ESPEN Congress Geneva 2014 NUTRITION AT EXTREMES: THE UNLIKELY BENEFITS OF STARVATION

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1 ESPEN Congress Geneva 2014 NUTRITION AT EXTREMES: THE UNLIKELY BENEFITS OF STARVATION Management of the severely malnourished: the case of anorexia nervosa C. De la Cuerda (ES)

2 Management of the severely malnourished: the case of anorexia nervosa Cristina Cuerda 7 September 2014

3 Anorexia nervosa Refusal to maintain a normal weight for height Intense fear to gaining weight Disturbance in the Severity: perception of body weight and shape Two distinct Mild: subtypes: BMI > 17 kg/m 2 Restrictive Moderate: BMI Severe: BMI and laxatives) Extreme: BMI < 15 Binge eating or purging (self induced vomiting and misuse of diuretics DSM V classification

4 Nutritional rehabilitation Family group psychoeducation Treatment Behavioral therapy Psychotherapy

5 Anorexia nervosa Main problems: Starvation related malnutrition Refeeding Syndrome Mental disease Fear to gain weight

6 Jensen GL, et al. JPEN 2009; 33:

7 x 3 risk of refeeding hypophosphatemia x 2 risk of hypoglycemia, independent of BMI at admission

8 Stanga Z, et al. Eur J Clin Nutr 2008; 62:

9 RFS: forms of presentation Symptomatic RFS Potential or biochemical RFS Stanga Z, et al. Eur J Clin Nutr 2008; 62:

10 Refeeding guidelines

11 overfeeding underfeeding

12 Cuerda C. Clin Nutr 2007; 26:

13 Cuerda C. Clin Nutr 2007; 26:

14 Start slow, advance slow Hofer M, et al. Nutrition 2014; 30: Stanga Z, et al. Eur J Clin Nutr 2008; 62:

15 Hofer M, et al. Nutrition 2014; 30:

16 Complications of refeeding Abdominal bloating and constipation (due to gastroparesis and increased colonic transit) Tachycardia may be a harbinger of RFS and cardiac compromise Edema Increase in liver enzimes (hepatic steatosis) Hypoglycemia (fasting hypog due to depletion of liver glycogen and gluconeogenesis substrates and postprandrial hypog during the RFS) Thiamine deficiency (wet beri beri and dry beri beri) Central pontine myelinolysis (due to RFS and hyponatremia) Mehler. J of Nutr Metab 2010; 2010: 1-7

17 Modes of refeeding The oral refeeding plan with a strict behavioral protocol is the first choice of treatment because it provides a less invasive, safer and more therapeutic mode of treatment There are some indications for TF and TPN Mehler. J of Nutr Metab 2010; 2010: 1-7

18 Start slow, advance slow Retrospective study 86 cases (65 patients), 5yr period Median hospital stay 49.5 days (IQR 52.3) BMI increased from 13.7 ±2.4 to 15.0 ±1.9 kg/m2 (p <0.001) During refeeding 47.7% cases received supplements of K, % P, 40.7% Mg No RFS Hofer M. Nutrition 2014; 30:

19 Aggressive refeeding 37% mild hypop Whitelaw M, et al. J Adolesc Health 2010; 46:

20 Whitelaw M, et al. J Adolesc Health 2010; 46:

21 NCP 2013; 28:

22 Garber AK. J Adolesc Health 2012; 50: 24-9.

23 Garber AK. J Adolesc Health 2013; 53:

24 Most moderately malnourished patients with AN (75% 85% IBW) can safely commence refeeding at 1,500 kcal or even higher Nutrition can be advanced at 250 kcal every day or every other day, approaching 2,500 3,000 kcal/day by day 14 Weekly weight gains of at least 1.5 kg is attainable within such a protocol None of the patients included in the studies (Leclerc et al, Agostino et al, Golden et al) developed the refeeding syndrome (mild levels of hypophosphatemia can be corrected by phosphate supplementation); and Medical stability can commonly be achieved at about day 14 of hospitalization, which supports the adolescent s early return to the family by drastically reducing the length of hospital stay. Start high (er), advance fast (er) Le Grange D. J Adolesc Health 2013; 53: 555-6, Leclerc A, et al. J Adolesc Health 2013; 53: Agostino H,et al. J Adolesc Health 2013; 53: 590-4, Golden NH, et al. J Adolesc Health 2013; 53:

25 Questions Is it necessary to adapt treatment according to the degree of malnutrition? i.e. severe < 70% IBW What is the best approach of refeeding? i.e. oral meals with snacks vs artificial nutrition (tube feeding) Does the composition of the diet and the form of administration important in the RFS? i.e. carbohydrate load, continuous feeding

26 Extreme malnutrition Retrospective study including 33 AN females, 60 days BMI 11.3 ± ±1 kg/m 2 Weight 29.1 ± ±3.3 kg 30/33 TF and 3/33 ONS, all received vitamins, and supplements of P and K No RFS Kcal/kgBW/day 32 ±20 70 ±26 72 ±19 Gentile MG, et al. Clin Nutr 2010; 29:

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28 Rigaud et al. Clin Nutr 2007; 26:

29 Rigaud et al. Clin Nutr 2007; 26:

30 Use of continuous feeding strategies with less than 40% of calories from carbohydrates Start with 2000 kcal Oral P mg/kg risk postprandial hypoglycemia, RFS safety and efficacy

31 kcal/kg No refeeding syndrome BMI 16.3 BMI 13.7

32 French multicenter study on AN in ICUs Retrospective study in 12 ICUs, 68 patients Average BMI at admission 12 ±3 kg/m2 Average caloric intake was 22.3 ±13 kcal/kg Refeeding syndrome 10% Crude mortality of 10% High percentage of metabolic, hepatic, hematological and infectious complications Vignaud M, et al. Crit Care 2010; 14 (5): R172.

33 Questions Is it necessary to adapt treatment according to the degree of malnutrition? i.e. severe < 70% IBW What is the best approach of refeeding? i.e. oral meals with snacks vs artificial nutrition (tube feeding) Does the composition of the diet and the form of administration important in the RFS? i.e. carbohydrate load, continuous feeding The most important clue is to have a protocol in each institution

34 Conclusions Starvation related MN is frequent in AN, so these patients are at risk of RFS It is very important to have a protocol in each institution to treat these patients Caloric prescription at admission should take into account the degree of MN and the risk of RFS The risk of hypophosphatemia is mostly related to the degree of MN at admission It is necessary to perform more studies to select the best approach to treat these patients

35 Thanks