Fellows journal Club
Article: Golden NH, Cheng J, Kapphahn CJ, et al. Higher- Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial. Pediatrics. 2021; 147(4): e2020037135
Fellow: Caroline Roth, MD; LSU/Children’s Hospital of New Orleans
Summary: In this study, the authors present the one year outcomes of the Study of Refeeding to Optimize Inpatient Gains (StRONG) trial which had previously shown in the short term that a higher-calorie refeeding (HCR) regimen, in comparison to a lower-calorie refeeding (LCR) regimen, resulted in a shorter time to medical stability, shorter length of stay, and reduced cost per participant without an increased rate of electrolyte abnormalities. Patients hospitalized for medical instability with a diagnosis of anorexia nervosa or atypical anorexia nervosa with mBMI >60% at two tertiary care centers were randomized to a LCR regimen or a HCR regimen. Height, weight, vital signs, information regarding medical readmissions, and an Eating Disorder Examination Questionnaire (EDE-Q) score were obtained over the course of a year at five follow-up visits or from outside records if in-person visits were not conducted. The authors found no statistically significant difference between the rates of clinical remission, change in percentage of mBMI, change in EDE-Q scores, proportion of patients who experienced medical rehospitalization, or duration of rehospitalization.
Strengths: The study had a randomized control trial design, demonstrated a long time frame for follow-up, and was adequately powered with an enrolled sample size of 120 patients and good retention. In terms of generalizability, the study was multicenter with two participating academic centers.
Limitations: The study population excluded patients who had an mBMI <60% who may potentially be at higher risk for refeeding syndrome. While the study was multicenter, the centers were in the same geographic region and were large academic centers where the majority of the patients followed up with clinicians within that institution which may limit generalizability to other regions or to hospitals with fewer resources.
Major takeaway: A HCR regimen can be used for most patients hospitalized for medical stabilization secondary to anorexia nervosa without significantly increasing the risk of long term rehospitalization and with statistically similar rates of clinical remission at one year when compared to patients who receive a LCR regimen.
How this article should impact our practice: While historically most institutions used a LCR regimen in their protocols for initial medical stabilization in patients with anorexia nervosa, the StRONG trial offers evidence that a HCR regimen is comparable in terms of risk of refeeding syndrome and long-term clinical remission and rehospitalization rates. As an HCR regimen also has the potential to expedite weight gain, shorten length of stay, and reduce cost, many hospitals may find this an appealing alternative to the LCR regimen. In a time when an increasing percentage of our acute care beds are occupied by patients admitted for disordered eating, any measures that have the potential to reduce time to medical stability, cost, and length of stay in addition to being safe should be considered in our care of these patients.
Fellow: Caroline Roth, MD; LSU/Children’s Hospital of New Orleans
Summary: In this study, the authors present the one year outcomes of the Study of Refeeding to Optimize Inpatient Gains (StRONG) trial which had previously shown in the short term that a higher-calorie refeeding (HCR) regimen, in comparison to a lower-calorie refeeding (LCR) regimen, resulted in a shorter time to medical stability, shorter length of stay, and reduced cost per participant without an increased rate of electrolyte abnormalities. Patients hospitalized for medical instability with a diagnosis of anorexia nervosa or atypical anorexia nervosa with mBMI >60% at two tertiary care centers were randomized to a LCR regimen or a HCR regimen. Height, weight, vital signs, information regarding medical readmissions, and an Eating Disorder Examination Questionnaire (EDE-Q) score were obtained over the course of a year at five follow-up visits or from outside records if in-person visits were not conducted. The authors found no statistically significant difference between the rates of clinical remission, change in percentage of mBMI, change in EDE-Q scores, proportion of patients who experienced medical rehospitalization, or duration of rehospitalization.
Strengths: The study had a randomized control trial design, demonstrated a long time frame for follow-up, and was adequately powered with an enrolled sample size of 120 patients and good retention. In terms of generalizability, the study was multicenter with two participating academic centers.
Limitations: The study population excluded patients who had an mBMI <60% who may potentially be at higher risk for refeeding syndrome. While the study was multicenter, the centers were in the same geographic region and were large academic centers where the majority of the patients followed up with clinicians within that institution which may limit generalizability to other regions or to hospitals with fewer resources.
Major takeaway: A HCR regimen can be used for most patients hospitalized for medical stabilization secondary to anorexia nervosa without significantly increasing the risk of long term rehospitalization and with statistically similar rates of clinical remission at one year when compared to patients who receive a LCR regimen.
How this article should impact our practice: While historically most institutions used a LCR regimen in their protocols for initial medical stabilization in patients with anorexia nervosa, the StRONG trial offers evidence that a HCR regimen is comparable in terms of risk of refeeding syndrome and long-term clinical remission and rehospitalization rates. As an HCR regimen also has the potential to expedite weight gain, shorten length of stay, and reduce cost, many hospitals may find this an appealing alternative to the LCR regimen. In a time when an increasing percentage of our acute care beds are occupied by patients admitted for disordered eating, any measures that have the potential to reduce time to medical stability, cost, and length of stay in addition to being safe should be considered in our care of these patients.
Fellow: Caroline (“Callie”) M. Roth, MD; First Year Pediatric Hospital Medicine Fellow; LSU; New Orleans, LA
Current Research: During her fellowship, Callie’s scholarly focus has been on medical education and quality improvement. She created a curriculum on Social Determinants of Health for the pediatric student clerkship and is currently in the process of data collection and analysis for this project. She is also working to improve multidisciplinary communication and care coordination for acute care patients using quality improvement methods. In addition to this, she is participating as a team member at her institution for the AAP VIP Network’s Better Antibiotic Selection in Children quality improvement initiative.
Future Plans: After completion of fellowship next year, Callie hopes to work as a Pediatric Hospitalist in an academic center with continued involvement in quality improvement and medical education scholarship.
Fun fact: Prior to pursuing a career in medicine, Callie was a middle school science teacher.
Current Research: During her fellowship, Callie’s scholarly focus has been on medical education and quality improvement. She created a curriculum on Social Determinants of Health for the pediatric student clerkship and is currently in the process of data collection and analysis for this project. She is also working to improve multidisciplinary communication and care coordination for acute care patients using quality improvement methods. In addition to this, she is participating as a team member at her institution for the AAP VIP Network’s Better Antibiotic Selection in Children quality improvement initiative.
Future Plans: After completion of fellowship next year, Callie hopes to work as a Pediatric Hospitalist in an academic center with continued involvement in quality improvement and medical education scholarship.
Fun fact: Prior to pursuing a career in medicine, Callie was a middle school science teacher.
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