For anorexia patients, does distress rise with higher caloric intake?

By Jess Berthold

photo of Erin Accurso with bookshelf background

“Patients and clinicians alike would benefit from the shorter hospitalization times we see with this higher-calorie regimen,” said study first author Erin Accurso, PhD.

A higher-calorie nutrition plan isn’t more distressing for hospitalized teens and young adults with anorexia than a lower-calorie plan, a new study led by UC San Francisco researchers found.

The new findings support a 2021 study by the same researchers that showed a higher-calorie plan was safe and reduced hospitalization time. Still, many clinicians have resisted adopting the higher-calorie plan out of concern it may cause psychological harm to patients, who are very sensitive to food intake and weight gain, said Erin Accurso, PhD, first author on the study and UCSF associate professor of psychiatry. 

“I feel hopeful these data will reassure the community that higher-calorie refeeding is acceptable and manageable for patients and clinicians, in addition to being superior to lower-calorie regimens in terms of clinical outcomes,” said Accurso. “Patients and clinicians alike would benefit from the shorter hospitalization times we see with this higher-calorie regimen.”

This is the first randomized trial to directly compare the two plans with an eye toward psychological outcomes, she added. Findings appear in the International Journal of Eating Disorders on March 15, 2023.

Several professional societies, including the American Psychiatric Association and Society for Adolescent Health and Medicine, endorse the higher-calorie regimen, noted Andrea K. Garber, PhD, RD, UCSF professor of pediatrics and the study’s senior author.

“We know from speaking with colleagues, however, that some of the programs they are implementing as ‘higher-calorie regimens’ are starting off with fewer calories than recommended, due to persistent concern about the psychological effects,” said Garber.

Shorter hospital stays

The study comprised 111 patients ages 12 to 24 with anorexia nervosa or atypical anorexia nervosa – those who have symptoms of anorexia but aren’t underweight – from two sites in the San Francisco area. The average age was 16 and 90% of patients were female. 

Patients were randomly assigned to higher-calorie nutrition plans (2,000 kilocalories [kcal] per day, increased by 200 kcal every day until calorie goals were met) or lower-calorie nutrition plans (1,400 kcal per day, increased by 200 kcal every other day until calorie goals were met). 

Researchers asked a subset of 45 patients to rate their distress before, during and after meals, as well as their daily mood during hospitalization; they also measured how much food patients left on their meal trays. Before randomization, the researchers asked all patients if they preferred a higher- or lower-calorie nutrition plan, and after the treatment, they asked which plan the patients believed they’d received, to see if their perceptions and preferences affected the treatment experience. 

Both groups refused the same amount of food, and had similar levels of mealtime distress and overall negative mood during hospitalization. Patients in the higher-calorie group stabilized more quickly. On average, they spent four fewer days in the hospital, for an average of eight days compared to 12 days for patients in the lower-calorie group. The results were the same for anorexia and atypical anorexia nervosa patients.

At discharge, most patients believed they had been in the higher-calorie group regardless of the group they were in; the majority stated before treatment that they preferred to be in the lower-calorie group.  

“This shows that patients with anorexia and atypical anorexia will be stressed out about eating during inpatient treatment, but they won’t be more stressed if they get a higher-calorie diet,” said Accurso. “Mealtime anxiety was moderate – actually lower than we might have expected – and part of the treatment is helping patients learn to tolerate their anxiety so they can continue making progress after discharge.”

Across both groups, patients who received more kcal per meal relative to their own body weight had slightly more distress with treatment. The researchers are pursuing this finding in a new study that aims to tailor nutritional plans based on individual weight and other factors. 

Authors: Additional authors are Daniel Le Grange, PhD, of the UCSF Department of Psychiatry and Behavioral Sciences; Jing Cheng, MD, MS, PhD, of the UCSF Department of Preventive & Restorative Dental Sciences; Vanessa I. Machen, MS, RD; Sara Buckelew, MD; and Sally Adams, PhD, RN, of the UCSF Department of Pediatrics; and Anna Kreiter, MS, PsyD; and Neville H. Golden, MD, of the Stanford School of Medicine Department of Pediatrics.

Funding and disclosures: Research was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Grant/Award Number: R01HD082166; National Institute of Mental Health, Grant/Award Number: K23MH120347.

Read the study

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