Restoring Nutritional Health in Anorexia Nervosa Recovery

Meal Plans for Anorexia Nervosa Recovery

The malnutrition that accompanies anorexia nervosa can negatively impact all systems of the body. Therefore, restoration of weight and nutritional health is an essential component of treatment for anorexia nervosa. Restoring a body malnourished by anorexia nervosa may take many months or even years. Patients with anorexia nervosa should generally be under the care of a treatment team, which commonly includes a medical doctor, a registered dietitian nutritionist, a psychotherapist, and a psychiatrist.

Anyone beginning nutritional rehabilitation must be aware of the potentially fatal refeeding syndrome. This article begins with necessary precautions to avoid this potential side-effect. It then offers strategies for outpatient nutritional rehabilitation, suggested meal plans, additional weight gain strategies, and suggestions for overcoming common challenges to recovery.

Avoiding Refeeding Syndrome

One potential risk to be considered before beginning nutritional rehabilitation is refeeding syndrome. Refeeding syndrome is caused by the rapid refeeding of someone in a state of starvation, usually chronic, and it may be fatal. It is characterized by electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing nutritional rehabilitation.

How could finally eating after a period of starvation possibly be harmful to the body? Biochemistry tells us that ketone bodies and free fatty acids from the breakdown (catabolism) of muscle and adipose tissue replace glucose as a major energy source in starvation.

During refeeding, there is a shift from fat to carbohydrate metabolism. The resulting insulin released from the pancreas increases cellular uptake of glucose, phosphate, potassium, magnesium, sodium, and water. The body also shifts into a building (anabolic) state of protein synthesis, which requires more nutrient uptake into the cells.

The body then is at risk for not having enough of these vital nutrients in the blood stream. Clinical consequences may include irregular heart rate, congestive heart failure, respiratory failure, coma, seizures, skeletal-muscle weakness, loss of control of body movements, and brain damage.

To avoid refeeding syndrome, levels of phosphorus, magnesium, potassium, calcium, and thiamin must be monitored for the first 5 days and every other day for several weeks. Electrocardiogram (EKG) should also be performed. Strict medical oversight is required.

The National Institute for Health and Clinical Excellence Criteria for Patients advises that there is a significant risk for refeeding syndrome if your starting point is 1,000 or fewer calories per day.  Refeeding syndrome risk increases greatly with the following:

  • Patients who have one of the following indicators:
    • Body mass index of less than 16
    • Weight loss of more than 15 percent in the past 3-8 months
    • Little or no nutritional intake for more than 10 days
    • Low levels of potassium, phosphate, and/or magnesium before refeeding
  • Patients who have two or more of the following indicators:
    • Body mass index of less than 18.5
    • Weight loss of more than 10 percent in the past 3-6 months
    • Little or no nutritional intake for more than 5 days
    • History of alcohol misuse or drugs, including insulin, chemotherapy, antacids or diuretics

Under these conditions, nutritional restoration must go slowly to avoid potential refeeding syndrome. A medical team is necessary including a medical doctor and a Registered Dietitian Nutritionist (RDN) to calculate, monitor, and increase daily food and fluid intake as well as monitor plasma and urinary electrolytes, plasma glucose, vital functions, and cardiac rhythm before and during refeeding.

Because of the risk for refeeding syndrome and countless other potential medical issues related to starvation, many patients with anorexia nervosa begin their nutritional rehabilitation in medical hospitals or residential treatment centers. The remainder of this article is directed towards those who are not at risk for refeeding syndrome and have been medically cleared to begin or continue nutritional rehabilitation on an outpatient basis.

Outpatient Nutritional Rehabilitation

Recent research has shown that for patients not at risk for refeeding syndrome, more aggressive and faster refeeding protocols lead to faster recovery and better overall outcomes. It is not uncommon for daily caloric needs of people recovering from anorexia to reach 3,000 to 5,000 daily calories for a sufficient one-half pound to two pounds per week weight gain until achieving goal weight. This is especially true for adolescents who are still growing and young adults.

Adolescents participating in Family-Based Treatment with parents in charge of nutritional rehabilitation support are usually able to be safely started at an intake of 2,000 to 2,500 calories per day. With an outpatient team supporting and monitoring, parents are often encouraged to increase meal plans to 3,000 to 5,000 calories per day for weight restoration.

Parents and patients are often perplexed at such high caloric needs as renourishing progresses. Why are they so high? Individuals with anorexia nervosa often become hypermetabolic, which means their metabolism has kicked into high gear as if the body is trying to defend the low weight. Individuals commonly experience elevated body temperature as energy intake may be converted into heat, rather than used to build tissue. This paradoxical symptom makes recovery even harder.

Additionally, many patients with anorexia nervosa engage in excessive exercise even despite severe emaciation. Such exercise may be hidden and can further undermine attempts at weight gain by increasing calorie expenditure. Exercise is usually not medically advised in the initial stages of nutritional rehabilitation, but patients may need monitoring to prevent it.

It is important to note that because increased caloric intake generates significant anxiety in those with anorexia nervosa, achieving these caloric goals may be very challenging even with additional support. However, it is imperative to allow enough caloric intake for the body to fully recover. Weight goals should always be calculated by your medical team. A return of menses in females is critical. Again a medical team is advised to calculate your specific individual calorie needs as they shift during the recovery process.

Suggested Meal Guidelines

If you are consuming more than 1,000 calories per day as your starting point, are not a risk for refeeding syndrome as discussed above, and have been medically cleared to do so, then you may consider beginning nutritional rehabilitation.

Please consult with a medical doctor and registered dietitian to tailor recommendations specifically for your body. For example, an illustrative nutritional rehabilitation recommendation for a 90-pound patient not at risk for refeeding syndrome could be as follows.

  • Day 1-4: 1,200-1,600 calories/day
  • Day 5-7: If no weight gain is observed, increase by 400 calories per day to 1,600-2,000 calories/day (If weight gain is occurring you may increase more gradually.)
  • Day 10-14: If weight gain is not reaching 1 to 2 pounds per week, increase daily intake again by 400-500 calories/day to 2,000-2,500
  • Day 15-21: 2,500-3,000 calories/day
  • Day 20-28: 3,000-3,500 calories/day

Remember caloric needs commonly increase as weight is gained. Therefore patients recovering from anorexia nervosa commonly require escalating caloric intake in order to maintain a steady weight gain. For this reason, weekly weigh-ins that record progress are desirable. If and when the rate of weight gain slows or stops, caloric intake must be increased.

The Meal Plan Recipe for Success

Since a calorie-focused meal plan could be triggering for those recovering from anorexia, it is not necessarily the first choice for registered dietitians to recommend. However, it could be helpful to have an idea of what calorie count to target, especially when reading food labels and menus. A good initial rule of thumb is three 500- to 800-calorie meals plus at least three 300-calorie snacks (after initial caloric estimates are calculated and monitored and refeeding syndrome has been ruled out). Again, calorie levels are always a moving target, depending on ​the rate of weight gain.

The preferred meal plan model for anorexia nervosa recovery is the exchange system. It is often used in hospital, residential and outpatient eating disorder recovery treatment. Originally designed for patients with diabetes, the system is versatile in recovery because it takes into consideration macronutrient proportions (protein, carbohydrate, fat) without a direct focus on calories.  Calculations often aim to reach 50-60% total calories from carbohydrates, 15-20% from protein, and 30-40% from dietary fat for metabolic efficiency. Each “exchange” (starch, fruit, vegetable, milk, fat, protein/meat) equates to a certain food and its portion size. This allows for a focus on balanced food group selection during the meal planning process.

However, having a balanced diet may not be as important as increased caloric intake during the weight restoration process. A Registered Dietitian Nutritionist can help calculate and design exchange meal plans taking this all into consideration.

An illustrative 3,000-calorie Exchange System Meal Plan for a day might comprise 12 starch, 4 fruit, 4 milk, 5 vegetables, 9 meat, and 7 fat. A daily regimen might divide the exchanges into meals and snacks as follows:

Breakfast: 2 Starch, 1 Fat, 2 Meat, 1 Milk, 2 Fruit

  • 2 slices of toast (2 starch exchanges) with 1 tsp. butter (1 fat exchange)
  • 2 scrambled eggs (2 meat exchanges) made with 2oz whole milk plus 6oz of whole milk on the side to drink (total-1 milk exchange),
  • 4 oz of orange juice & 1/2 cup fruit salad (total-2 fruit exchanges)

Lunch: 2 Starch, 2 Vegetable, 3 Meat, 2 Fat, 1 Milk

  • Grilled cheese sandwich:  2 slices of bread (2 starch exchanges), 2 tsp butter (2 fat exchanges), 3 slices of cheese (3 meat exchanges)
  • Tomato soup (1 cup tomato soup condensed-2 vegetable exchanges) made with 1 cup whole milk (1 milk exchange)

Dinner: 4 Starch, 3 Meat, 3 Fat, 2 Vegetable, 1 Fruit

  • 1 cup cooked pasta (2 starch exchanges)
  • 2 pieces garlic toast (2 starch exchanges) + 2 tsp butter (2 fat exchanges)
  • 3 oz of ground beef or turkey (3 meat exchanges) browned in 1 tsp olive oil (1 fat exchange)
  • ½ cup tomato sauce with ½ cup cooked broccoli (2 vegetable exchange)
  • 1 orange (1 fruit exchange)

Snack #1: 2 Starch, 1 Milk

  • 1 large muffin (2 starch exchanges)
  • 1 cup whole milk (1 milk exchange – half & half could be added for more calories)

Snack #2: 1 Fruit, 1 Milk

  • ½ banana (1 fruit exchange)
  • 1 cup whole milk yogurt (1 milk exchange)

Snack #3: 1 Meat, 2 Starch, 1 Vegetable, 1 Fat

  • 1 tsp peanut or almond butter (1 meat exchange)
  • 2 bread slices (2 starch exchanges)
  • 1 cup raw carrots (1 vegetable exchange), 1 oz hummus (1 fat exchange)

Other Weight Gain Strategies

In order to increase caloric intake to achieve a steady weight gain course, you can always remember some simple tactics:

  • Increase the frequency of eating (from three times per day to six times per day)
  • Increase actual portion size
  • Increase caloric density (add fat while cooking such as oil, butter, cream, cheese which can increase calories without increasing portion size)
  • Cut back on raw fruits and vegetables which can contribute to early fullness
  • Supplementing with liquid nutrition (Ensure Plus, Boost Plus) providing 350-360 calories per 8 ounces could prove very helpful for caloric density. Liquid nutrition in this form is recommended immediately as caloric replacement for skipped or unfinished meals or snacks.

Overcoming Challenges on the Road to Weight Restoration

Since a primary symptom of the disorder is dietary restriction, what patient with anorexia will willingly eat more? Resistance is common and calls for direct support from loved ones and a team of professionals who can help hold patients accountable to meal plans and weight gain as well as challenge the eating disorder mindset and encourage consumption of fear foods on a daily basis. Vegetarian, low fat, low carb, and non-dairy diets should be discouraged (unless a diagnosed allergy) as they often are a symptom of the disorder and not based on legitimate health concerns.

Delayed gastric emptying or gastroparesis is common with anorexia nervosa and can contribute to early fullness and bloating. This further complicates the renourishing process as eating the required increased intake may be physically uncomfortable. Frequent nutrient-dense meals and snacks that allow for smaller portions without sacrificing calorie content is the key to overcoming this hurdle. Eating disorder recovery teams can help support renourishing's physical side effects as well as the psychological resistance to such aspects of recovery. Teams usually include a medical doctor, registered dietitian nutritionist, psychotherapist, and psychiatrist. When searching and building outpatient teams, it is advisable to make sure practitioners have an eating disorder specialty.

Allowing a loved one to help with accountability and provide recovery support can be extremely powerful in recovery. Family Based Treatment (FBT or Maudsley) is an evidence-based model designating parents as the primary support for refeeding of children and adolescents with anorexia nervosa. Other models of treatment that provide family support for adults with anorexia nervosa have been developed as well.

Recovery is not a linear process and may be slow. Remember that life stresses and major life changes can possibly activate relapse. Support and re-evaluation of progress and goals are constantly needed. Making peace with food and having restored psychological, emotional, and physical health and well-being is indeed possible.

Sources:

American Psychiatric Association. (2006). Treatment of patients with eating disorders, 3rd edition. American Journal of Psychiatry, 163(7 Suppl.), 4-54.

Crook, M. A., V. Hally, and J. V. Panteli. "The Importance of the Refeeding Syndrome." Nutrition 7-8 17 (n.d.): 632-37. Hopkinsmedicine.org. Elsevier Science Inc., 2 Jan. 2001. Web.

Garber, A. K., Mauldin, K., Michihata, N., Buckelew, S. M., Shafer, M.-A., & Moscicki, A.-B. (2013). Higher Calorie Diets Increase Rate of Weight Gain and Shorten Hospital Stay in Hospitalized Adolescents With Anorexia Nervosa. The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine53(5), 579–584.

Marzola, E., Nasser, J. A., Hashim, S. A., Shih, P. B., & Kaye, W. H. (2013). Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment. BMC Psychiatry, 13, 290.

Mehanna, Hisham M., Jamil Moledina, and Jane Travis. "Refeeding Syndrome: What It is, and How to Prevent and Treat It." BMJ : British Medical Journal. BMJ Publishing Group Ltd., 2008. Web. 27 Nov. 2016.

Waterhous, T .& Jacob, Melanie A.. "Nutrition Intervention in the Treatment of Eating Disorders." Practice Paper of the American Dietetic Association: American Dietetic Association, n.d. Web. 27 Nov. 2016.

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