Refeeding Patients with Moderate and Severe Eating Disorders: A Retrospective Cohort Study

Special Article - Malnutrition

Int J Nutr Sci. 2021; 6(2): 1050.

Refeeding Patients with Moderate and Severe Eating Disorders: A Retrospective Cohort Study

Rabito GS1*, Blalock DV1, Beaty LR1, Harr BL1, Manwaring J1, Rienecke RD1,2, Trees NM1 and Mehler PS1,3

¹Eating Recovery Center and Pathlight Mood and Anxiety Centers, 8199 E 1st Ave Denver, CO 80230, USA

²Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago IL 60611, USA

³ACUTE c/o Denver Health, 723 Delaware St, 3rd Floor Pavilion M, Denver, CO 80204, USA

*Corresponding author: Rabito GS, Eating Recovery Center and Pathlight Mood and Anxiety Centers, 8199 E 1st Ave Denver, CO 80230, USA

Received: March 26, 2021; Accepted: April 28, 2021; Published: May 05, 2021


Background: Anorexia Nervosa (AN) is a life-threatening mental illness that can cause significant medical complications, including the potentially fatal refeeding syndrome. Registered dietitians (RDs) are a critical part of an eating disorder multidisciplinary team that focuses treatment on safe weight restoration and nutrition rehabilitation.

Method: This study is a description of how the nutrition rehabilitation protocol of 395 adult patients diagnosed with AN and admitted to residential eating disorder treatment is implemented, how the protocol is sustained throughout a patient’s treatment stay to achieve desired weight gain, and how the patients’ biochemical and clinical progress proceeded between admission and discharge, including laboratory results and body mass index (BMI).

Results: One hundred twenty-six patients required phosphorus supplementation for refeeding hypophosphatemia (RH); admission BMI was not significantly different between those with and without RH. The 15% of patients who required enteral nutrition at any point during their admission gained significantly less weight than patients who only received an oral meal plan. 34.4% of patients admitted with starvation induced hepatitis, 28.6% experienced refeeding hepatitis at some point, 21.0% of patients had elevated liver function tests 2 weeks into refeeding and 28.6% at discharge.

Conclusions: This study demonstrated overall effectiveness in achieving weight restoration goals with aggressive kcal increases without a single incidence of refeeding syndrome and infrequent RH. No significant biochemical changes were observed during refeeding. With close medical supervision and concurrent RD oversight, a refeeding approach with consistent calorie increases that is more aggressive than previously recommended appears to be safe.

Keywords: Anorexia Nervosa, Eating Disorders, Refeeding Syndrome, Nutritional Care Plan


Anorexia Nervosa (AN) is a multidimensional life-threatening mental illness. The American Psychiatric Association (DSM-V) diagnostic criteria for AN are defined by three components: 1) Restriction of energy intake relative to requirements, leading to significantly low body weight; 2) Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain; and 3) Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight [1]. AN is classified into two different subtypes: restricting type and binge-eating/purging type. Restricting type (AN-R) is characterized by severe food restriction. Binge-eating/ purging type (AN-BP) is characterized by calorie restriction as well as purging behavior. AN severity can be defined by using an individual’s body mass index (BMI; kg/m²), with a BMI less than 15kg/m² deemed severe AN and a BMI of 15-16 deemed moderate AN [1].

AN has one of the highest mortality rates of all psychiatric disorders, and the highest rate of medical complications out of all the psychiatric disorders [2,3], causing disruption to most organ systems including cardiovascular, gastrointestinal, endocrine, and other metabolic alterations. Another potentially fatal medical complication that can occur is termed refeeding syndrome, which is biochemically characterized by hypophosphatemia, hypomagnesemia, hypokalemia, glucose intolerance, fluid overload, and thiamine deficiency as a result of inadequate monitoring during the early phase of refeeding a patient with AN [4]. Table 1 outlines the major medical consequences of full-blown refeeding syndrome.