Compulsory Refeeding for Severely Ill AN Patients: Extreme measures worked for one group of critically ill patients.

Reprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Effective treatments for AN are badly needed, particularly for adults, according to Christoph Born, MD, and a team at Ludwig Maximillians-University in Munich, Germany. These researchers recently described their group’s novel intensive care approach for severely ill patients with AN, a program involving mandatory hospitalization, guardianship, and for some, installation of a percutaneous gastric feeding tube (BMC Psychiatry 15:57, 2015.). 

A study group with extremely low body weight

The authors reported on a group of 68 patients with AN who were severely underweight and who had been admitted to their hospital between 2000 and 2013; relapse and remission were common. Seventy-five percent of participants had BMIs under 13 kg/m2 on admission. Legal guardianship was established on the basis of Bavarian law. Patients were offered regular meals and a percutaneous gastric feeding tube was recommended (84% received them). 

The percutaneous feeding tube was thought to have several advantages over a nasogastric tube, including avoidance of damage to the nose or upper GI tract. In addition, patients were able to take food orally, and the tube could be used for supplementary feeding. Other important considerations were potentially decreasing the chances that patients could manipulate or remove the tube and minimizing the stigma. All the AN patients were required to participate in common meals on the ward. Gastric tube feeding with a high-caloric solution (up to 3000 kcal/day) was provided on an individualized basis. The primary goal was to help patients attain a BMI of 17 by gaining 700 to 1000 gm per week.

Tube feeding was halted once the patient reached a BMI of 17, and the feeding tube was removed after body weight remained stable for 2 weeks. Aftercare within a specialized ED setting was then arranged.

Was the extreme program effective?

Dr. Born reported that 84% of the patients had a percutaneous gastric feeding tube implanted; 3 had nasogastric tubes inserted; and 8 had neither because of contraindications. Mean BMI at admission was 12.3, and this rose to a mean of 16.7 at discharge. Duration of illness was shorter and weight gain during treatment was higher in those with restrictive type AN (ANR group) than in those with binge-purge type AN (ANBP group). 

Treatment lasted significantly longer in those with feeding tubes, but those without a feeding tube were younger, had been ill for a shorter time (7.3 vs. 9.9 years), and had slightly higher admission BMIs. Patients who attained the BMI goal of 17 were actively encouraged to seek further therapy. Those with ANBP were more likely to seek treatment in a psychotherapeutic or psychiatric hospital than were patients with ANR

The authors concluded that patients with severe AN can be successfully treated using a guardianship and tube feeding regimen such as theirs. They added, however, that little is known about the long-term outcome of AN patients after refeeding programs are completed, and they correctly note that the amount of lasting cognitive change is unknown. Furthermore, the goal BMI (17) represented a clinically significant change in this severely ill group, but was still a very low target BMI. 

The authors referenced an earlier 13-year follow-up program of 484 adult patients with AN in which 60.3% of patients had fully recovered, 25.8% had good outcomes, 6.4% had bad outcomes, 6.4% had a severe outcome, and 1.2% had died (Diabetes Metab2011; 37:305). In that study, 8 factors were linked to the lack of recovery at 2 years: low BMI at discharge, low energy and low fat intakes, high drive for excessive exercising, high scores for perfectionism, interpersonal distrust and anxiety, use of tube feeding, and poor adherence to treatment.