A new study by Johns Hopkins Medicine researchers of adults hospitalized for the eating disorder anorexia nervosa has strengthened the case for promoting rapid weight gain as part of overall efforts for a comprehensive treatment plan. The study findings, after analyzing data regarding 149 adult inpatients with anorexia nervosa in the Johns Hopkins Eating Disorders Program, stand in contrast to long held beliefs that patients would not tolerate a faster weight gain plan because it would be too traumatic.
In a report on the work published online Oct. 7 in the International Journal of Eating Disorders, researchers say a majority of patients not only tolerated the regimen, they also met their weight gain goals in weeks rather than months, they would recommend the program to others and they would be willing to repeat it, if needed.
A form of self-starvation, anorexia nervosa is a serious psychiatric disorder in which people feel fat or fear gaining weight despite being very underweight. Over time, people with anorexia experience physical, psychological and social complications with a high risk of long-term consequences that can include heart, kidney and liver damage, bone loss, depression and self-harm. Anorexia has one of the highest mortality rates of any psychiatric condition.
The investigators say their findings also suggest that inpatient eating disorder programs that focus on rapid weight gain can minimize a patient's time away from home, work and family, help curb treatment costs by reducing lengths of stay in a hospital or residential treatment program and be rated helpful by most patients.
"Treating anorexia is expensive due to the high cost of inpatient and residential treatment, and the cost of health care is important to both patients and health systems," says Angela Guarda, M.D., director of the Eating Disorders Program at The Johns Hopkins Hospital. Guarda is also the Stephen and Jean Robinson Associate Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. "Our findings suggest that a meal-based nutritional approach that emphasizes faster weight gain coupled with different types of behavioral therapy and meal support is well tolerated and achieves weight restoration in a majority of patients."
Earlier work by Guarda and others countered the belief that patients with anorexia need to gain weight slowly to avoid a potentially life threatening condition called re-feeding syndrome, which is a metabolic imbalance that can occur when severely malnourished people take in too much food or drink. Despite these safety studies, clinicians are still reluctant to implement rapid re-feeding strategies, combined with behavioral treatment approaches, because they fear that patients won't endure them. With the new study, Guarda and her team sought the patients' perception of the Johns Hopkins rapid re-feeding program.
For the study, researchers analyzed information gathered on 134 women and 15 men, averaging 35 years of age, who were treated and discharged from the integrated inpatient-partial hospitalization eating disorders program at The Johns Hopkins Hospital between February 2014 and June 2017. They were underweight when admitted to the program and placed on a regimen emphasizing faster weight gain, balanced meals and behavioral therapies designed to prevent relapses. The program aims to normalize eating and weight control behaviors, encourage healthier eating habits and help patients overcome their anxieties about eating a variety of foods.
More than 70% of the patients in the study reached a healthy body mass index (BMI). BMI is a measure of body fat based on height and weight. For most adults, a healthy BMI is between 18.5 and 24.9. Patients in the study achieved an average BMI of at least 19, which is within the healthy range, compared to an average of 16.1 at the beginning of the program. The average hospital stay was just 39 days, and patients gained 4 pounds per week on average -- "close to twice what many intensive treatment programs achieve, which means half as much hospital time is needed to reach a healthy weight," says Guarda.
Upon hospital discharge, patients were invited to complete an anonymous questionnaire to rate their satisfaction with the treatment. Some 107 participants (72%) completed the questionnaire. Overall, 71% of respondents said they would come back if they needed help with their eating disorder in the future, while 83% would recommend the program to others.
Like faster weight gain, Guarda explains, behavioral management is often criticized by clinicians as poorly tolerable by patients. However, the program's focus on behavior change was rated good or very good by 83% of the patients.
Participants also rated the degree to which they felt included in the treatment (78%), and their level of satisfaction with staff members (clinical nurses: 96%, occupational therapists: 99%, dietitians: 45%, social workers: 75%). Satisfaction with intervention factors (group therapies: 79%, family meetings and education: 63%) and environmental factors (comfort of units: 50%, presentation/taste of food: 36%) was also assessed.
"Our program is solely meal-based and does not employ tube feeding," says Guarda. Occupational therapists and nursing and dietician staff members assist patients in preparing and portioning meals, and in eating food prepared by others in cafeteria and restaurant settings. "We want to help our patients translate what they're learning here to a more real world environment so they can stay healthy once back at home."
According to Guarda, most patients go to inpatient programs like the one at Johns Hopkins under pressure from family members, employers or a significant other, and they are often anxious and apprehensive about entering treatment. "At the beginning, they often don't see the need to be here," she says, "but these results show that for most patients, their overall perception is positive by the end of treatment."
Guarda says she's encouraged that the field of anorexia nervosa is gradually moving toward greater and more uniform accountability about outcomes. "The standard of care should be based on evidence. Uniform, transparent reporting of weight and behavioral outcomes by treatment programs is needed so that patients, their families and referring clinicians can be more informed about treatment programs," she says.
According to the National Eating Disorders Association, 0.9% of women and 0.3% of men will develop anorexia during their lifetime.
Additional authors on the study include Marita Cooper, Allisyn Pletch, Lori Laddaran, Graham Redgrave and Colleen Schreyer. The authors have no conflicts to declare.
This research was supported in part by the Stephen and Jean Robinson Fund.
International Journal of Eating Disorders