Elsevier

Clinical Nutrition

Volume 26, Issue 4, August 2007, Pages 421-429
Clinical Nutrition

ORIGINAL ARTICLE
A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: A 1-year follow-up study

https://doi.org/10.1016/j.clnu.2007.03.012Get rights and content

Summary

Background & aims

Despite the high mortality rate in malnourished anorexia nervosa (AN) patients, very few trials have prospectively studied the efficacy of tube feeding.

Methods

This open prospective study was conducted in malnourished AN patients, who were randomized in tube feeding (n=41) or control (n=40) groups during a 2-month period. Thereafter, body weight, body mass gain, energy intake, eating behavior and relapse rates were compared during a 1-year follow-up, using paired Student t-test and ANOVA.

Results

At the end of the 2-months period, weight gain was 39% higher in the tube feeding group than in the control group (194±14 vs 126±19 g/day; P<0.01). The fat-free mass gain was greater in the tube-feeding group: 109±14 vs 61±17 g/day (P<0.01). Energy intake was higher in the tube feeding group than in the control group (P<0.05), as well as the decrease in bingeing episodes (P<0.01). Most patients thought that CEN improved their eating disorder. After discharge, the relapse-free period was longer in the CEN group than in the control one: 34.3±8.2 weeks vs 26.8±7.5 weeks (P<0.05).

Conclusion

CEN is helpful in malnourished AN patients for weight restoration, without hindrance on the eating behavior therapy nor inducing a more rapid relapse.

Introduction

Anorexia nervosa (AN) is a chronic and relapsing disease characterized by the fear of gaining weight and becoming obese.1 There are two types of AN1, 2: the restrictive and the binge-eating/purgative ones. In both types, fear of gaining weight is often related to a desire to eat, which appears to be out of control. The mortality rate from AN is high, around 4–8%, with a standardized mortality ratio of 10.5,3 among patients who are young adults or adolescents.2, 3, 4, 5, 6, 7, 8 The prognosis is conditioned, beside psychiatric comorbidity, by malnutrition and vomiting-induced disorders. Both could alter muscle function, in particular at cardiac and respiratory levels.6, 8, 9, 10, 11, 12 Another AN complication is the risk of osteopenia and osteoporosis which appears after 5 years of disease.13, 14 Women who improved weight, regardless of whether they recovered menstrual function, demonstrated a mean increase of bone mineral density.14

In AN, there is a body image distortion and a dread of fatness as an intrusive idea. Thus it will be very difficult to the patients to take the responsibility to eat at her (his) own hunger. The fear to be responsible for an increase in their body weight precludes these patients to normalize their weight by food intake alone. It is very difficult to obtain enough increase in energy intake from food to reach weight gain. This gain is made more difficult by the increase in energy expenditure (EE) during refeeding: resting EE, which is low during starving, increases by 10% soon after the start of refeeding.8, 15, 16, 17 This was also true for the diet-induced thermogenesis, which was shown to raise by as high than 40%.17 EE related to physical activity should also increase, due to the fear of gaining weight and to the improvement of muscle function by renutrition.15, 18 Despite EE increase, oral refeeding was preferred by most of the teams to tube feeding, because of the supposed psychological side effects of the tube feeding in these patients.19 In many reviews and textbooks, tube feeding is even left unquoted as a possible treatment for AN.2, 7, 19

Despite the known difficulties of any malnourished patient to eat at the level of his needs, very few studies addressed the question of the efficacy of tube feeding in malnourished AN patients. Only ten studies were published on this topic so far.20, 21, 22, 23, 24, 25, 26, 27, 28, 29 Most of them included only 1–9 patients.20, 21, 22, 23, 25, 28 Three of them were retrospective chart reviews21, 27, 29 and one concerned the subjective experience of tube feeding from AN patients.24 None of them was randomized and none has been constructed in order to evaluate the long-term efficacy of tube feeding. Robb et al.27 compared the short-term outcomes of oral vs tube feeding regimens in 100 adolescent girls, half of them being on tube feeding (n=52); the authors found that tube feeding induced a greater weight gain at discharge, but unfortunately they did not measure body composition. Zuercher et al.,29 studying the chart of 381 inpatients, found that the 155 patients receiving tube feeding gained significantly more body weight than those who received oral refeeding (1 vs 0.77 kg/week). De Caprio et al.21 found that an integrated medical intervention including artificial nutrition represented an effective treatment in 15 malnourished AN patients of mean age of 19.6 years: enteral nutrition was prescribed in four of them.

Based on the lack of controlled trials in AN patients, we conducted a prospective randomized study to evaluate the effect of cyclic enteral nutrition (CEN) on weight gain and fat free mass gain, as compared to classical treatment, in adult AN malnourished patients. The present prospective 2-month trial was conducted in 81 malnourished AN patients randomized to have CEN (n=41) or not (n=40). Other end points were eating behavior and the 1-year prognosis.

Section snippets

Patients and methods

Eighty-one adult patients suffering from AN were prospectively included. From them, 25 patients suffered from the binge/purging type of AN and 56 from the restrictive one. All patients fulfilled the AN criteria of the DSM IV1; 98.4% were amenorrhoeic and 36% had physical hyperactivity of at least 3 h per day. Characteristics of these malnourished patients are seen in Table 1. Patients having a BMI lower than 11 kg/(m)2 were not considered for inclusion, in order to avoid any refeeding syndrome

Methods

The staff explained and discussed the four major treatment's goals with each patient30: (1) reaching and maintaining a minimal body weight, calculated from a body mass index (BMI) of 18.5 kg/(m)2; (2) reaching nutrients intake able to maintain this target weight, (3) obtaining normal eating patterns and behaviors, (4) working on psychological and behavioral dysfunctionings. All patients participated on dietary, behavioral therapy, psychotherapy and self-help group sessions.30 The advantages of

Nutritional criteria

Were measured body weight, BMI and body composition by anthropometry32 and 2-frequences bioelectrical impedance analysis to obtain fat free mass, fat mass, total body water and extra- and intracellular fluids.33 Resting energy expenditure was determined by indirect calorimetry as previously described.16, 17 Questionnaire and biological markers tracked vomiting every week: hypokaliemia, increased level of serum proteins, amylase, ALAT, ASAT and creatinine, blood alkalosis and hyponatremia, as

Results

One patient did not want to continue with CEN after the 12th day. She did not accept to gain weight further and moved out of the Nutrition unit 1 week later, without significant weight gain (1.6 kg). Neither refeeding syndrome, severe hypokaliemia nor hypophosphatemia was observed in these 81 patients during this study with our refeeding protocol. From the blood variables measured, 94% felt into the normal range before starting refeeding. No patient was lost during the follow-up.

Discussion

The present randomized open trial was the first study constructed to demonstrate the efficacy of cyclic enteral nutrition in a multidisciplinary program in malnourished AN patients. As compared to the control group (i.e. oral refeeding plus psychotherapy plus behavior treatment), better results were obtained with CEN concerning body weight gain, rate of weight gain, fat-free mass gain, total energy intake and decrease in purging/binges episodes. This has been obtained without any significant

Acknowledgments

English translation by Abbie Smith (USA); Association Autrement, for grants (www.autrement.asso.fr).

Rigaud: design study and practical performance, data analysis and preparation of manuscript.

Brondel: data analysis and preparation of manuscript.

Poupard: dietetic analyses.

Brun: data analysis and preparation of manuscript.

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