How many who are suffering from anorexia are able to maintain their weight on just a few hundred calories and live a functioning life is a puzzling phenomenon to the medical profession, it contradicts the calorie-model. Another mystery used to be the much lower than expected weight gain in inpatient treatments, a „metabolic barrier to weight gain of unknown origins“ was hypothesized.
As a consequence the weekly weight gain trajectory for anorexia recovery was set very low, anyway many treatment centers even failed to reach this goal:
“Guidelines for anorexia nervosa (AN) inpatient treatment suggest weight gain of 0.5–1.0 kg per week. Data were collected retrospectively from hospital records for all underweight patients admitted to a specialised eating disorders unit. The mean weekly weight gain was 0.51 kg the first 11 weeks and 0.18 kg from week 12 to discharge. Conclusion: The rate of weekly weight gain was lower than recommended by guidelines for AN inpatient treatment.“pubmed
Recently the John Hopkins Treatment Center showed a weekly weight gain of four lbs is possible. This is their secret:
„Redgrave is confident that the program’s refeeding strategy will withstand the test of time. He cites 19th century British physician William Gull’s advice that doctors shouldn’t spend too much time asking patients what they want to eat. “Just feed them,” Gull said. “Patients have to eat to get better.”
Ironically Dr. Redgrave authors an article titled: „Speaking of that: Is the term "refeeding" offensive, and should it be avoided in the eating disorders literature?“ (“renourishing” or “nutritional rehabilitation“ is politically more correct, “just feed them“ seems to be still OK, though, and patronising your patients by ignoring individual food preferences (not related to ED), too.)
If it’s that simple, “just feed them“, (the philosophy of a poultry farmer) how could they have missed this for such a long time??
The main reason for poor weight gain in the past, and this will sound paradoxically, was the health care professionals’ irrational fear of calories (in spite their obsession with weight restoration, I know it sounds paradoxically) accompanied with unwise nutritional choices while discarding the underlying issues. I agree in the short term weight gain is the most important part in recovery, but this doesn’t work well if you ignore the root causes and use an extremely reductionist approach. Many other factors should be considered:
1. Negative emotions
Experiments show the harmful effects of negative frequencies on plant growth and fruit yields. Humans are electromagnetic beings, too. Those with anorexia have a negative attitude towards weight gain, don’t experience eating as a pleasure and often perceive residential ED treatment programs – voluntary or involuntary – as torture. Treatment staff are often annoyed by ED patients and lack empathy. According to a study every third therapist would rather not work with ED patients, which is a bad prerequisite for treatment success.
2. Dysbiosis
Several studies established that anorectic patients have a dysbiotic intestinal microbiota and also have shown that the gut microbiome plays an important role in weight gain. Other studies include those linking obesity to specific gut bacteria as well as studies that show transplantation of bacteria, specifically Christensenella minuta, reduced weight gain in mice. A reduced bacterial diversity is also linked to depression and other comorbidities. A probiotic treatment hasn’t been part of eating disorder treatment.
3. Touch deprivation
Touch deprivation has a negative impact on the psyche and the nervous system. Those with anorexia usually are as touch deprived as they are malnourished. Many anorexia patients rate skin stroking as less pleasant than matched healthy participants. (although I met anorexics that were very touch-needy, too). Food and touch aversions you need to overcome your way to recovery. We need human touch just as we need food. Infants die without it.
Deprived of human touch contributes greatly to overeating or undereating, self-destructive habits. Touch deprivation creates a sense of feeling alienated from ourselves and isolated from other people. Being deprived of touch is connected to depression, anxiety disorders, low self-esteem, and illness. empirical findings suggest that touch deprivation may play a role in body image pathologies. Prematurely born infants that received three times daily a massage gained 47% more weight than infants not being touched, while consuming the equal amount of calories. Their weight gain seemed due to the effect of contact on their metabolism. Institutions are very touch-phobic. Where I was treated there was a touch prohibition, patients were strongly discouraged to even hug each other.
4. Thermogenesis
Night-sweats, which occur frequently during refeeding, increase the energy loss.
5. Lack of sunshine and fresh air
For 'safety reasons' anorexics with a low BMI are often locked in (or even tied to the bed) for months. This is not only very detrimental to general health, but IMO also to weight gain.
While continuous tube-feeding might maximize the amount of calories, it can lead to complications and digestive upsets. Formula tube-feeds and supplemental drinks are known appetite killers and more suitable for weight-loss diets. Empirical evidence shows it’s not in any way beneficial for weight gain but comes along with a variety of health risks. Artificial feeding can make dependent and a relapse more likely, it is a hindrance in re-learning healthy eating habits and getting in touch with your body.
Hospital food being notoriously unappetizing is no incentive to eat more. ED patients are expected to accept gratefully (and enjoy!) any food they are being offered and not to be picky. Exposure therapy includes having to eat foods you find disgusting. Poor quality food (ripe fruit was rare) plays a role, too.
Patients are discouraged to listen to their own body. For decades ED patients were kept back from giving in to their 'extreme ‚hunger‘ to eat when they are hungry as much as they feel like. For decades they started refeeding at 5-10 kcal/ kg (=2,2 lbs) body weight.
“Up to now, “slower is safer” has been the clinical view, says Guarda, senior author of the study. “But at what price? If a patient needs to gain XX pounds but only gains XX pounds in the hospital, the result is only a temporary improvement.” Furthermore, she adds, recent studies under traditional protocols demonstrate that people can actually lose weight in the hospital during the first few weeks…“
They are openly admitting that countless inpatients starved to death because clinicians reduced or restricted their calorie intake. I wonder if this fear of too many calories (as well as the fat-phobia) transferred to their patients.
Any kind of coercion, especially forcing patients to compromise their morality by eating animals food and physical coercion (restraining, force-feeding) is very detrimental, will lead to defiant behavior and destroy the therapeutic alliance.
10. Nutritional deficiencies and hormonal imbalances
Of the 90 essential nutrients only a fraction is contained in tube feeds or supplemental drinks, hospital food rarely is very nutritious neither. Most deficiencies remain undetected, some can have an influence on body weight.
Being underweight and immuno-compromised leaves you more vulnerable to parasite infestations which can induce weight losses and nutritional deficiencies.
Exposure to toxic chemicals (e.g. food additives) which are widespread in a hospital environment signal to the body to stop eating and might induce loss of appetite and nausea.
Since mainstream science is not concerned about the dangers of non-ionizing radiation, institutions usually have Wi-Fi and other EMF-sources which can have many negative health effects, including nausea, appetite and weight loss.
Pharmaceutical drugs can both cause an increased appetite and loss of appetite. Antidepressants can worsen ED symptoms. Generally drugs have a negative impact on the body’s microbial environment. Many drugs cause gastrointestinal disturbances.
There’s a strong correlation with eating disorders, but I never experienced ED patients being screened for it. May or may not be drug-induced, impairs digestion and nutrient absorption.
Some conditions cause diarrhea, malabsorption and indigestion (IBS, inflammatory bowel diseases, pancreatitis).
17. Cognitive behavioral therapy
The attempt to make patients understand intellectually the dangers of starving and purging is more harmful than helpful. FBT (Maudsley, which is symptom-orientated, too), doing without psychotherapy, has far higher success rates and less relapses than inpatient treatment.
18. A higher meaning of life and everything
Philosophical, existential questions are not being discussed in therapy. If you believe life is random and meaningless and nothing but a hedonistic treadmill you have no incentive for recovery.
19. Unripe fruit
Fully ripe, high quality fruit is a rarity in hospitals.
20. Insufficient dietary fat
High-protein or low-fat diets are not ideal for weight gain in severe cachexia.
21. Cash cow
Since the higher-calorie group was able to stabilize earlier, they were well enough to be discharged on average at eight days, versus 12 days for the lower-calorie group. This yielded significant savings in hospital charges, the amount a hospital bills the insurance carrier. Charges averaged $57,168, for each lower-calorie patient, compared with $38,112 for each higher-calorie patient.
https://www.ucsf.edu/news/2020/10/418836/higher-calorie-diets-patients-anorexia-nervosa-shorten-hospital-stays
$4,765 / day (= $1,738,316 / year)? How do they justify charging that much? From the perspective of the insurance company, it’s money saved, from the medical industry complex’ perspective, it’s money lost.
Average charge/day in the IP-PH program was $2295 for IP and $1567 for PH, yielding an average cost/pound gained of $4089 and $7050, respectively, with 70% of patients achieving weight restoration.
https://pubmed.ncbi.nlm.nih.gov/28130794/
Doesn’t it make you feel like cattle if they only think in weight numbers and the financial costs (the financial burden)?
An important implication of this study is that finding cases earlier, and initiating treatment earlier in the course of weight loss, appear to diminish costs. This seems to make a strong case for aggressive early treatment.
https://eatingdisordersreview.com/analyzing-the-cost-of-inpatient-treatment-for-anorexia-nervosa/
First of all, why would they keep saying ”aggressive” treatment? ED sufferers are in need of compassion and empathy, not aggression. Obviously, waiting until the patient is half dead, before accepting them for inpatient treatment doesn’t save money. Nor does it save money, treating only the symptoms (weight restoration, CBT), which leads in many cases to multiple readmissions.
You can milk a cash cow only that long, I think that’s why they tracked back on calorie restriction, it was too obvious to many people that it was nonsensical. We’ll see if and when other changes are going to happen in future.