Artigo - Reabilitacao nutricional em transtornos alimentares

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3 Nutritional Challenges in Special Conditions and Diseases 
 Key Words 
 Eating disorders · Malnutrition · Oral nutritional 
supplements · Nasogastric tube feeding · 
Refeeding syndrome 
 Key Messages 
 • Anorexia nervosa (AN) is an eating disorder charac-
terized by a fear of weight gain, unusual eating hab-
its and restricted food consumption 
 • AN predominantly manifests in adolescent females 
 • AN patients tend to restrict their energy intake, 
avoid energy-dense and fatty foods, choose a nar-
row range of foods and consume vegetarian diets 
with a low energy density 
 • Severe malnutrition develops regularly, with mark-
edly reduced body weight, BMI and body fat con-
tent as well as numerous complications (e.g. sec-
ondary amenorrhoea, osteopenia, short stature, 
bradycardia and a high mortality risk) 
 © 2015 S. Karger AG, Basel 
 Introduction 
 Anorexia nervosa (AN) is a complex and usually 
chronic disorder characterized by a fear of weight 
gain, unusual eating habits and restricted food in-
take. AN typically manifests predominantly in 
adolescent females and may affect up to 0.7% of 
this age group [1] . AN patients tend to restrict 
their energy intake, avoid energy-dense and fatty 
foods, choose a narrow range of foods and con-
sume vegetarian diets with a low energy density 
 [1] . As a result, AN patients often consume no 
more than 10–20 kcal/kg per day and develop se-
vere malnutrition with markedly reduced body 
weight, BMI and body fat content, which can re-
sult in numerous complications (e.g. secondary 
amenorrhoea, osteopenia, short stature, brady-
cardia and a high mortality risk). Treatment must 
address psychological and medical issues. It is 
based on inpatient or outpatient psychiatric treat-
ment but regularly needs to involve several medi-
cal professions, including experts in nutritional 
rehabilitation [2] . 
Nutritional Rehabilitation
 Guidelines for nutritional rehabilitation of AN 
have been published by the American Psychiatric 
Association [3] ( table 1 ) and the UK National In-
stitute for Health and Clinical Excellence [4] ( ta-
ble 2 ). Both guidelines advise aiming for only a 
 Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265 
 DOI: 10.1159/000375192 
 3.22 Nutrition Rehabilitation in Eating Disorders 
 Berthold Koletzko 
 
 
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260 Koletzko 
Table 1. Guidelines of the American Psychiatric Association for nutritional rehabilitation in AN
The goals of nutritional rehabilitation for seriously underweight patients are to restore 
weight, normalize eating patterns, achieve normal perceptions of hunger and satiety, and 
correct biological and psychological sequelae of malnutrition.
I
In working to achieve target weights, the treatment plan should also establish expected 
rates of controlled weight gain. Clinical consensus suggests that realistic targets are 2 – 3 
lb/week for hospitalized patients and 0.5 – 1 lb/week for individuals in outpatient 
programs.
II
Registered dietitians can help patients choose their own meals and can provide a 
structured meal plan that ensures nutritional adequacy and that none of the major food 
groups are avoided.
I
It is important to encourage patients with AN to expand their food choices to minimize 
the severely restricted range of foods initially acceptable to them.
II
Caloric intake levels should usually start at 30 – 40 kcal/kg per day (approx. 1,000 – 1,600 
kcal/day). During the weight gain phase, intake may have to be advanced progressively 
to as high as 70 – 100 kcal/kg per day for some patients; many male patients require a 
very large number of calories to gain weight.
II
Patients who require much lower caloric intakes or are suspected of artificially increasing 
their weight by fluid loading should be weighed in the morning after they have voided 
and are wearing only a gown; their fluid intake should also be carefully monitored.
I
Urine specimens obtained at the time of a patient’s weigh-in may need to be assessed for 
specific gravity to help ascertain the extent to which the measured weight reflects 
excessive water intake.
I
Regular monitoring of serum potassium levels is recommended in patients who are 
persistent vomiters.
I
Weight gain results in improvements in most of the physiological and psychological 
complications of semistarvation.
I
It is important to warn patients about the following aspects of early recovery: I
As they start to recover and feel their bodies getting larger, especially as they approach 
frightening, magical numbers on the scale that represent phobic weights, they may 
experience a resurgence of anxious and depressive symptoms, irritability and sometimes 
suicidal thoughts. These mood symptoms, non-food-related obsessional thoughts, and 
compulsive behaviours, although often not eradicated, usually decrease with sustained 
weight gain and weight maintenance. Initial refeeding may be associated with mild 
transient fluid retention, but patients who abruptly stop taking laxatives or diuretics may 
experience marked rebound fluid retention for several weeks. As weight gain progresses, 
many patients also develop acne and breast tenderness and become unhappy and 
demoralized about resulting changes in body shape. Patients may experience abdominal 
pain and bloating with meals from the delayed gastric emptying that accompanies 
malnutrition. These symptoms may respond to promotility agents.
III
When life-preserving nutrition must be provided to a patient who refuses to eat, 
nasogastric feeding is preferable to intravenous feeding.
I
 I = Recommended with substantial clinical confidence; II = recommended with moderate clinical 
confidence; III = may be recommended on the basis of individual circumstances. Modified from 
American Psychiatric Association [3].
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265 
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moderate rate of weight gain up to ∼ 1 kg/week. 
However, the implementation of increased nutri-
ent intakes from foods, oral nutritional supple-
ments or tube feedings is often made difficult by 
the denial of illness and resistance to treatment 
that is frequently found in AN patients, who tend 
to drop out of recommended treatment pro-
grammes.
 While healthy women without an eating dis-
order require 20–40 kcal/kg per day to maintain 
their weight, the energy intake of AN patients 
needs to be increased stepwise to about 60–100 
kcal/kg per day to achieve a sustained weight gain 
 [1] . This rather high energy need reflects a hyper-
metabolic state, which in part may be due to ex-
cessive physical activity and exercise – a common 
behaviour in AN. Increasing energy and nutrient 
intake to achieve nutritional rehabilitation can be 
approached either by increased intakes of regular 
foods, energy-dense oral nutritional supplements 
with an energy density of ≥ 1 kcal/ml, nasogastric 
tube feeding or a combination thereof. There is 
broad agreement that parenteral nutrition should 
generally be avoided unless a severely impaired 
gut function prevents the use of oral or enteral 
nutrition. 
Table 2. Guidelines of the UK National Institute for Health and Clinical Excellence for nutritional 
rehabilitation in AN
Managing weight gain in AN
In most patients with AN, an average weekly weight gain of 0.5 – 1 kg in inpatient settings 
and 0.5 kg in outpatient settingsshould be an aim of treatment. This requires about 
3,500 – 7,000 extra calories a week.
C
Regular physical monitoring, and in some cases treatment with a multivitamin/
multimineral supplement in oral form, is recommended for people with AN during 
both inpatient and outpatient weight restoration.
C
Total parenteral nutrition should not be used for people with AN, unless there is 
significant gastrointestinal dysfunction.
C
Managing risk in AN
Health care professionals should monitor physical risks in patients with AN. If this leads 
to the identification of increased physical risks, the frequency and the monitoring and 
nature of the investigations should be adjusted accordingly.
C
People with AN and their carers should be informed if the risk to their physical health is 
high.
C
The involvement of a physician or paediatrician with expertise in the treatment of 
physically at-risk patients with AN should be considered for all individuals who are 
physically at risk.
C
Pregnant women with either current or remitted AN may need more intensive prenatal 
care to ensure adequate prenatal nutrition and fetal development.
C
Oestrogen administration should not be used to treat bone density problems in children 
and adolescents as this may lead to premature fusion of the epiphyses.
C
 Evidence C: this grading indicates that directly applicable clinical studies of good quality are 
absent or not readily available. Modified from National Institute for Health and Clinical Excellence 
[4].
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265 
DOI: 10.1159/000375192
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262 Koletzko 
Benefits Disadvantages
Only regular foods
– It teaches skills for eating, promotes normal 
behaviour and challenges unhelpful coping 
strategies 
– Less energy is delivered from food when compared 
with nasogastric feeding
– Patients experience the amount of food necessary 
for weight gain and weight maintenance 
– Food makes hospital meal management home-like 
and realistic, which exposes patients to a situation 
which is anxiety-provoking, and gives them 
confidence in managing meals at home
High-energy oral nutritional supplements
–
–
Supplements can meet the high-energy 
requirements needed for weight gain in a smaller 
volume than food
They are helpful as a top-up for patients struggling 
with satiety and the quantities of food required to 
promote weight gain
– The frequent use of supplements encourages patients 
away from the experience of food, re-enforces their 
avoidance of food and can foster dependency on 
artificial food sources
– It can be seen as a type of medicine 
Nasogastric tube feeding
–
–
–
More comfortable for the patient with less pain, 
physical discomfort and abdominal distension than 
large amounts of food 
A helpful strategy aiding recovery:
it transfers the responsibility of weight gain from the 
patient to the treatment team;
if placed upon admission, it ‘medicalises’ the 
treatment and reduces the ‘power struggle’ 
between the patient and clinicians
Opinions from patients and carers:
nasogastric feeding was seen as necessary by some 
patients because they believed they lacked the 
physical or psychological capacity to eat;
parents recognized it as a last resort that was 
required to keep their child alive;
it reduces the pressure patients perceive is being 
placed on them to eat and temporarily relieves them 
from the responsibility for adopting improved 
eating behaviours
–
–
–
–
–
–
–
It interferes with the fragile alliance between the 
patient and treatment team
The patient may feel disempowered and embittered 
towards the treatment team, which may have an 
impact on future personal and professional 
relationships 
There is an emotional toll on staff treating involuntary 
patients
Not helpful for long term recovery:
patients may demonstrate an inability to maintain an 
adequate intake and weight gain once the tube is 
removed;
force-feeding in low-weight patients achieves little in 
relation to remitting illness or suffering; 
patients tamper with the tube by adjusting the control, 
decanting the feed into other containers when 
unobserved, biting, and removing the tube
Medical complications (i.e. aspiration, nasal bleeding 
and nasal irritation, reflux and sinusitis)
The tube may not be inserted properly, which is more 
likely when patients have it inserted against their will
Opinions from patients and carers:
it disguises the consumption of food;
patients become emotionally attached to and 
physically reliant on nasogastric feeding, and
are anxious about the tube being removed;
it is used as a form of punishment and seen as a 
strategy that doctors use to assert their control
Table 3. Benefits and disadvantages of different feeding methods in AN patients
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265 
DOI: 10.1159/000375192
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Choice of Refeeding Methods
 Hart et al. [5] reviewed the literature to identify 
which of the different feeding methods is most ef-
fective and advantageous in AN. An analysis of the 
published information revealed that the most 
common method of refeeding was by nasogastric 
feeding and food, followed by high-energy density 
oral nutritional supplements and food [5] . How-
ever, due to the limited evidence available, no con-
clusion could be drawn on the most effective meth-
od of nutritional rehabilitation in AN. However, 
the authors compiled benefits and disadvantages 
of the different feeding methods for AN patients 
( table 3 ). Similarly, Rocks et al. [6] concluded from 
their review of the available literature that a con-
sensus on the most effective and safe treatment for 
weight restoration in inpatient children and ado-
lescents with AN is not currently feasible. None-
theless, these authors concluded that the use of 
tube feeding in addition to normal food intake in-
creased energy intake and body weight, although it 
was associated with more frequent adverse effects.
 A particular concern related to the use of na-
sogastric tube feeding in malnourished patients 
is the risk of inducing refeeding syndrome with 
hypophosphataemia. Adaption to starvation in 
malnourished children and adolescents is associ-
ated with a reduced metabolic turnover, cellular 
activity and organ function, low insulin secre-
tion, and deficiencies in a variety of micronutri-
ents, minerals and electrolytes [7] . Catabolic pa-
tients use substrates from adipose tissue and 
muscle as sources of energy, and the total body 
stores of nitrogen, phosphate, magnesium and 
potassium become depleted. The sudden provi-
sion of energy and nutrients reverses catabolism 
and leads to a surge of insulin secretion, which in 
turn leads to massive intracellular shifts of phos-
phate, magnesium and potassium with a subse-
quent fall in their serum concentrations. The 
clinical consequences of the resulting electrolyte 
disturbances with hypophosphataemia include 
haemolytic anaemia, muscle weakness and im-
paired cardiac function, with the risks of fluid 
overload, cardiac failure, arrhythmia and death.
Table 3 (continued)
Benefits Disadvantages
Parenteral nutrition
– It requires minimal patient cooperation – It may reinforce a tendency to focus only on physical 
symptoms rather than the psychiatric implications of 
AN
– Sabotage occurs by pouring solutions into the sink and 
removing the device
– It cannot teach patientsanything about eating, food 
choice or portion size, or about perceiving their bodies 
more accurately
– Medical complications [i.e. infections; arterial injury; 
cardiac arrhythmias (from placement); changes in 
vascular endothelium; hyperosmolarity and 
hyperglycaemia; hypophosphataemia and 
hypokalaemia]
– More medically intensive, incurring high costs
Modified from Hart et al. [5].
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265 
DOI: 10.1159/000375192
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Refeeding Syndrome and Outcome
 The risk of refeeding syndrome is highest in AN 
patients with severe underweight, which is a better 
risk predictor than total energy intake [8] . The first 
week after starting enteral nutrition is the time with 
the highest rate of refeeding syndrome manifesta-
tions. To reduce the risk, a patient’s nutritional sta-
tus and hydration as well as serum electrolytes, 
magnesium and phosphate should be assessed pri-
or to initiating tube feeding. During the initial 
phase of refeeding, daily monitoring of plasma 
electrolytes, phosphate, magnesium, calcium, urea 
and creatinine as well as of cardiac status (pulse, 
heart failure) is advisable [8] . Initial enteral feeding 
should be limited to provide only about three quar-
ters of the estimated requirements in severe cases 
(i.e. 11–14 years: 45 kcal/kg per day; 15–18 years: 
40 kcal/kg per day). If this supply is tolerated and 
no imbalances are encountered, the supply may be 
gradually increased over 1–3 weeks towards reach-
ing intakes that achieve a sustainable weight gain. 
Frequent small feeds with an energy density of 1 
kcal/ml should be used in order to minimize fluid 
load. The following supplements may be provided: 
Na + at 1 mmol/kg per day, K + at 4 mmol/kg per 
day, Mg 2+ at 0.6 mmol/kg per day and phosphate 
at ≤ 100 mmol orally for children and adolescents 
>5 years of age [8] . An occurring hypocalcaemia 
must be corrected. Thiamine, riboflavin, folic acid, 
ascorbic acid, pyridoxine and fat-soluble vitamins 
should be supplemented along with trace elements. 
Patients with a BMI <16, weight loss of >15% with-
in the previous 3–6 months, very little or no nutri-
ent intake for >10 days, and low levels of potassi-
um, phosphate or magnesium prior to any feeding 
are considered a high-risk group for developing 
refeeding syndrome and should not only have an 
initial restriction of their protein and energy intake 
but also be given thiamin and other B group vita-
mins, a balanced multivitamin and trace element 
supplement, as well as potassium, magnesium and 
phosphate under close monitoring of plasma con-
centrations.
 Agostino et al. [9] reviewed the outcomes of 
AN patients treated with nasogastric tube feed-
ing or a standard bolus meal treatment in one 
centre. The patients with nasogastric tube feed-
ing had a significantly shorter hospital stay (33.8 
vs. 50.9 days; p = 0.0002) and an improved rate of 
weight gain, while the rate of complications or 
electrolyte abnormalities with prophylactic phos-
phate supplementation from admission was not 
different. One may conclude that even though an 
individualized approach to refeeding AN pa-
tients is appropriate, the available data support 
the option of treating undernourished AN inpa-
tients with nasogastric tube feeding while using 
appropriate precautions and monitoring.
 Conclusions 
 • AN patients require inpatient or outpatient 
psychiatric treatment, but they also regularly 
need treatment involving experts in nutrition-
al rehabilitation 
 • Nutritional rehabilitation aims at only a mod-
erate rate of weight gain up to ∼ 1 kg/week 
 • Refeeding can be achieved by increased nutri-
ent intake from foods, oral nutritional supple-
ments or tube feedings but is often made dif-
ficult by the denial of illness and resistance to 
treatment frequently found in AN patients 
 • A slow initiation of refeeding as well as close 
monitoring are needed, particularly in mark-
edly malnourished patients, to reduce the risk 
of refeeding syndrome and hypophosphatae-
mia 
 • The energy intake in AN patients needs to be 
slowly increased to ∼ 60–100 kcal/kg per day to 
achieve a sustained weight gain, partly due to 
high energy expenditure resulting from exces-
sive physical activity 
 • In addition to regular foods, the use of oral nu-
tritional supplements and nasogastric tube 
feedings is a suitable option for refeeding AN 
patients 
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265 
DOI: 10.1159/000375192
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 7 Koletzko B, Goulet O: Nutritional sup-
port in infants, children and adoles-
cents; in Sobotka L (ed): Basics in Clini-
cal Nutrition. Prague, Galén, 2011, pp 
625–653. 
 8 O’Connor G, Nicholls D: Refeeding hy-
pophosphatemia in adolescents with 
anorexia nervosa: a systematic review. 
Nutr Clin Pract 2013; 28: 358–364. 
 9 Agostino H, Erdstein J, Di Meglio G: 
Shifting paradigms: continuous naso-
gastric feeding with high caloric intakes 
in anorexia nervosa. J Adolesc Health 
2013; 53: 590–594. 
 
 References 
 1 Marzola E, Nasser JA, Hashim SA, Shih 
PA, Kaye WH: Nutritional rehabilitation 
in anorexia nervosa: review of the litera-
ture and implications for treatment. 
BMC Psychiatry 2013; 13: 290. 
 2 Weaver L, Sit L, Liebman R: Treatment 
of anorexia nervosa in children and ado-
lescents. Curr Psychiatry Rep 2012; 14: 
 96–100. 
 3 American Psychiatric Association: 
Treatment of patients with eating disor-
ders, third edition. American Psychiat-
ric Association. Am J Psychiatry 2006; 
 163(suppl):4–54. 
 4 National Institute for Health and Clini-
cal Excellence: Eating Disorders. Man-
chester, National Institute for Health 
and Clinical Excellence, 2004. 
 5 Hart S, Franklin RC, Russell J, Abraham 
S: A review of feeding methods used in 
the treatment of anorexia nervosa. J Eat 
Disord 2013; 1: 36. 
 6 Rocks T, Pelly F, Wilkinson P: Nutrition 
therapy during initiation of refeeding in 
underweight children and adolescent 
inpatients with anorexia nervosa: a sys-
tematic review of the evidence. J Acad 
Nutr Diet 2014; 114: 897–907. 
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265 
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