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A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders

Published:April 12, 2018DOI:



      Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using “start low, go slow” refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts.


      To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs.


      This was a retrospective pre-test–post-test study.


      One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013.

      Main outcome measures

      Differences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined.

      Statistical analysis performed

      χ2 tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols.


      Descriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391).


      A higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial.


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      K. Matthews is a PhD candidate, School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Australia.


      J. Hill is director, Department of Nutrition and Dietetics, Princess Alexandra Hospital, Woolloongabba, Australia; at the time of the study, she was assistant director, Nutrition and Dietetics Department, Royal Brisbane and Women’s Hospital, Herston, Australia.


      S. Jeffrey is a senior dietitian and clinical manager, Food Mind Body, Paddington, Australia; at the time of the study, he was a dietitian, Eating Disorder Outreach Service, Indooroopilly, Australia.


      S. Patterson is a principal research fellow-mental health, Metro North HHS, and an associate professor of applied psychology, Griffith University, Mount Gravatt, Queensland, Australia.


      A. Davis is a senior dietitian, Queensland Eating Disorder Service, Queensland, Australia.


      W. Ward is an associate professor, School of Medicine. University of Queensland, Royal Brisbane Women’s Hospital, Herston, Queensland, Australia.


      M. Palmer is a team leader, Nutrition and Dietetics Department, Logan Hospital, Meadowbrook, Australia.


      S. Capra is a professor of nutrition, School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Australia.