NEDA TOOLKIT for Parents
For individuals who are markedly underweight and for
children and adolescents whose weight has deviated
below their growth curves, hospital-based programs
for nutritional rehabilitation should be considered [I].
For patients in inpatient or residential settings, the
discrepancy between healthy target weight and
weight at discharge may vary depending on patients’
ability to feed themselves, their motivation and ability
to participate in aftercare programs, and the
adequacy of aftercare, including partial
hospitalization [I]. It is important to implement
refeeding programs in nurturing emotional contexts
[I]. For example, it is useful for staff to convey to
patients their intention to take care of them and not
let them die even when the illness prevents the
patients from taking care of themselves [II]. It is also
useful for staff to communicate clearly that they are
not seeking to engage in control battles and have no
punitive intentions when using interventions that the
patient may experience as aversive [I].
In working to achieve target weights, the treatment
plan should also establish expected rates of
controlled weight gain. Clinical consensus suggests
that realistic targets are 2-3 pounds (lb)/week for
hospitalized patients and 0.5-1 lb/week for individuals
in outpatient programs [II]. Registered dietitians can
help patients choose their own meals and can provide
a structured meal plan that ensures nutritional
adequacy and that none of the major food groups are
avoided [I]. Formula feeding may have to be added to
the patient’s diet to achieve large caloric intake[II]. It
is important to encourage patients with anorexia
nervosa to expand their food choices to minimize the
severely restricted range of foods initially acceptable
to them [II]. Caloric intake levels should usually start
at 30-40 kilocalories/kilogram (kcal/kg) per day
(approximately 1,000-1,600 kcal/day). During the
weight gain phase, intake may have to be advanced
progressively to as high as 70-100 kcal/kg per day for
some patients; many male patients require a very
large number of calories to gain weight [II].
Patients who require much lower caloric intakes or
are suspected of artificially increasing their weight by
fluid loading should be weighed in the morning after
they have voided and are wearing only a gown; their
fluid intake should also be carefully monitored [I].
Urine specimens obtained at the time of a patient’s
weigh-in may need to be assessed for specific gravity
to help ascertain the extent to which the measured
weight reflects excessive water intake [I]. Regular
monitoring of serum potassium levels is
recommended in patients who are persistent vomiters
[I]. Hypokalemia should be treated with oral or
intravenous potassium supplementation and
rehydration [I].
Physical activity should be adapted to the food intake
and energy expenditure of the patient, taking into
account the patient’s bone mineral density and
cardiac function [I]. Once a safe weight is achieved,
the focus of an exercise program should be on the
patient’s gaining physical fitness as opposed to
expending calories [I].
Weight gain results in improvements in most of the
physiological and psychological complications of
semistarvation [I]. It is important to warn patients
about the following aspects of early recovery [I]: As
they start to recover and feel their bodies getting
larger, especially as they approach frightening,
magical numbers on the scale that represent phobic
weights, they may experience a resurgence of anxious
and depressive symptoms, irritability, and sometimes
suicidal thoughts. These mood symptoms, non-food-
related obsessional thoughts, and compulsive
behaviors, although often not eradicated, usually
decrease with sustained weight gain and weight
maintenance. Initial refeeding may be associated with
mild transient fluid retention, but patients who
abruptly stop taking laxatives or diuretics may
experience marked rebound fluid retention for several
weeks. As weight gain progresses, many patients also
develop acne and breast tenderness and become
unhappy and demoralized about resulting changes in
body shape.
Page | 48