Email updates

Keep up to date with the latest news and content from Journal of Eating Disorders and BioMed Central.

Journal App

google play app store
Open Access Highly Accessed Research article

A review of feeding methods used in the treatment of anorexia nervosa

Susan Hart12*, Richard C Franklin3, Janice Russell124 and Suzanne Abraham45

Author Affiliations

1 Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia

2 Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, The University of Sydney, Camperdown, NSW 2006, Australia

3 School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, QLD 4811, Australia

4 Northside Clinic Eating Disorder Program, Greenwich, NSW 2065, Australia

5 Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards 2065, NSW, Australia

For all author emails, please log on.

Journal of Eating Disorders 2013, 1:36  doi:10.1186/2050-2974-1-36

The electronic version of this article is the complete one and can be found online at: http://www.jeatdisord.com/content/1/1/36


Received:15 October 2012
Accepted:26 July 2013
Published:2 September 2013

© 2013 Hart et al.; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Clear evidence based guidelines on the best and safest method of achieving and maintaining normal body weight during inpatient treatment of Anorexia Nervosa (AN) are currently not available. Oral feeding with food alone, high-energy liquid supplements, nasogastric feeding and parenteral nutrition all have the potential to achieve weight gain in the treatment of AN but the advantages and disadvantages of each method have not been comprehensively evaluated.

A literature search was undertaken to identify papers describing feeding methods used during inpatient treatment of AN. The selection criteria searched for papers that described the feeding method; and reported weight change variables such as admission and discharge weight in kilograms, or Body Mass Index; or weight change over the course of inpatient treatment.

Results

Twenty-six papers were identified, describing a total of 37 samples with a mean sample size of 58.9 participants, and a range from 6 to 318. The majority (84.6%) of papers were observational cohorts and retrospective chart reviews. The most common feeding method described was nasogastric feeding and food, then high-energy liquid supplements and food.

Conclusions

There is limited evidence on the efficacy of feeding methods used in the refeeding and nutritional rehabilitation of AN, therefore no conclusion can be made about the most effective method of achieving weight gain during inpatient treatment. While there are a number of papers exploring this issue there is no consistency in the way the information is reported to enable comparisons between the different methods. There is an urgent need for research in this area to guide decision-making in the inpatient management, refeeding and nutritional rehabilitation of AN.

Keywords:
Anorexia nervosa; Feeding; Enteral; Nasogastric; Refeeding; Parenteral

Background

Under-nutrition and its sequelae are a major consequence of Anorexia Nervosa (AN) with refeeding and restoration of nutrition status a primary aim of the initial treatment. Guidelines on the treatment of AN [1-6] highlight the importance of nutrition intervention to restore weight, and help patients normalise their eating. However, clear evidence based guidelines on the best and safest method of achieving normal body weight during inpatient treatment, are currently not available.

There are several feeding methods used as part of the refeeding process in AN, such as with food alone, using high-energy liquid supplements, nasogastric (or enteral) feeding, and parenteral nutrition [7-10]. This review defines “food only” to be when all energy and nutrients are provided by whole food alone. “High-energy liquid supplements” are drinks, which provide energy and micronutrients delivered in portion-controlled packaging. “Nasogastric feeding” is where nutrients are delivered directly into the gastrointestinal tract with a thin plastic tube through the nose, and the tip of the tube sitting in the stomach, duodenum or jejunum [11]; energy and micronutrients are provided as a liquid formula delivered via the tube. “Parenteral nutrition” provides elemental nutrition in solution, in the form of amino acids, lipids and dextrose, which are delivered directly into the systemic circulation by a peripheral or central vein, bypassing the gastrointestinal tract [12-14].

Liquid supplements, nasogastric feeding and parenteral nutrition have the potential to provide one hundred percent of an individual’s recommended daily intake of nutrients or may be used to provide additional energy to any food that is eaten, in order to meet nutritional requirements and assist with weight gain. Nasogastric feeding and parenteral nutrition have an established use in acutely ill hospitalised patients who are unable to eat secondary to their illness or injury [15,16]. All four methods have the potential to achieve weight gain in the treatment of AN but the benefits and adverse effects of each method have not been comprehensively evaluated when used as a treatment strategy for AN.

This paper aims to review the published peer-reviewed literature on the feeding methods used in the inpatient treatment of AN, and to report any advantages and disadvantages of each method. Additionally, the authors aimed to determine if there is evidence of one feeding method being superior to another in terms of weight gain during inpatient treatment.

Methods

A keyword search of the databases Medline and PsycINFO was undertaken between June and December 2012, to identify papers describing feeding methods used during inpatient treatment of AN. Five searches were undertaken using the key word “anorexia nervosa” combined with a second key word. The second key words used for the literature search, when combined with “anorexia nervosa”, were “nasogastric”, “enteral”, “feeding”, “parenteral” and “refeeding”. Additionally, a hand search was undertaken of key eating disorder journals as was snowballing of the published literature to identify any additional papers. The selection criteria for this review were papers which: described inpatients with a diagnosis of AN; provided a description of the feeding method used; and included weight change variables such as admission and discharge weight in kilograms, or Body Mass Index (BMI), or weight change over the course of inpatient treatment. Articles meeting the criteria (N = 26) were reviewed for study design, sample size, age of participants, length of stay, and prescribed energy intake. Papers that did not meet the inclusion criteria but described benefits or adverse effects of a feeding method were identified and pooled.

Papers were excluded if: they were case studies with less than 10 participants; there was no description of the feeding method used; it was not clear which feeding method was being used; the subjects were not inpatients or were combined cohorts of inpatients and outpatients and unable to be separated; or it did not report weight change, or admission and discharge BMI. Only articles in English were reviewed. The results were tabulated in PASW Statistics GradPack 18.0.

Results

In this literature search of feeding methods and inpatient treatment of AN, 26 papers were identified that met the inclusion criteria (Table 1). As 10 papers also included a comparator group (with one paper having two comparator groups), the search resulted in a total of 37 samples (Table 2).

Table 1. Papers meeting the inclusion criteria

Table 2. Summary of results

Search one of “nasogastric” and AN identified 23 papers, of which 10 were reviewed, and seven were kept. Four of these seven papers included a comparator group. Reviewed papers were excluded because they were case series with less than 10 participants (n = 2), and did not describe any weight data (n = 1). Search two of “enteral” and AN identified 104 papers; 17 were reviewed and three were kept. Two of these three papers included a comparator group. Reviewed papers (n = 14) were excluded because they were case studies with less than 10 participants (n = 8), had insufficient weight data (n = 3), were a descriptive paper (n = 1), and presented data that could not be extracted (n = 2). Search three of “feeding” and AN identified 613 papers. Thirty-two papers were reviewed and three were kept. Two of the three papers included a comparator group. Reviewed papers were excluded because they had insufficient weight data (n = 10), were case series with less than ten participants (n = 2), did not adequately describe the feeding method (n = 13); or were review studies (n = 4). Search four, which used the keywords “parenteral” and AN identified 101 papers. Thirteen were reviewed, one was kept, which did not have a comparator group. Reviewed papers were excluded because they were case series with less than 10 participants (n = 5), had insufficient detail of the feeding method (n = 1) or were descriptive papers with no data (n = 6). Search five, using the keywords “refeeding” and AN identified 279 papers. Eleven were reviewed, and two were kept. Nine reviewed papers were excluded because there was insufficient detail on weight variables (n = 3), they were case series with less than 10 participants (n = 3), had insufficient detail on the feeding method (n = 1), the feeding method was not clear (n = 1), and described pooled data from 30 separate treatment facilities (n = 1). None of these papers had a comparator group. Ten relevant papers were identified using the hand search and snowballing methods, of which one paper had a comparator sample, and one paper had two comparator samples.

The majority (84.6%) of papers were observational cohorts (n = 10) and retrospective chart reviews (n = 12). Two papers were randomised controlled trials, both by the same author, and one study had a prospective longitudinal design. Numerical data was extracted for age, sample size, admission and discharge BMI, total weight change in kilograms, prescribed energy in kilocalories, and length of stay in days, and are tabulated for each paper (Table 1), and pooled with means and ranges calculated (Table 2). The mean sample size for each of the feeding methods was 58.9 participants, with a range of 6 to 318. The method that was used for the greatest number of participants (n = 1189) was for food only samples. The greatest mean weight change was 8.4 kilograms (kg) for nasogastric feeding and food, then parenteral nutrition and food (7.1 kg), then food only (6.0 kg) and liquid supplements and food (4.3 kg). As the reviewed papers that the data was extracted from were predominantly observational and retrospective chart reviews, no further analysis was undertaken.

Fourteen out of 26 papers meeting the inclusion criteria had the description and evaluation of a feeding method as its main aim. Only 16 of 37 samples reported prescribed energy intake, and only 27 of 37 samples reported length of stay. Only three papers of 26 (11%) reported numerical data for all seven variables (i.e. sample size, age, admission and discharge BMI, weight change, length of stay and energy intake). The most frequent feeding method described was nasogastric feeding and food, then liquid supplements and food. There were only three studies meeting the inclusion criteria that described the use of parenteral nutrition. Food only was described in six studies where it was the only method of refeeding however in 11 papers, food was the comparator group for the other feeding methods, resulting in a total of 17 food only samples. Most information about the benefits and adverse effects of the feeding methods were extracted from descriptive papers, which are pooled in Table 3.

Table 3. Benefits and adverse effects of four feeding methods

Discussion

The initial aim of this paper was to undertake a meta-analysis of all papers describing the feeding methods used for the inpatient treatment of AN, to determine which feeding method was the most effective, and to document occurrence of any adverse effects in the samples examined. As the majority of studies (84.6%) were observational cohorts and retrospective chart reviews, and much of the content of these papers were based on descriptions of practice rather than being based on data obtained from a robust research method, it was not possible to complete a meta-analysis.

While there is much to be learnt from clinical expertise it is impossible to determine the superiority of any feeding methods based on this alone. Instead, an attempt was made by the authors to extract data from papers that met the inclusion criteria on sample size, age, admission and discharge weight, weight gain during treatment, length of stay and energy prescribed during treatment. This task was a difficult one, due in most cases to the data being presented in a non-standardised or inconsistent way that made it impossible to compare the results between papers. For example, 17 papers reported admission weight in kilograms, 31 reported admission BMI, seven reported percentage of ideal body weight, and only seven reported height measurements. Some papers reported more than one weight variable, for example, admission weight in kilograms and admission BMI. Discharge weight variables were reported in 31 of 37 samples, however 20 reported discharge weight in kilograms, 21 reported discharge BMI, and four reported percentage of ideal body weight. For the 33 samples that reported a weight change variable over the course of treatment, weight change was reported in kilograms for 24 samples, three reported weight change in grams per day, and seven reported the change in BMI. It could be argued that these variables (i.e. sample size, age, admission and discharge weight/BMI, weight gain during treatment, length of stay and energy prescribed) be mandatory in any research describing inpatients with AN to further knowledge of the effectiveness of treatment.

All feeding methods, apart from six papers that used food only, were mixed feeding methods. That is, the method of feeding was a combination of oral food intake as meals and snacks, and liquid supplements, nasogastric feeding or parenteral nutrition. The majority of papers described the use of a second feeding method, in addition to food, to increase the intake of energy to achieve weight gain. High-energy liquid supplements were used to supplement meals and snacks if the prescribed amount of food was not consumed at the meal [20]. Nasogastric feeding was also used overnight to contribute extra energy [33,34] in addition to what was consumed during the day. Pertushuk, et al. (1983) described the same rationale for the use of parenteral nutrition in achieving additional energy for weight gain, with parenteral nutrition discontinued once the patient was eating adequate amounts [31]. Diamanti, et al. (2008) described a similar process for the use of parenteral nutrition with infusions tapered off as voluntary oral intake increases [8].

The authors’ recommendation is that a randomised prospective study (with sufficient power) be undertaken exploring different feeding methods. It should collect all the necessary data to make an informed decision about the relative effectiveness of each feeding method. We note that good clinical practice may include mixed methods and as such this should be seen as a feeding method and described in detail to allow for appropriate comparisons.

The largest numbers of participants were treated with food only (n = 1189), and notably with less disadvantages reported when compared to nasogastric feeding (n = 560) and parenteral nutrition (n = 173) (Table 3). Most concerns with nasogastric feeding (Table 3) were in regards to medical complications such as reflux, throat pain, nasal irritation, a bleeding nose, the effects of tube tampering, and damage to the psychological engagement with patients. In one study, 55% of patients removed the tube, and all but three removed it five or more times with repeated insertions of tube increasing the risk of complications [27]. Central device infections while being re-fed were one of the main concerns with parenteral nutrition [8].

No deaths were reported in the nasogastric, food only and liquid supplement samples, however four deaths were reported in samples that were treated with parenteral nutrition and food. However, these deaths cannot necessarily be attributed to the method, as Tonoike, et al. (2004) reported that two out of 51 participants died after inpatient treatment when they were followed up 25 months after discharge [36]. An additional death was reported in this sample on day nine of treatment after being transferred from another hospital [36]. Another death was reported from the refeeding syndrome in Weinsier, et al. (1981) [51].

While nasogastric feeding and parenteral nutrition appear to have more adverse effects than food only and liquid supplements, it is not possible to determine whether this is a result of the feeding method or resulting from another factor. For example, it is possible that subjects treated with nasogastric feeding or parenteral nutrition were more unwell, had greater severity of illness, or were less motivated to eat food orally. In most papers, confounding factors were not discussed in consideration of the results presented. For example, in most papers there was no discussion of the role of meal supervision in ensuring that nutrients that are prescribed are actually ingested. Only two papers were identified in this literature search, which described the benefits of meal supervision, and defined the processes involved [18,52]. Notably, Leichner (2005) found that when meal supervision was implemented on an adolescent eating disorder specialist unit, the rates of nasogastric feeding reduced [52].

The best that could be achieved from this review was a description of benefits versus adverse effects of the feeding methods, which are summarised in Table 3. In single studies, some authors have concluded that the described feeding method was a superior method, however, these conclusions are not supported by this current analysis. For example, Rigaud, et al. (2007) concluded that nasogastric feeding is superior to other feeding methods [9]. The study demonstrated slightly better short-term rate of weight gain with non significant differences at 12 month follow up in reference to; percent of patients relapsing, those patients maintaining a BMI > 18.5 kg/m2, higher energy intake and total score on the Eating Disorder Inventory. However, there were no differences between the nasogastric feeding and food only groups in regards to psychological recovery, satisfaction with treatment or medical complication frequency. This paper did demonstrate that nasogastric feeding is equally safe as food only feeding owing to the lack of reported medical complications in this study.

The study by Zuercher (2003) showed differences in mean weight gain between 226 receiving food only compared to 84 patients receiving nasogastric feeding (0.82 versus 1.0 kg per week) and delivery of more energy via nasogastric feeding [38]. However, the length of stay for the nasogastric feeding group was longer (61 versus 48 days). Both methods were effective in achieving the National Institute of Clinical Excellence recommendations of 0.5 to 1.0 kg/week in the short term [2]. One of the advantages of nasogastric feeding is that it can be a life saving option [27,53] as it can be implemented if a patient refuses nutrition orally, and it enables clinicians to take control of treatment in life threatening situations. Whether nasogastric feeding should be used as standard treatment or only in life saving or medically compromised patients warrants further examination because of reports from patients that they experienced harm from this method [47].

Diamanti, et al. (2008) compared 104 food only feeding patients and 94 parenteral nutrition patients and found no significant differences with respect to weight gain, recovery and rehospitalisation rate [8]. There were however, more medical complications in the parenteral nutrition sample (Table 3); and an increased cost of parenteral nutrition at 1.7 times more expensive than food only feeding [8]. There have been three subsequent publications disagreeing with this author about the routine use of parenteral nutrition [54-56]. Melchior and Corcos (2009) commented that parenteral nutrition offers less support to the immune and gastrointestinal systems than enteral nutrition, leading to higher rates of infection, impairment of gastric emptying and colonic motility [54].

Conclusion

Based on the results of this literature review, there is limited evidence on the efficacy of feeding methods used in the refeeding and nutritional rehabilitation of AN, therefore no conclusion can be made about the most effective method of achieving weight gain during inpatient treatment. Considering the importance of re-nutrition in the overall treatment of AN, this is a concern. While there are a number of papers exploring this issue there is no consistency in the way the information is reported to enable comparisons between the different methods. There is an urgent need for research in this area to guide decision-making, as currently little research directs clinicians towards best practice. The literature does provide direction for further research which can be achieved if clinicians working in the area work collaboratively to further knowledge and understanding of refeeding and nutritional rehabilitation in AN. The summary of benefits and adverse effects in Table 3 needs to be observed with caution, and is not necessarily a guide that can be extrapolated to clinical practice.

In order to improve our knowledge of feeding methods in AN, there should be a minimum data set reported on research describing inpatient treatment for AN that includes admission and discharge BMI (or weight and height), weight change during treatment, and length of stay. Additionally, details of the feeding regime, such as nutrient composition and energy delivered would be useful. The authors also recommend that the short term benefits of feeding methods used in the treatment of AN, such as weight gain, and long term benefits, such as recovery rate of participants, be examined using a robust study design.

Limitations

It is a limitation that only English articles were reviewed. Additionally, it was difficult to extract papers from the literature search using key words, as there was diverse usage and no consistent keywords used, which made identifying useful papers difficult. Some authors have published a number of papers, and it is unclear whether the papers describe the same or different cohorts.

Abbreviations

AN: Anorexia nervosa; BMI: Body mass index; kg: Kilograms; kg/m2: Kilograms per metre squared; kg/week: Kilograms per week; kCal: Kilocalories; NG: Nasogastric feeding; PN: Parenteral nutrition; SUP: High-energy liquid supplements; RCT: Randomised controlled trial.

Competing interests

The authors declare that they have no financial or non-financial competing interests.

Authors’ contributions

SH – Completed literature search; analysed papers and determined which papers met inclusion and exclusion criteria; wrote and reviewed manuscript. RF - Analysed papers and determined which papers met inclusion and exclusion criteria; wrote and reviewed manuscript. SA - Wrote and reviewed manuscript. JR - Wrote and reviewed manuscript. All authors read and approved the final manuscript.

References

  1. Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Anorexia Nervosa: Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa.

    Aust N Z J Psychiatry 2004, 38(9):659-670. PubMed Abstract | Publisher Full Text OpenURL

  2. National Institute for Clinical Excellence:

    Eating disorders – Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. 2004.

    [http://www.nice.org.uk/guidance/CG9 webcite]

    PubMed Abstract OpenURL

  3. Royal College of Psychiatrists:

    Guidelines for the nutritional management of anorexia nervosa. 2005.

    [http://www.rcpsych.ac.uk/files/pdfversion/cr130.pdf webcite]

    OpenURL

  4. ADA: Position of the American Dietetic Association: nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders.

    J Am Diet Assoc 2006, 106:2073-2082. PubMed Abstract OpenURL

  5. Yager J, Devlin MJ, Halmi KA, Herzog DB, Mitchell JE, Powers P, Zerbe KJ: Practice guideline for the treatment of patients with eating disorders. In American Psychiatric Association Practice Guidelines. Volume 163. 3rd edition. American Psychiatric Association; 2006:1-128. OpenURL

  6. Dietitians Association of Australia:

    Practice recommendations for the nutritional management of anorexia nervosa in adults. 2009.

    [http://dmsweb.daa.asn.au/files/DINER/Anorexia%20Nervosa_Final.pdf webcite]

    OpenURL

  7. Imbierowicz K, Braks K, Jacoby GE, Geiser F, Conrad R, Schilling G, Liedtke R: High-caloric supplements in anorexia treatment.

    Int J Eat Disorder 2002, 32(2):135-145. Publisher Full Text OpenURL

  8. Diamanti A, Basso M, Castro M, Bianco G, Ciacco E, Calce A, Caramadre A, Noto C, Gambarara M: Clinical efficacy and safety of parenteral nutrition in adolescent girls with anorexia nervosa.

    J Adolesc Health 2008, 42(2):111-118. PubMed Abstract | Publisher Full Text OpenURL

  9. Rigaud D, Brondel L, Poupard AT, Talonneau I, Brun JM: A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: A 1-year follow-up study.

    Clin Nutr 2007, 26(4):421-429. PubMed Abstract | Publisher Full Text OpenURL

  10. Castro-Fornieles J, Casula V, Saura B, Martinez E, Lazaro L, Vila M, Plana MT, Toro J: Predictors of weight maintenance after hospital discharge in adolescent anorexia nervosa.

    Int J Eat Disorder 2007, 40(2):129-135. Publisher Full Text OpenURL

  11. Holmes S: Enteral feeding and percutaneous gastrostomy.

    Nurs Stand 2004, 18(20):41-43. PubMed Abstract | Publisher Full Text OpenURL

  12. Shils ME: Parenteral Nutrition. In Modern nutrition in health and disease. Volume 2. Edited by Shils ME, Olson JA, Shike M. Pennsylvania: Lea and Febiger; 1994:1430-1458. OpenURL

  13. Btaiche IF, Khalidi N: Metabolic complications of parenteral nutrition in adults, part 1.

    Am J Health Syst Pharm 2004, 61(18):1938-1949. PubMed Abstract | Publisher Full Text OpenURL

  14. Btaiche IF, Khalidi N: Metabolic complications of parenteral nutrition in adults, part 2.

    Am J Health Syst Pharm 2004, 61(19):2050-2059. PubMed Abstract | Publisher Full Text OpenURL

  15. Nespoli L, Coppola S, Gianotti L: The role of the enteral route and the composition of feeds in the nutritional support of malnourished surgical patients.

    Nutrients 2012, 4(9):1230-1236. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  16. Palmer AJ, Ho CKM, Ajibola O, Avenell A: The role of omega-3 fatty acid supplemented parenteral nutrition in critical illness in adults: A systematic review and meta-analysis.

    Crit Care Med 2013, 41(1):307-316. PubMed Abstract | Publisher Full Text OpenURL

  17. Castro J, Gila A, Puig J, Rodriguez S, Toro J: Predictors of rehospitalization after total weight recovery in adolescents with anorexia nervosa.

    Int J Eat Disorder 2004, 36(1):22-30. Publisher Full Text OpenURL

  18. Couturier J, Mahmood A: Meal support therapy reduces the use of nasogastric feeding for adolescents hospitalized with anorexia nervosa.

    Eat Disord 2009, 17(4):327-332. PubMed Abstract | Publisher Full Text OpenURL

  19. Dalle Grave R, Bartocci C, Todisco P, Pantano M, Bosello O: Inpatient treatment for anorexia nervosa: A lenient approach.

    Eur Eat Disord Rev 1993, 1(3):166-176. Publisher Full Text OpenURL

  20. Garber AK, Michihata N, Hetnal K, Shafer MA, Moscicki AB: A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol.

    J Adolesc Health 2012, 50:24-29. PubMed Abstract | Publisher Full Text OpenURL

  21. Gentile MG, Pastorelli P, Ciceri R, Manna GM, Collimedaglia S: Specialized refeeding treatment for anorexia nervosa patients suffering from extreme undernutrition.

    Clin Nutr 2010, 29:627-632. PubMed Abstract | Publisher Full Text OpenURL

  22. Gentile MG, Manna GM, Ciceri R, Rodeschini E: Efficacy of inpatient treatment in severely malnourished anorexia nervosa patients.

    Eat Weight Disord 2008, 13:191-197. PubMed Abstract | Publisher Full Text OpenURL

  23. Hart S, Abraham S, Franklin RC, Russell J: A description of weight changes in underweight eating disorder patients.

    Eur Eat Disord Rev 2011, 19(5):390-397. OpenURL

  24. Krahn DD, Rock C, Dechert RE, Nairn KK, Hasse SA: Changes in resting energy expenditure and body composition in anorexia nervosa patients during refeeding.

    J Am Diet Assoc 1993, 93(4):434-438. PubMed Abstract | Publisher Full Text OpenURL

  25. Lay B, Jennen-Steinmetz C, Reinhard I, Schmidt MH: Characteristics of inpatient weight gain in adolescent anorexia nervosa: relation to speed of relapse and re-admission.

    Eur Eat Disord Rev 2002, 10(1):22-40. Publisher Full Text OpenURL

  26. Lund BC, Hernandez ER, Yates WR, Mitchell JR, McKee PA, Johnson CL: Rate of inpatient weight restoration predicts outcome in anorexia nervosa.

    Int J Eat Disorder 2009, 42:301-305. Publisher Full Text OpenURL

  27. Neiderman M, Farley A, Richardson J, Lask B: Nasogastric feeding in children and adolescents with eating disorders: toward good practice.

    Int J Eat Disorder 2001, 29(4):441-448. Publisher Full Text OpenURL

  28. Okamoto A, Yamashita T, Nagoshi Masui Y, Wada Y, Kashima A, Arii I, Nakamura M, Fukui K: A behaviour therapy program combined with liquid nutrition designed for anorexia nervosa.

    Psychiatry Clin Neurosci 2002, 56(5):515-520. PubMed Abstract | Publisher Full Text OpenURL

  29. Ornstein RM, Golden NH, Jacobson MS, Shenker RI: Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring.

    J Adolesc Health 2003, 32(1):83-88. PubMed Abstract | Publisher Full Text OpenURL

  30. Ostuzzi R, Didonna F, Micciolo R: One-year weight follow-up in anorexia nervosa after inpatient psycho-nutritional rehabilitative treatment.

    Eat Weight Disord 1999, 4(4):194-197. PubMed Abstract OpenURL

  31. Pertschuk MJ, Crosby LO, Mullen JL: Total parenteral nutrition in anorexia nervosa.

    Curr Psychiatr Ther 1983, 22:207-214. PubMed Abstract OpenURL

  32. Rigaud DJ, Brayer V, Roblot A, Brindisi MC, Verges B: Efficacy of tube feeding in binge-eating/vomiting patients: a 2 month randomized trial with 1 year follow up.

    J Parenter Enteral Nutr 2011, 35(3):356-364. Publisher Full Text OpenURL

  33. Robb AS, Silber TJ, Orrell-Valente JK, Valadez-Meltzer A, Ellis N, Dadson MJ, Chatoor I: Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa.

    Am J Psychiatry 2002, 159(8):1347-1353. PubMed Abstract | Publisher Full Text OpenURL

  34. Silber TJ, Robb AS, Orrell-Valente JK, Ellis N, Valadez-Meltzer A, Dadson MJ: Nocturnal nasogastric refeeding for hospitalized adolescent boys with anorexia nervosa.

    J Dev Behav Pediatr 2004, 25(6):415-418. PubMed Abstract | Publisher Full Text OpenURL

  35. Stordy BJ, Marks V, Kalucy RS, Crisp AH: Weight gain, thermic effect of glucose and resting metabolic rate during recovery from anorexia nervosa.

    Am J Clin Nutr 1977, 30(2):138-146. PubMed Abstract | Publisher Full Text OpenURL

  36. Tonoike T, Takahashi T, Watanabe H, Kimura H, Suwa M, Akahori K, Itakura Y: Treatment with intravenous hyperalimentation for severely anorectic patients and its outcome.

    Psychiatry Clin Neurosci 2004, 58(3):229-235. PubMed Abstract | Publisher Full Text OpenURL

  37. Walker J, Roberts SL, Halmi KA, Goldberg SC: Caloric requirements for weight gain in anorexia nervosa.

    Am J Clin Nutr 1979, 32(7):1396-1400. PubMed Abstract | Publisher Full Text OpenURL

  38. Zuercher JN, Cumella EJ, Woods BK, Eberly M, Carr JK: Efficacy of voluntary nasogastric tube feeding in female inpatients with anorexia nervosa.

    J Parenter Enteral Nutr 2003, 27(4):268-276. Publisher Full Text OpenURL

  39. Cockfield A, Philpot U: Feeding size 0: the challenges of anorexia nervosa. Managing anorexia from a dietitian’s perspective.

    P Nut Soc 2009, 68:281-288. Publisher Full Text OpenURL

  40. Williams H, O‘Connor M: Dietetics and Nutrition. In The Encultured body: Policy implications for healthy body image and disordered eating behaviours. Volume 1. Edited by Gaskill D, Sanders F. Queensland: Queensland University of Technology; 2000:126-131. OpenURL

  41. Sandy KJ, Chernecki LL, Leichner PP: Eating disorder patients’ opinions of cafeteria-style vs hospital-style presentation of meals.

    J Am Diet Assoc 2007, 107(3):376-378. PubMed Abstract | Publisher Full Text OpenURL

  42. Arii I, Yamashita T, Kinoshita M, Shimizu H, Nakamura M, Nakajima T: Treatment for inpatients with anorexia nervosa: comparison of liquid formula with regular meals for improvement from emaciation.

    Psychiatry Clin Neurosci 1996, 50(2):55-59. PubMed Abstract | Publisher Full Text OpenURL

  43. Hill KK, Maloney MJ: Treating anorexia nervosa patients in the era of managed care.

    J Am Acad Child Adolesc Psychiatry 1997, 36(11):1632-1633. PubMed Abstract OpenURL

  44. Mehler PS, Weiner KL: Anorexia nervosa and total parenteral nutrition.

    Int J Eat Disorder 1993, 14(3):297-304. Publisher Full Text OpenURL

  45. Breier-Mackie S: Ethics connection. Percutaneous feeding tube placement and severe anorexia nervosa.

    Gastroenterol Nurs 2006, 29(6):484-486. PubMed Abstract | Publisher Full Text OpenURL

  46. Dalzell AM, Wilcox J, Patrick MK, Shepherd RW: Management of self starvation: a greater role for the nutritionist?

    J Hum Nutr Diet 1994, 7:25-30. Publisher Full Text OpenURL

  47. Halse C, Boughtwood D, Clarke S, Honey A, Kohn M, Madden S: Illuminating multiple perspectives: meanings of nasogastric feeding in anorexia nervosa.

    Eur Eat Disord Rev 2005, 13(4):264-272. Publisher Full Text OpenURL

  48. Hebert PC, Weingarten MA: The ethics of forced feeding in anorexia nervosa.

    Can Med Assoc J 1991, 144(2):141-144. OpenURL

  49. Rock CL, Curran-Celentano J: Nutritional management of eating disorders.

    Psychiat Clin N Am 1996, 19(4):701-713. Publisher Full Text OpenURL

  50. Croner S, Larsson J, Schildt B, Symreng T: Severe anorexia nervosa treated with total parenteral nutrition. Clinical course and influence on clinical chemical analyses.

    Acta Paediatr Scand 1985, 74(2):230-236. PubMed Abstract | Publisher Full Text OpenURL

  51. Weinsier RL, Krumdieck CL: Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited.

    Am J Clin Nutr 1981, 34:393-399. PubMed Abstract | Publisher Full Text OpenURL

  52. Leichner P, Hall D, Calderon R: Meal support training for friends and families of patients with eating disorders.

    Eat Disord 2005, 13(4):407-411. PubMed Abstract | Publisher Full Text OpenURL

  53. Paccagnella A, Mauri A, Baruffi C, Berto R, Zago R, Marcon ML, Pizzolato D, Fontana F, Rizzo L, Bisetto M, Agostini S, Foscolo G: Application criteria of enteral nutrition in patients with anorexia nervosa: correlation between clinical and psychological data in a “lifesaving” treatment.

    J Parenter Enteral Nutr 2006, 30(3):231-239. Publisher Full Text OpenURL

  54. Melchior JC, Corcos M: Parenteral nutrition and anorexia nervosa: Is it useful, is it ethical?

    J Adolesc Health 2009, 44:410-412. PubMed Abstract | Publisher Full Text OpenURL

  55. Smith AL: Comment on: clinical efficacy and safety of parenteral nutrition in adolescent girls with anorexia nervosa.

    Nutr Clin Pract 2008, 23:443. Publisher Full Text OpenURL

  56. Silber TJ: A change of paradigm in the treatment of anorexia nervosa? Not so soon.

    J Adolesc Health 2008, 42:109-110. PubMed Abstract | Publisher Full Text OpenURL