Nutritional Rehabilitation for Eating Disorders: River Centre Clinic Program Description

Special Article - Eating Disorders

Ann Nutr Disord & Ther. 2017; 4(2): 1044.

Nutritional Rehabilitation for Eating Disorders: River Centre Clinic Program Description

Garner DM1,2*, Desai JJ¹, Desmond M¹, Good A¹ and Wohlers J³

¹River Centre Clinic, USA

²River Centre Foundation, USA

³Centre Syracuse and Buffalo Centre for Eating Disorders, USA

*Corresponding author: David M Garner, River Centre Clinic, 5465 Main Street, Sylvania, OH 43560, USA

Received: April 09, 2017; Accepted: May 11, 2017; Published: May 18, 2017


Nutritional rehabilitation plays a central role in the treatment of eating disorders, and the varied plans recommended; however, it is noteworthy that the details of this aspect of treatment are rarely specified and little has been written on the theoretical principles behind the different approaches. This report describes our approach in sufficient detail to allow our outcomes to be replicated and compared with other programs. Our approach to meal planning has been referred to as “mechanical eating” and consists of a structured eating program in which quantity of food consumed, type of food consumed and spacing of meals, are all specified in advance. This approach is designed to temporarily remove decision-making associated with eating and relies on a set of rules for starting, maintaining, and stopping eating designed to override the complex physiological and psychological cues that typically disrupt normal eating among those with eating disorders. It diverges markedly from the Exchange System recommended in many nutritional rehabilitation programs. It relies heavily on using commercially available packaged meals and prescribing the exact number of Calories to be consumed throughout the day. Body weight is checked on each treatment day and Calories are adjusted to promote steady weight gain in anorexia nervosa and weight stabilization in other eating disorders when weight suppression is less prominent. We have anticipated potential criticisms of this approach and have provided the theoretical and practical basis for our model.

Keywords: Anorexia nervosa; Eating disorders; Nutritional rehabilitation; Body weight


The plan for nutritional rehabilitation varies significantly between different eating disorder programs. Despite the central role of nutritional rehabilitation in the treatment of eating disorders, and the varied plans recommended, it is noteworthy that the details of this aspect of treatment are rarely specified and there is even less written on the theoretical principles behind the different approaches. Hart, Franklin, Russell & Abraham [1] reviewed 26 papers describing the feeding methods used in the inpatient treatment of Anorexia Nervosa (AN) and conclude that there are no evidence-based guidelines for the best and safest method for nutritional rehabilitation comparing four different feeding methods: 1) food only, 2) high energy food supplements plus food, 3) nasogastric feeding and 4) Total Parenteral Nutrition (TPN). Most papers reviewed describe two or more of these methods applied during treatment. Similar findings are reported by Garber and colleagues [2] in another recent review of inpatient programs indicating that the most popular approaches to re-nutrition use either meals only or combine meals with nasogastric feeding. Both reviews recommend that all reports on refeeding should include, at a minimum, admission and discharge BMI, weight change during treatment and length of stay. The lack of detail regarding the feeding regimes employed as well as the limited evidence on efficacy led to the view that no conclusion could be offered regarding the most effective method of achieving nutritional rehabilitation in AN. The aim of this paper is to provide sufficient detail about our approach to facilitate replication in other settings as well as understand the methods we follow so that our outcomes [3] can be compared to other programs.

Our approach to nutritional rehabilitation has been employed for more than 20 years in our Partial Hospitalization Program (PHP) and Adolescent Residential Program (ARP) in Ohio and more recently in two programs in New York. The Ohio PHP is for adults and combines 35 hours per week (11:30 am - 6:30 pm, 5 days-a-week, 7 hours-aday) of programmatic treatment with the option of independent dormitory-style living outside of program hours at no additional cost. The average age for those admitted to the PHP is 25.7 years (range: 18-67 years old). The ARP is 24 hours a day, 7 days-a-week; however, patients are often stepped down to fewer days near discharge based on clinical need and parent availability for monitoring. The average age for adolescents is 15.5 years (range: 9-17 years). Both programs follow a well-established evidence-based enhanced cognitivebehavioral treatment model that integrates individual, group, and family therapy [4-8]. The nutritional rehabilitation component of our structured approach, sometimes referred to as “mechanical eating,” has been described earlier for outpatient treatment [9,10]. Because of its meticulous attention to detail, the use of Calories (rather than the exchange system) and the reliance on commercially available packaged meals, our current approach to meal planning has been the subject of some controversy, although to our knowledge, not in the written literature. Thus, we will try to anticipate and address possible concerns that could be raised about certain aspects of this highly effective approach to nutritional rehabilitation.

The ultimate nutritional goals in the treatment of eating disorders are to help patients: 1) achieve and maintain an appropriate body weight, and 2) become more relaxed about the process of eating evidenced by eating a wide variety and enough food without guilt or resorting to dangerous compensatory behaviors. Most nutritional programs recognize the importance of encouraging regular eating patterns and incorporating previously avoided foods into the food plan. One of the first steps in this process is nutrition education with particular emphasis on dispelling myths about food and eating that are typical of those suffering from eating disorders [10]. The response to accurate information about eating and weight is central to mapping the proper course of treatment that addresses motivational impediments to change. Food, eating and weight are highly emotionally charged topics and failure to present a clear rationale behind the approach to nutritional rehabilitation can seriously impede motivation to change.

Different systems employed for food intake and meal planning

In a review of feeding methods used in inpatient treatment of AN, Hart and colleagues [11] reported that the most common protocol was nasogastric feeding and food followed by high-energy liquid supplements and food. In a separate review, Garber et al. [2] found that meal-based approaches and nasogastric plus oral intake were both common in inpatient treatment settings and that both can administer higher Calorie levels safely in mildly or moderately malnourished patients. Most inpatient programs for anorexia nervosa rely upon meals alone for energy intake; however, a significant proportion either combines meals or meal supplements with nasogastric feeding [12]. A minority rely upon total parenteral nutrition for weight restoration. There is some evidence for the success of non-hospital treatment settings in weight restoration; however, most of the studies published provide insufficient detail in the description of the nutritional rehabilitation program to allow replication in other settings [2]. An important consideration in describing nutritional rehabilitation for AN as well as other eating disorders is the system for planning and implementing meals.

Most authorities agree that planning meals in advance and eating according to a schedule are useful strategies in the management of eating disorders. However, descriptions of meal planning differ markedly in the details of the approach. Recommendations diverge in the degree to which structure and rigidity are applied to meal planning. Some programs are highly structured and insist on adherence to a specific plan for eating with clear rules pertaining to the amounts and types of food to be eaten. Others are more flexible and encourage patients to eat what is comfortable with gradual progression toward improved eating patterns. In some cases, advice is inconsistent. Sometimes there is a mix of planning meals in advance alongside strategies that encourage flexibility or spontaneity in eating with little attention to the potential impact of inconsistencies and contradictions in methods. For example, Brunzell and Hendrickson- Nelson [13] suggest planning eating in advance but also advocate eating in response to hunger and satiety cues without clarifying when to use these different approaches. We find that patients find this mixing of models to be confusing.

Our approach to meal planning consists of a structured eating program in which quantity of food consumed, type of food consumed and spacing of meals, are all specified in advance. We explain the plan and the rationale in the initial assessment to increase compliance on the first day of treatment. It is emphasized that this process is not designed to take away control from patients but rather to ultimately increase their sense of control and choice around food intake. Patients are encouraged to accept the view that adherence to the structured plan may be thought of as “an experiment” that will give them a better understanding of the relationship between caloric intake and weight [4,8]. Resistance can be diminished by reminding patients that they are not making a commitment to permanent change by participating in this “experiment” and it does not prohibit them from returning to their eating disorder in the future if they are unhappy with recovery. The aim of structured eating is to replace their current depleted state, dietary chaos and sense of hopelessness with predictability, control and possibly new options for the future.

Goal weight range: It is well established that low discharge weights are negatively associated with outcomes in studies of adolescent and adult AN patients [14-21]. In multisite study, Steinhausen and colleagues [22] present convincing data indicating the “strong effect of insufficient weight gain during first admission and lower BMI at the first discharge emphasizes the importance of adequate interventions” (p. 29). Traditionally, objectively low body weight, usually measured as BMI, has been the target for measuring outcome; however, recent studies have identified the magnitude of weight suppression as an important predictive variable in AN [23,24]. Determining the goal weight range for an eating disorder patient entering treatment is not a precise science since there are genetic and environmental factors responsible for significant individual differences in expected body weight. In setting goal weights, we are informed by highest past high weights as well as growth chart trajectories, particularly for adolescents. Patients begin treatment with the knowledge that they are on a weight gain or a weight maintenance protocol but we generally do not share an exact target weight range at the beginning of treatment. It is explained that with enough information, we can usually arrive at a good estimate of a healthy body weight; however, it is first necessary to collect detailed information on their weight history, growth charts and metabolic response to Calories prescribed during treatment. Most patients initially disagree with goal weight ranges and it is important to gently convey the notion that we really do not determine body weight in the strict sense since it is their biology that establishes and regulates body weight. Obviously, goal weight is a sensitive topic for patients and discussions must be sensitive to the patient’s level of insight and tolerance for change. As patients receive more education on the biology of weight regulation and its implications regarding their personal weight history, preliminary weight goals are established and shared with the patient along with the knowledge that the goal weight range may need to be adjusted over time. Again, it is important to convey the concept of treatment as “an experiment” designed to restore health, eliminate food preoccupations, and reduce vulnerability to binge eating that can result in marked increases in body weight.

For patients who need to gain weight in treatment, Calories need to be prescribed to create gradual and systematic weight gain at a rate of 2-3 pounds a week. If patients gain too quickly, then they need to know that their Calories will be cut. Once a maintenance weight has been achieved, Calories will be adjusted to keep weight within a 5-pound range. This reassurance can be bolstered by reviewing examples of weight charts like the one in Figure 1 which shows this steady and predictable increase in weight followed by maintenance in the goal weight range. It is both surprising and reassuring to many patients how rapidly metabolic rate is boosted in response to increases in Calories prescribed [25] (see triangles in Figure 1). Patients are encouraged to view food as “medication” and the “dosage” is designed to increase metabolic rate while creating predicable weight gain. If weight gain is not the main goal of treatment, then the Calories are adjusted to maintain a stable body weight that is consistent with the patient’s genetic and/or biological predisposition and this can be expected to lead to a marked decline in disturbed eating patterns, as well as emotional and cognitive symptoms. It is our assumption that normalization of body weight is absolutely required to promote “healing” from the ravages of chaotic eating patterns and chronic starvation/dieting.

Citation: Garner DM, Desai JJ, Desmond M, Good A and Wohlers J. Nutritional Rehabilitation for Eating Disorders: River Centre Clinic Program Description. Ann Nutr Disord & Ther. 2017; 4(2): 1044.