mouth' status during nasogastric feeding further impacts recommencing an oral diet to progress treatment. Improvements are required within the current service, including improved communication, additional educational resources for patients,and allowing patients to partake in decision-making as able.

Liver and vitamin B12 parameters in patients with anorexia nervosa before and after short-term weight restoration

Hepatic involvement in anorexia nervosa (AN) has been previously reported, but a link to elevated vitamin B12 concentrations, which can be a sign for liver damage, has not been thoroughly examined. We measured liver enzymes (alanine aminotransferase, aspartate aminotransferase, gamma-glutamyltransferase) and vitamin B12 parameters (total B12, holotranscobalamin, methylmalonic acid) in the plasma of young female patients with acute AN (n=77) and after short-term weight restoration (n=58, median body mass increase=25%), in comparison to healthy control participants (n=63). For a comprehensive assessment of vitamin B12 status, the combined marker cB12 was calculated. In acute AN, activities of alanine aminotransferase and gamma-glutamyltransferase as well as holotranscobalamin concentrations were elevated, and alanine aminotransferase activities positively correlated with total B12, holotranscobalamin and cB12 in patients with elevated liver enzyme activities. After weight restoration, alanine aminotransferase activities and holotranscobalamin concentrations were elevated, and cB12 increased above the level of the healthy control group. The present study provides further evidence for a hepatic involvement in acute AN in concert with vitamin B12 parameters and points to refeeding-associated alterations of liver and vitamin B12 parameters. Future studies should include non-invasive methods to characterize hepatic involvement and evaluate vitamin B12 status as a potential marker of liver damage/irritation.

Optimising Treatment Delivery and Reducing Length of Stay in an Adult In-Patient Unit

AimsLifetime prevalence of eating disorders worldwide is 8.4% (3.3–18.6%) for women and 2.2% (0.8–6.5%) for men and this prevalence has been increasing over time. Anorexia nervosa has become a greater burden on secondary care: Not only have admission rates increased, but so too have multiple admissions per person with Anorexia Nervosa. Conservative treatment approaches and long lengths of stay have both direct and indirect costs for patients, hinder access to the service for potential patients and reduce service cost effectiveness. Ramsay Clinic Hollywood is a voluntary, private ten bed adult eating disorder inpatient service in Perth, Western Australia (WA). It is the only inpatient eating disorder specialist service for people over the age of 16, in both the private and public sector in WA. Over the past eight years, our focus has been on optimizing treatment delivery to minimise time spent in hospital for individuals with anorexia. The aim of this study was to evaluate whether instituting a rapid refeeding protocol was effective in optimising treatment outcomes, such as rate of refeeding and reducing length of stay (LOS).MethodsA retrospective review of data collected for all inpatients from 2013–2019 was conducted. The outcomes evaluated were length of stay and number of readmissions.ResultsUtilising a rapid refeeding protocol successfully increased the rate of refeeding from 0.6kg/week to 1.5kg/week. This led to a reduction in average length of stay from 52 days in 2013 to 24 days in 2017. Concomitantly we have been able to double the number of patients admitted to the service/ year and reduce the number of readmissions/ patientsConclusionThese results suggest that it is possible to lower length of stay by increasing the rate of refeeding and this in turn allows more patients access to hospital care for their eating disorder.

Rapid refeeding in anorexia nervosa: A dialectic balance.

ObjectiveTo examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion.MethodThis cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m2 and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant.ResultsTotal length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol.DiscussionThis is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life.Public SignificanceThis study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost‐savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life.

35. Sex Differences in Nutritional Refeeding Treatment Among Adolescents and Young Adults Hospitalized for Eating Disorders

Eating disorders in male populations are underrecognized and undertreated, leading to delays in identification, diagnosis, and treatment. Although male adolescents and young adults generally have greater energy requirements than females due to greater body weights, metabolic response, and exercise, current inpatient nutritional refeeding protocols support a single caloric prescription regardless of sex. The objective of this study was to determine sex differences in nutritional refeeding outcomes among adolescents and young adults hospitalized for eating disorders.

To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol.

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

Hepatic Global DNA Hypomethylation Phenotype in Rainbow Trout Fed Diets Varying in Carbohydrate to Protein Ratio

BackgroundA high carbohydrate–low protein diet can induce hepatic global DNA hypomethylation in trout. The mechanisms remain unclear. ObjectivesWe aimed to investigate whether an increase in dietary carbohydrates (dHCs) or a decrease in dietary proteins (dLPs) can cause hepatic global DNA hypomethylation, as well as explore the underlying mechanisms in trout. MethodsTwo feeding trials were conducted on juvenile males, both of which involved a 4-d fasting and 4-d refeeding protocol. In trial 1, trout were fed either a high protein–no carbohydrate [HP-NC, protein 60% dry matter (DM), carbohydrates 0% DM] or a moderate protein–high carbohydrate (MP-HC, protein 40% DM, carbohydrates 30% DM) diet. In trial 2, fish were fed either a moderate protein–no carbohydrate (MP-NC, protein 40% DM, carbohydrates 0% DM), an MP-HC (protein 40% DM, carbohydrates 30% DM), or a low protein–no carbohydrate (LP-NC, protein 20% DM, carbohydrates 0% DM) diet to separate the effects of dHCs and dLPs on the hepatic methylome. Global CmCGG methylation, DNA demethylation derivative concentrations, and mRNA expression of DNA (de)methylation-related genes were measured. Differences were tested by 1-factor ANOVA when data were normally distributed or by Kruskal–Wallis nonparametric test if not. ResultsIn both trials, global CmCGG methylation concentrations remained unaffected, but the hepatic 5-mdC content decreased after refeeding (1–3%). The MP-HC group had 3.4-fold higher hepatic 5-hmdC and a similar 5-mdC concentration compared with the HP-NC group in trial 1. Both MP-HC and LP-NC diets lowered the hepatic 5-mdC content (1–2%), but only the LP-NC group had a significantly lower 5-hmdC concentration (P < 0.01) compared with MP-NC group in trial 2. ConclusionsdHC and dLP independently induced hepatic global DNA demethylation in trout. The alterations in other methylation derivative concentrations indicated the demethylation process was achieved through an active demethylation pathway and probably occurred at non-CmCGG sites.

Rapid renutrition improves health status in severely malnourished inpatients with AN - score-based evaluation of a high caloric refeeding protocol in severely malnourished inpatients with anorexia nervosa in an intermediate care unit.

ObjectiveRefeeding syndrome is a feared complication of refeeding patients with anorexia nervosa. There are now a number of controlled studies showing that refeeding with an initial high calorie count is more beneficial than cautious refeeding and is safe under continuous monitoring. However, there have yet not been studies in severe anorexia nervosa.MethodWe present an observational study in two different samples. The first sample consists of those 1075 out of a total of 3230 patients with anorexia nervosa treated in our hospital within 4 years for whom a complete admission laboratory was available and who had an age of at least 18 years at admission. A risk score was calculated from the number of pathological laboratory values out of 12 parameters indicating either refeeding syndrome or health hazards related to malnutrition. The second sample was obtained from a special ward for patients with eating disorders medically at‐risk. During the period in question, 410 patients with anorexia nervosa were treated there. 142 patients had a BMI of 13 or less and at the same time a complete data set with the mentioned 12 laboratory parameters at admission and weekly in the following 4 weeks after admission.ResultsThe risk represented by the laboratory parameters is significantly and negatively correlated to BMI and much higher for the group of patients with a BMI below 13 than for those with a higher BMI (χ 2 sig < 0.000). The 142 patients in the special care unit gain an average of more than 4.1 kg within 4 weeks on the high‐calorie diet. With this rapid weight gain, the risk score decreases highly significantly. Neither hypophosphatemia nor rhabdomyolysis is found under phosphate substitution. Hyperhydration occurred often, which manifests itself in the drop in haematocrit by the second week.DiscussionUnder thorough medical surveillance, supplementation of phosphate and thiamine, and substitution of electrolytes whenever necessary rapid renutrition appeared to be save even in extremely malnourished inpatients with anorexia nervosa. As measured by the laboratory values, the health status of the severely malnourished patients improves significantly on a high‐calorie diet. Except for hyperhydration, there was no evidence of a refeeding syndrome.

Rapid refeeding does not worsen anxiety in adolescents with anorexia nervosa: a pilot study

ABSTRACT The study aimed to describe the progression of state anxiety in adolescents with anorexia nervosa (AN) hospitalized on a high calorie refeeding (HCR) protocol. Participants, 12–21 years, admitted for malnutrition due to AN were placed on a HCR protocol in which calories were advanced by 300 kcal/day. The State-Trait Anxiety Inventory for Children (STAIC) was given to participants within 24 hours of hospitalization and the state anxiety component of the STAIC was administered daily immediately before and after breakfast until discharge. Of 22 patients enrolled, 86% were female, mean age was 14.9 ± 2.0 years, and 95% had AN-restrictive type. The median state and trait anxiety scores at time of admission were 37.0 (28–55) and 35.5 (23–51), respectively. There was no significant difference in median pre-meal state anxiety from hospital day 1 to 6 (34.0(26–55) vs. 38.5(25–55), p-value = 0.079) or in median post-meal state anxiety from hospital day 1 to 6 (35.5(29–56) vs. 37(24–56), p-value = 0.484). Similarly, we found minimal correlation between change in caloric intake and change in pre-meal S-anxiety (Spearman correlation coefficient = −0.032) or post-meal S-anxiety (Spearman correlation = 0.032). While this was a small sample observing anxiety over one week, we found no evidence that state anxiety increased with advancing calories, providing additional support for the use of more rapid refeeding protocols.