Practical methods for refeeding patients with anorexia nervosa

Abstract

Volume 4(3): 2-5 best practices for nutrition counseling in AN suggests that RDs should help the patients process their false nutrition beliefs and weight/body distortions and incorporate "motivational interviewing" to encourage the connection of mind and body [9]. Moreover, RDs often need to address limited food acceptance at the beginning stages of the refeeding process, as patients often enter treatment with a myriad of preexisting food rules and limitations tied to their eating disorder which are impediments to weight restoration [10]. These food restrictions are typically created by the patient from false nutrition beliefs, but can also be related to an emotional or physical trauma history. RDs are able to educate the patient on correct nutrition information while encouraging flexibility to incorporate the eliminated foods back into the patients' diet. This often necessitates beginning with smaller food exposures and working toward a normalized and balanced diet. These food exposures can be done in conjunction with the therapist or other members of the treatment team. Food restrictions are sometimes masked by certain diets that may be recognized as socially acceptable or trending within modern day culture, such as vegetarianism, veganism, gluten-free or low-fat diets [11]. These diets create an easy way for patients to eliminate whole food groups based on a very strict and inflexible basis, for example a patient eliminating all foods with cheese or milk, while claiming to follow a vegan diet. Guidelines exist to address these dietary limitations, at an inpatient/residential level of care, which promote an "all foods fit" model, encouraging variety and flexibility in food choices upon admission. A study by Schebendach et al. assessed the correlation between variety in food selections and treatment outcome, and demonstrated that patients who chose a more varied diet while in treatment, including added sugars, fats, caloric beverages and starchy carbohydrates, had a better treatment outcome one year post-hospitalization [12]. It was also suggested that the inclusion of highly palatable foods encourages increased food intake and therefore improved outcomes with weight restoration. RDs and treatment teams, however, must be empathetic regarding the emotional difficulty for the patient to include foods previously eliminated from their diet. Working toward increased variety and inclusion of highly palatable foods should be addressed at each meeting with the RD, while setting measurable goals for inclusion of fear or challenge foods. Patients sometimes will also present with reported food allergies or intolerances, most commonly gluten/wheat and lactose/dairy, which further present the challenge of a limited caloric diet. RDs should therefore request medical documentation of these allergies. However, if no documentation is presented and the patient is unwilling to incorporate the eliminated foods, RDs should request testing for food allergies. Once results are available, false reports of allergens can be addressed by the RD and start to be incorporated into the diet. Even with confirmed negative testing for food allergies, patients can still have difficulty with food acceptance and require ongoing counseling within the scope of practice of the RD. If a patient has mild intolerances or reports adverse reactions to certain foods such as gastrointestinal discomfort, bloating, diarrhea or constipation, these symptoms may actually be a result of the physical refeeding process and not the food itself [8]. These gastrointestinal symptoms can be addressed by the medical doctor with medications or supplements like Lactase, so that the RD is able to continue addressing food acceptance.