Patients should start with approximately 1,200 calories per day and advance slowly by 200 calories every other day, according to The American Psychiatric Association, American Dietetic Association and others. The aim of this "start low and go slow" method is to avoid refeeding syndrome - a potentially deadly condition as a result of rapid electrolyte shifts, a well-known risk when introducing nutrition therapy in a malnourished patient.
This study is the first to test these recommendations, which were established in 2000. Andrea Garber, PhD, RD, associate professor of pediatrics in the Division of Adolescent Medicine at UCSF, who led the study with colleagues in the UCSF Adolescent Eating Disorders Program, explained:
"Our findings show that the current recommendations are
just not effective."
There were 35 teenage female participants in this study; most of them were Caucasian. They had been admitted to hospital with the following malnutrition signs:
- Low blood pressure
- Low body mass index (BMI)
- Low heart rate
- Low body temperature
Even though those who received the low calorie diets did not develop refeeding syndrome, approximately 83% lost significant initial weight loss and no overall weight gain until their eighth day of hospitalization. Garber explained this discovery represents "a missed opportunity"
"Studies show that weight gain during hospitalization is crucial for patients' long-term recovery, we have to make the most out of their short time in the hospital."
Even though 94% of study participants started on less than 1,400 calories per day, the study included diets that ranged from 800 to 2,200 calories in order for the investigators to analyze the effect of increasing calories.
The team found that:
- Participants who started on lower calorie diets lost considerably more weight in the hospital
- Higher calorie diets resulted in less time in the hospital
According to the researchers, the current guidelines are to cautious and the study has raised other questions. For example, while insurances costs may be reduced as a result of shorter hospital stay, patients might not be ready to be discharged.
"Shorter is not necessarily better. We have to consider the potential implications down the line, both psychological and emotional.
According to Barbara Moscicki, MD, a professor of pediatrics in the Division of Adolescent Medicine at UCSF and senior author on the report, another unanswered question relates to refeeding syndrome, which remains "a very real fear." Moscicki explains that the researchers are proceeding cautiously, as more aggressive strategies to feeding and supplementation have not yet been well investigated.
The team explain that results from the investigation are a promising start, because no adverse events were observed in those on the higher calorie diets.
"If we can improve weight gain with higher calories,
then we're on the right path."
Other co-authors are Nobuaki Michihata, MD, Katherine Hetnal, and Mary-Ann Shafer, MD, all of UCSF. The study was conducted in the Pediatric Clinical Research Center through UCSF's NIH-funded Clinical and Translational Science Institute (CTSI). About UCSF Benioff Children's Hospital