Refeeding syndrome is a metabolic disturbance that can affect severely underweight people when they return too quickly to regular meals. A new study of anorexia nervosa patients shows that faster weight gain during hospitalization is effective and will not lead to refeeding complications.

The work challenges long-held national as well as some international guidelines for refeeding and stabilizing eating and nutrition among dangerously underweight patients.

“Our study shows what's actually possible. Now we'd like national guidelines and practices to reflect that,” Dr. Graham Redgrave, the study's first author and a psychiatrist and an expert in eating disorders at Johns Hopkins Medicine, stated in a press release.

During starvation, a malnourished body falls into a metabolic holding pattern that drains available glucose, phosphate, and other mineral reserves. When eating is rapidly restored, some of the body’s major organs draw on these same reserves to resume normal functioning, depleting them even more. In some severe cases, this syndrome may result in cardiac, respiratory, and neuromuscular dysfunction.

“The initial drop in available phosphate puts patients at risk of a lethal heart arrhythmia and failure, the most serious aspect of refeeding syndrome,” Dr. Angela Guarda, director of the Johns Hopkins Eating Disorders Program, stated in a press release. Other effects can include confusion, convulsions, and even coma.

Justified safety concerns about a too-fast return to normal eating have led the American Psychiatric Association, the American Dietetic Association, and international organizations to recommend a weight gain of only 1 to 3 pounds per week for near-starved patients. Many anorexia treatment programs set even lower rates of weight gain, Redgrave noted, to address the common and challenging problem of a relapse after intensive, hospital-based treatment.

But is it necessary to gain weight so slowly? Redgrave and his colleagues wondered.

Gaining Faster To Stay Alive

Over an eight-year period, 361 patients with anorexia nervosa and related disorders went through an inpatient study program the Johns Hopkins research team had, in their words, “designed to produce rapid weight gain and weight restoration in the majority.” Patients ranged in age from 11 to 78 and included those who suffered from both major types of anorexia nervosa — food-restricting or binging and purging. Many had additional psychiatric diagnoses.

Those who entered the inpatient program with a dangerously low body mass index had their phosphate and glucose levels tested daily. Monitoring continued until normal levels had been restored. Less than one-fifth of the patients experienced a drop in phosphates during more rapid weight gain, and no one developed refeeding syndrome. According to Redgrave, abnormal phosphate levels were tied less to the rate of gain and more to how little patients weighed when first entering the hospital.

At the end of the program, more than 70 percent of adult patients reached a normal BMI of 19 or higher, and 80 percent of adolescents were within 5 pounds of their target weight.

“We were able to get patients with anorexia to safely gain around 4 pounds a week. That's twice the national average,” Redgrave said.

This higher rate is crucial, he explained, because it means most patients left the hospital at a normal weight. And, past research indicates those patients who gain more weight during treatment are less likely to relapse in the first two years after treatment "when they're most vulnerable,” Redgrave said. Meanwhile, careful monitoring in an inpatient treatment setting prevented refeeding syndrome among the patients as the results clearly indicate.

The researchers believe the positive results may be due to behavior-focused therapy that motivated patients while changing their thinking. Redgrave noted that extremely low weight patients are not thinking clearly while also being more obsessional, anxious, and depressed.

"Weight restoration reverses that," he said.

Source: Redgrave GW, Coughlin JW, Schreyer CC, et al. Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines. International Journal of Eating Disorders. 2015.