Correspondence
Behavioral Management for Anorexia Nervosa
N Engl J Med 2009; 360:2141-2142May 14, 2009
- Article
To the Editor:
In their article on behavioral management for anorexia nervosa (Jan. 29 issue),1 Attia and Walsh state that the Maudsley Method (in which parents take control of refeeding of their child) is the preferred treatment for children and adolescents, but I wonder why they do not recommend it for the 23-year-old woman described in the vignette. For decades, the conventional wisdom was that a “toxic” parent–child relationship caused this disorder. Parents were told to “back off” and were barred from the treatment team.2 This cruel and inaccurate bias has lingered in psychiatry. Attia and Walsh note that weight restoration is accepted as being paramount for treatment. They also note that inpatient treatment lasts for 18 days, on average, and is associated with a relapse rate of 50% in the first year after hospitalization. When parents are empowered to refeed their child, they do so for as long as it takes, which is usually many months.3 We await clinical trials using the Maudsley Method in young adults.
3 ReferencesBarbara Scolnick, M.D.
11 Irvington St., Waban, MA 02468
pressberg@comcast.net 1
Attia E ,Walsh BT . Behavioral management for anorexia nervosa. N Engl J Med 2009;360:500-506
Full Text | Web of Science | Medline2
Bruch H. The golden cage: the enigma of anorexia nervosa. Cambridge, MA: Harvard University Press, 1978.
3
Collins L. Eating with your anorexic: how my child recovered through family-based treatment and yours can too. New York: McGraw-Hill, 2005.
To the Editor:
We agree with the authors that structured multidisciplinary behavioral programs that integrate nutritional and psychological treatments are the most promising approaches in the management of anorexia nervosa. However, their nutritional-support program raises concern. Certainly, priority is given to providing adequate calories,1 and institutions may opt for different protocols. However, in our experience, patients frequently report considerable difficulties in beginning therapy with such large quantities of solid food (1800 kcal per day); such quantities are probably unrealistic and may be harmful. Patients with anorexia nervosa are at high risk for the refeeding syndrome.2-4 When similar high-calorie nutritional regimens are enforced, the risk of complications is very high.1-4 To avoid complications, both current guidelines and expert panels suggest 10 kcal per kilogram of body weight per day for nutritional support during the first 3 days, regardless of the route of administration.3,4 A cautious increase (by 400 to 500 kcal every 3 days) can then be proposed to obtain a positive energy balance.1,3 Weight and electrolyte levels should be checked daily to rule out excessive water retention and correct any impairment.
4 ReferencesEmanuele Cereda, M.D.
Manuela C. Sacchi, Psy.D.
University of Milan, 20133 Milan, Italy
emanuele.cereda@virgilio. it Carlo Pedrolli, M.D.
Trento Hospital, 38100 Trento, Italy1
Yager J ,Andersen AE . Anorexia nervosa. N Engl J Med 2005;353:1481-1488
Full Text | Web of Science | Medline2
Miller SJ . Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited. Nutr Clin Pract 2008;23:166-171
CrossRef | Web of Science | Medline3
Mehanna HM ,Moledina J ,Travis J . Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008;336:1495-1498
CrossRef | Web of Science | Medline4
Stanga Z ,Brunner A ,Leuenberger M , et al. Nutrition in clinical practice -- the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 2008;62:687-694
CrossRef | Web of Science | Medline
Author/Editor Response
In response to Scolnick: we did not recommend a prime role for the family of the 23-year-old patient described in our review because the limited data available suggest that the Maudsley family-based approach is not particularly effective in this age group.1 However, we concur that it is important to involve the family to the degree that family members are available to help. Controlled trials would be useful to obtain empirical data regarding the usefulness of family members' taking a major role in the refeeding of persons with anorexia nervosa in this age group.
Cereda et al. express concern about the refeeding syndrome. In our review, we recommend careful medical monitoring during initial refeeding. The guidelines of the National Institute for Health and Clinical Excellence2 suggest starting nutritional support at 10 kcal per kilogram per day in order to avoid the refeeding syndrome. However, this recommendation appears to be overly cautious for most persons with anorexia nervosa, since it is intended to assist in the care of all malnourished persons, including those who may have underlying cardiovascular compromise or who may have suddenly interrupted intake for 15 days or more.3 The American Psychiatric Association guidelines for the treatment of patients with eating disorders suggest starting refeeding at 30 to 40 kcal per kilogram per day,4 as do Golden and Meyer in their review of refeeding in anorexia nervosa.5 In our experience, persons with anorexia nervosa may report a reluctance to eat, but they will commonly tolerate being offered 1800 kcal in solid food, generally consuming this diet successfully within a few days after hospital admission and showing physiological tolerance of this caloric load as well as additional increases needed to achieve consistent weight gain in the weeks that follow.
As mentioned in the review by Mehanna et al.,3 vitamin supplementation should be started immediately on refeeding, and supplements of potassium, phosphate, calcium, and magnesium should be considered. Lower levels of initial caloric intake may be appropriate for persons with weights that are unusually low (body-mass index [the weight in kilograms divided by the square of the height in meters], ≤14), who have undergone particularly abrupt weight loss before presentation, or who are known to have ingested negligible calories in the previous 2 weeks.
5 ReferencesEvelyn Attia, M.D.
B. Timothy Walsh, M.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032
ea12@columbia.edu 1
Russell GF ,Szmukler GI ,Dare C ,Eisler I . An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987;44:1047-1056
CrossRef | Web of Science | Medline2
National Institute for Health and Clinical Excellence. Nutrition support in adults: clinical guideline CG32. London: NICE, 2006. (Accessed April 24, 2009, at http://www.nice.org.uk/page.aspx?o=cg032.)
3
Mehanna HM ,Moledina J ,Travis J . Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008;336:1495-1498
CrossRef | Web of Science | Medline4
American Psychiatric Association
Medline5
Golden NH ,Meyer W . Nutritional rehabilitation of anorexia nervosa: goals and dangers. Int J Adolesc Med Health 2004;16:131-144
CrossRef | Medline
