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Can high-calorie refeeding process lead to better anorexia outcomes?


When treating patients with anorexia nervosa and malnourishment, the current standard of care involves starting with low calories and then advancing with caution. A new investigation examines whether a higher calorie refeeding protocol could be more beneficial to patients with no increase in adverse events.

When a patient is in the early days of being treated for the malnourishment associated with anorexia nervosa, the current standard of care includes administering low calorie refeeding and being cautious in increasing the number of calories. A new investigation in JAMA Pediatrics looks at whether utilizing a higher-calorie regimen could perform just as well or even better.1 It was the first randomized clinical trial in the United States to compare refeeding protocols.

The investigators ran a multicenter randomized clinical trial that had prospective follow-up. It was conducted at large tertiary care hospitals, using 2 inpatient eating disorder programs . The participants were hospitalized for anorexia nervosa or atypical anorexia nervosa. They had 60% or more of median body mass index. The investigators were comparing lower-calorie refeeding, which started at 1400 kcal and increased by 200 kcal every other day, with higher-calorie refeeding, which started at 2000 kcal and increasing by 200 kcal per day.

There were 120 participants enrolled in the study, but 9 withdrew before treatment, leaving 111 participants who were aged 12 to 24 years. The researchers found that higher-calorie refeeding reestablished medical stability significantly earlier than the lower-calorie refeeding protocol (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). However, electrolyte abnormalities as well as other adverse events were not different between the groups. Patients who were given the higher-calorie refeeding regimen had a hospital stay that was on average 4.0 days shorter (95% CI, −6.1 to −1.9 days). The shorter stay led to an average savings of $19,056 in hospital charges per participant.

The researchers concluded that using a more rigorous refeeding program in malnourished patients with both anorexia nervosa and atypical anorexia nervosa led to nutritional gains. Most importantly, these gains did not come with an increased number of safety events during the patient’s hospitalization. Plus, patients who received the higher calorie refeeding program were able to leave the hospital earlier than those who received the standard of care program, meaning significant medical savings.


1. Garber A, Cheng J, Accurso E, et al. Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with anorexia nervosa. JAMA Pediatr. October 19, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.3359

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