Higher Calorie Refeeding Approach Superior for the Treatment of Anorexia-Associated Malnutrition

woman with anorexia sitting on bed
woman with anorexia sitting on bed
How does higher-calorie refeeding compare with the standard of care, lower-calorie refeeding, for malnourished patients with anorexia nervosa?

Higher-calorie refeeding (HCR) was efficacious in the short-term for the treatment of patients with anorexia nervosa (AN) or atypical anorexia nervosa (AAN). These findings, from a multicenter, randomized clinical trial, were published in JAMA Pediatrics.

Patients (N=111) aged 12 to 24 years who were hospitalized for AN- or AAN-related malnutrition between 2016 and 2019 at 2 sites associated with the University of California San Francisco and Stanford University were recruited for this study. Patients were randomized to receive a lower-calorie refeeding (LCR) (n=51) which consisted of 1400 kcal/d or an HCR (n=60) which consisted of 2000 kcal/d. Both treatments increased by 200 kcal every other day.

Each treatment included 3 meals and 2 or 3 snacks per day which consisted of 15%-25% protein, 30%-40% fat, and 35%-55% carbohydrates. Patients were monitored during mealtimes and for 30-45 minutes after. Refused calories were replaced by high-energy oral liquid (1.50 kcal/mL).

Participants were majority women (91%) who were White (63%) aged mean 16.4 (standard deviation [SD], 2.5) years. At baseline, bradycardia (79%), hypotension (31%), orthostatic heart rate increase (24%), hypokalemia (14%), and hypophosphatemia (5%) were observed.

During the first week of treatment approximately 250-350 kcal per day were provided by the high-energy liquid, which did not differ between treatment groups.

Patients in the HCR group reached medical stability 3 (95% CI, -4.9 to -1.2) days earlier than those in the LCR group (hazard ratio [HR], 1.67; 95% CI, 1.10-2.53; P =.01). Medical stability was achieved by 87% of the HCR and 84% of the LCR groups.

Among patients admitted with bradycardia, 83% in the HCR and 79% of the LCR groups were able to restore their heart rates. Heart rate was restored 4 (95% CI, -6.5 to -1.5) days earlier for those in the HCR group.

Weight gain was greater (2.3% median body mass index) among the HCR group. Participants receiving HCR gained weight by day 2 and participants receiving LCR initially lost weight.

The faster time to medical stability after HCR was associated with an estimated savings of $5518 (95% CI, -$8266 to -$2770) per participant and by $19,056 (95% CI, -$28,819 to -$9293) per participant for hospital charges.

This study was potentially biased by the choice to exclude patients who had a body mass index more than 60% lower than the median for their height and sex due to concerns about fragility. It remains unclear whether these results would be generalizable for severely ill patients with AN or AAN.

The study authors concluded that an HCR was superior to an LCR allowing patients to achieve medical stability and weight gain more quickly. These patients are still being followed for data on long-term clinical outcomes of HCR and LCR treatments.

Disclosure: An author declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Garber AK, Cheng J, Accurso EC, et al. Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with anorexia nervosa: a multicenter randomized clinical trial. JAMA Pediatr. 2020;e203359. doi:10.1001/jamapediatrics.2020.3359.