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Anorexia patients need realistic nutrition goals.

TUCSON, ARIZ. -- Nutritional rehabilitation may require involuntary hospitalization in patients with eating disorders. "These behaviors can be easily defined as self-harming behaviors, and these patients can and should be committed if they fall below a certain weight," Dr. Chelsea Chesen reported at a psychopharmacology conference sponsored by the University of Arizona.

The most important rules for a psychiatrist are to put safety first, take a multidisciplinary approach rather than going it alone, and create an individualized treatment plan.

Weight goals should be realistic, but there also needs to be an understanding that, should the patient fail to meet the goal, there will be certain consequences, including hospitalization. A weight gain of 0.5-1.5 pounds/week is appropriate for outpatients, and 2-3 pounds/week for inpatients, said Dr. Chesen, of the psychiatry department at the university.

Clinicians should consult with a nutritionist, if possible, to develop regular, structured diets for their patients. They also might want to adopt a behavioral contract with the patient or the patient's parent for eating meals and choosing foods. Anxiolytics given 30-60 minutes before meals can help patients with anxiety about eating.

It is particularly important to encourage patients with anorexia to eat small, frequent meals, typically about six a day. "Part of the reason for that is that they will be extremely uncomfortable physically if they take in a large amount of food because their gut won't know what to do with it, and it takes time to literally process the food," she said.

Some patients referred to Dr. Chesen have been on total parenteral nutrition, but this approach doesn't teach the gut to work properly for the long term and can cause liver abnormalities, she said.

If nasogastric feeding is necessary, she recommends using the smallest tube possible, such as a pediatric tube, and feeding continuously over 24 hours at the slowest possible rate. A bolus or gastrostomy tube should not be used to administer feedings.

Too-rapid refeeding is a major problem in patients with anorexia, because their bodies can become overwhelmed with the sudden intake of nutrients, leading to severe fluid retention, electrolyte disturbances, arrhythmias, seizures, coma, and death. "You want to be really gentle and really slow," Dr. Chesen said. "Keep in mind that they didn't get this way overnight, so you're not going to get them healthy overnight."

Physical examinations and laboratory evaluations should be performed every 2 weeks, especially in patients who are severely malnourished at the start of treatment. Clinicians should be aware that during refeeding, changes in body shape and clothing fit can trigger severe anxiety or depression.

All patients with eating disorders should take a multivitamin plus vitamin D and calcium. Because of the risk of death secondary to cardiac arrhythmias in patients with anorexia, clinicians should consider oral vitamin K supplementation, which has been shown to normalize the QT interval. "I'm not saying you should put every anorexic on potassium, but they should have an EKG, and their potassium levels should be followed by their primary care physician," she said.


Chicago Bureau
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Title Annotation:care and treatment
Author:Wendling, Patrice
Publication:Clinical Psychiatry News
Geographic Code:1U8AZ
Date:May 1, 2006
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