Food for thought

Supportive relationships, together with a carefully planned nutritional program, are important ingredients in a treatment plan that will help patients with anorexia nervosa recover, safely.

Anorexia nervosa is a serious and complex illness characterised by an ongoing restriction of energy intake accompanied by an overwhelming fear of weight gain and an obsessive, distorted view of one’s own body weight or shape¹.

It has the highest mortality rate of any psychiatric illness with suicide being the leading cause of death among sufferers². There are a myriad of health complications associated with anorexia nervosa including, but not limited to, anxiety and depression, post-traumatic stress disorder, impaired short-term memory and concentration, significant electrolyte imbalances, bradycardia and cardiac deconditioning³. Due to the seriousness of this condition, patients must be promptly medically stabilised, and nutrition requirements must be met in order to undo the above effects. Evidence-based strategies for how to do this while ensuring patient safety are outlined below.

Patient treatment plan

The first goal of treatment for people with anorexia nervosa is medical stabilisation, followed by weight restoration (with consideration given to refeeding syndrome), and finally, psychotherapy once the cognitive effects of malnutrition have been reversed^3,4. These goals should be written into a thorough treatment plan, taking into account the individual’s circumstances and including a risk assessment in the interest of patient safety. An outpatient setting is recommended when the patient is not at imminent medical risk; however, the rate of weight gain tends to be far superior in a more restrictive, inpatient setting³.

Research in weight restoration specifically for people with anorexia nervosa is limited and guidelines for refeeding vary between facilities, states and countries so it is difficult to give an exact caloric prescription to ensure weight gain. The Queensland Eating Disorder Service (QuEDS) recommends all inpatients with anorexia nervosa commence a continuous 24-hour nasogastric feed of 6300 kJ/day (1500 kcal) with an increase of 2000 kJ (~500 kcal) every few days, building up to an adequate energy level for each patient to achieve weight restoration^3,4.

In a recent literature review on nutritional rehabilitation in anorexia nervosa, a range of calorie requirements were identified⁵. Healthy young women who do not have an eating disorder require 30 (20-40) kcal/kg/day for weight maintenance,⁶ while energy requirements for healthy males are 20–25% higher on average¹¹. Meanwhile, it has been observed that people with anorexia nervosa have a tendency to become hypermetabolic when oral intake is increased, whereby the amount of food needed for weight gain to be sustained may be higher than expected. As much as 60–100 kcal/kg/day could be necessary for weight gain to be sustained although the starting point for the prescribed kcal/kg/day will vary between patients⁵.

Achieving stabilisation

Inpatients should not be discharged until a BMI of 17-20 kg/m2 has been reached⁴. Once weight restoration has been achieved, psychotherapy should commence and regular weight monitoring should continue due to the risk of relapse. Data suggests a full recovery rate of 46% for Australians with anorexia nervosa, while for 20% of people, it remains a long-term chronic illness^2,7. In line with this statistic, a topic to be discussed in an outpatient setting is the effect of exercise on weight gain because many people with anorexia nervosa regularly exhibit excessive exercise and restlessness⁸. During recovery, people who exercise very little could gain 1 kg of body weight with an excess of 4000 kcal, whereas with excessive exercise, the same amount of weight gain could require an excess of 12,000 kcal⁹.

Although the risks of morbidity and mortality associated with anorexia nervosa are a confronting reality, consideration should be given to how the patient would like to be treated. An online survey conducted by The Butterfly Foundation gathered responses from 117 Australians on their experiences of recovery from an eating disorder, with 72% of participants having been diagnosed with anorexia nervosa¹⁰. The survey identified that throughout treatment, participants most valued having supportive relationships, and a sense of confidence, hope, autonomy and control, as well as feeling safe and understood.

Furthermore, honesty, compassion and understanding were identified as the most helpful traits in a therapeutic relationship¹⁰. Although patient safety should remain a top priority throughout all stages of treatment, health practitioners should give thought to these survey responses in order to engage the patient due to the strong influence of therapeutic alliance on positive outcomes.

The long road ahead

Recovery from anorexia nervosa is a long and challenging road, with many setbacks to be expected. As health practitioners, the best we can do is to work alongside our colleagues and guide these patients to reach medical stabilisation and continually meet their nutritional requirements so that all aspects of their health are supported and maintained. Through all stages of treatment, our expertise, encouragement, understanding, non-judgment and priority of patient safety can provide the strength a person needs to claim their life back from the debilitating grip of anorexia nervosa.

An Accredited Practising Dietitian (APD) is an integral part of the management team for people with anorexia nervosa. To find an APD, visit www.daa.asn.au and search ‘Find an Accredited Practising Dietitian’ with ‘Eating disorders’ selected under ‘Area of Practice’.

*Hannah Niven is an Accredited Practising Dietitian working in private practice in Brisbane and the Gold Coast. Hannah has a lived experience with eating disorders and this has given her a passion to work alongside other people and their loved ones during their recovery. She combines her professional and personal knowledge to give hope, empathy and tailored practical strategies to support each individual on their recovery journey.

References

1. National Eating Disorders Collaboration (NEDC). (2017). What is anorexia nervosa? Retrieved from http://www.nedc.com.au/anorexia-nervosa

2. Watson, H.J., & Bulik, C.M. (2013). Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychological Medicine, 43, 2477-2500.

3. Hay, P., Chinn, D., Forbes, D., Madden, S., Newton, R., Sugenor, L., Touyz, S., & Ward, W. (2014). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian and New Zealand Journal of Psychiatry, 48(11), 1-62.

4. Queensland Eating Disorders Service. (2015). A guide to admission and inpatient treatment for people with eating disorders in Queensland. Metro North Hospital and Health Service: Queensland Government.

5. Marzola, E., Nasser, J.A., Hashim, S.A., Shih, P.B., & Kaye, W.H. (2013). Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment. BMC Psychiatry, 13, 290.

6. Petersen, R., Kaye, W., & Gwirtsman, H. (1986). Comparison of calculated estimates and laboratory analysis of food offered to hospitalized eating disorder patients. Journal of the American Dietetic Association, 86(4), 490-492.

7. National Eating Disorders Collaboration. (2016). Eating disorders in Australia. Retrieved from http://www.nedc.com.au/eating-disorders-in-australia

8. Kron, L., Katz, J.L., Gorzynski, G., & Weiner, H. (1978). Hyperactivity in anorexia nervosa: a fundamental clinical feature. Comprehensive Psychiatry, 19(5), 433-440.

9. Kaye, W., Gwirtsman, H., Obarzanek, E., & George, D. (1988). Relative importance of calorie intake needed to gain weight and level of physical activity in anorexia nervosa. American Journal of Clinical Nutrition, 47, 989-994.

10. Butterfly Foundation. (2016a). Insights in recovery: An overview of the research project informing the insights in recovery guide. Sydney: Mental Health Commission of NSW.

11. Trumbo, P., Schlicker, S., Yates, AA. & Poos, M. (2002). Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. Journal of the American Dietetic Association, 102(11), 1621-1630.

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