ESPEN Congress Geneva 2014NUTRITION AT EXTREMES: THE UNLIKELY BENEFITS OF STARVATION

Management of the severely malnourished: the case of anorexia nervosaC. De la Cuerda (ES)

Management of the severely malnourished: 

the case of anorexia nervosaCristina Cuerda

7 September 2014

Anorexia nervosa• Refusal to maintain a normal weight for height• Intense fear to gaining weight• Disturbance in the perception of body weight and shape

• Two distinct subtypes: – Restrictive – Binge eating or purging (self‐induced vomiting and misuse of diuretics 

and laxatives)

DSM V classification

Severity:

Mild: BMI > 17 kg/m2

Moderate: BMI 16-16.99Severe: BMI 15-15.99

Extreme: BMI < 15

Treatment

Nutritionalrehabilitation

Behavioraltherapy

Psychotherapy

Family grouppsycho‐education

Anorexia nervosa

• Main problems:– Starvation related malnutrition Refeeding Syndrome

– Mental disease  Fear to gain weight

Jensen GL, et al. JPEN 2009; 33: 710-6.

x 3 risk of refeeding hypophosphatemiax 2 risk of hypoglycemia,independent of BMI at admission

Stanga Z, et al. Eur J Clin Nutr 2008; 62: 687‐94

RFS: forms of presentation 

Symptomatic RFS

Potential or biochemical RFS

Stanga Z, et al. Eur J Clin Nutr 2008; 62: 687‐94

Refeeding guidelines

overfeeding

underfeeding

Cuerda C. Clin Nutr 2007; 26: 100-6.

Cuerda C. Clin Nutr 2007; 26: 100-6.

Hofer M, et al. Nutrition 2014; 30: 524‐30.

Start slow, advance slow

Stanga Z, et al. Eur J Clin Nutr 2008; 62: 687‐94

Hofer M, et al. Nutrition 2014; 30: 524-30.

Complications of refeeding

• Abdominal bloating and constipation (due to gastroparesis and increased colonic transit)

• Tachycardia may be a harbinger of RFS and cardiac  compromise• Edema• Increase in liver enzimes (hepatic steatosis)• Hypoglycemia (fasting hypoG due to depletion of liver glycogen 

and gluconeogenesis substrates  and postprandrial hypoG during the RFS)

• Thiamine deficiency (wet beri beri and dry beri beri)• Central pontine myelinolysis (due to RFS and hyponatremia)

Mehler. J of Nutr Metab 2010; 2010: 1-7

Modes of refeeding

• The oral refeeding plan with a strict behavioral protocol is the first choice of treatment because it provides a less invasive, safer and more therapeutic mode of treatment

• There are some indications for TF and TPN

Mehler. J of Nutr Metab 2010; 2010: 1-7

Start slow, advance slow

• Retrospective study 86 cases (65 patients), 5yr period• Median hospital stay 49.5 days (IQR 52.3)• BMI increased from 13.7 ± 2.4 to 15.0 ± 1.9 kg/m2 (p <0.001)• During refeeding 47.7% cases received supplements of K, 

32.65 % P, 40.7% Mg

Hofer M. Nutrition 2014; 30: 524-30

No RFS

Whitelaw M, et al. J Adolesc Health 2010; 46: 577-82

Aggressive refeeding

37% mild hypoP

Whitelaw M, et al. J Adolesc Health 2010; 46: 577-82

NCP 2013; 28: 358-64

Garber AK. J Adolesc Health 2012; 50: 24-9.

Garber AK. J Adolesc Health 2013; 53: 579-84.

• Most moderately malnourished patients with AN (75%‐85% IBW) can safely commence refeeding at 1,500 kcal or even higher

• Nutrition can be advanced at 250 kcal every day or every other day, approaching 2,500 ‐3,000 kcal/day by day 14

• Weekly weight gains of at least 1.5 kg is attainable within such a protocol• None of the patients included in the studies (Leclerc et al, Agostino et al, 

Golden et al) developed the refeeding syndrome (mild levels of hypophosphatemia can be corrected by phosphate supplementation); and 

• Medical stability can commonly be achieved at about day 14 of hospitalization, which supports the adolescent’s early return to the family by drastically reducing the length of hospital stay.

Le Grange D. J Adolesc Health 2013; 53: 555-6, Leclerc A, et al. J Adolesc Health 2013; 53: 585-9Agostino H ,et al. J Adolesc Health 2013; 53: 590-4, Golden NH, et al. J Adolesc Health 2013; 53: 573-8.

Start high (er), advance fast (er)

Questions• Is it necessary to adapt treatment according to thedegree of malnutrition? – i.e. severe < 70% IBW

• What is the best approach of refeeding? – i.e. oral meals with snacks vs artificial nutrition (tubefeeding)

• Does the composition of the diet and the form of administration important in the RFS? – i.e. carbohydrate load, continuous feeding

Extreme malnutrition

Kcal/kgBW/day 32 ± 20 70 ± 26 72 ± 19

Gentile MG, et al. Clin Nutr 2010; 29: 627-32

• Retrospective study including 33 AN females, 60 days• BMI 11.3 ± 0.7   13.5 ± 1 kg/m2

• Weight 29.1 ± 3.2  34.5 ± 3.3 kg• 30/33 TF and 3/33 ONS, all received vitamins, and 

supplements of P and K No RFS

Rigaud et al. Clin Nutr 2007; 26: 421-9.

Rigaud et al. Clin Nutr 2007; 26: 421-9.

• Use of continuous feeding strategies with less than 40% of calories from carbohydrates

• Start with 2000 kcal• Oral P 20‐30 mg/kg

↓ risk postprandial hypoglycemia, RFS ↑ safety and efficacy

kcal/kg

BMI13.7

BMI16.3

No refeeding syndrome

French multicenter study on AN in ICUs

• Retrospective study in 12 ICUs, 68 patients• Average BMI at admission 12 ± 3 kg/m2• Average caloric intake was 22.3 ± 13 kcal/kg• Refeeding syndrome 10%• Crude mortality of 10% • High percentage of metabolic, hepatic, hematological and infectious complications

Vignaud M, et al. Crit Care 2010; 14 (5): R172.

Questions• Is it necessary to adapt treatment according to thedegree of malnutrition? – i.e. severe < 70% IBW

• What is the best approach of refeeding? – i.e. oral meals with snacks vs artificial nutrition (tubefeeding)

• Does the composition of the diet and the form of administration important in the RFS? – i.e. carbohydrate load, continuous feeding

The most important clue is to have a protocol in each institution

Conclusions• Starvation related MN is frequent in AN, so thesepatients are at risk of RFS

• It is very important to have a protocol in eachinstitution to treat these patients

• Caloric prescription at admission should take intoaccount the degree of MN and the risk of RFS

• The risk of hypophosphatemia is mostly related to thedegree of MN at admission

• It is necessary to perform more studies to select thebest approach to treat these patients

Thanks