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 the 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.
Refeeding Syndrome
One potential risk to be considered before beginning nutritional rehabilitation is refeeding syndrome.
What is Refeeding Syndrome?
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 bloodstream. Clinical consequences may include irregular heart rate, congestive heart failure, respiratory failure, coma, seizures, skeletal-muscle weakness, loss of control of body movements, and neurological symptoms.
Preventing Refeeding Syndrome
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 patients who have one of the following indicators:
BMI: Body mass index of less than 16Electrolyte imbalances: Low levels of potassium, phosphate, and/or magnesium before refeedingRecent intake: Little or no nutritional intake for more than 10 daysWeight loss: Losing more than 15% of body weight in the past 3–8 months
Patients with two or more of the following indicators are also at higher risk of refeeding syndrome:
BMI: Body mass index of less than 18.5History: Alcohol misuse or drugs, including insulin, chemotherapy, antacids or diureticsRecent intake: Little or no nutritional intake for more than 5 daysWeight loss: Losing more than 10% of body weight in the past 3–6 months
Additional guidance regarding the prevention of refeeding syndrome is available via the Academy for Eating Disorders’ Guide to Medical Management. 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. 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 1/2 pound to 2 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.
Achieving High-Calorie Intake Requirements
Parents and patients are often perplexed at such high caloric needs as renourishing progress. Why are they so high? Individuals with anorexia nervosa often become hypermetabolic, which means their metabolism has kicked into high gear as the body tries to rebuild all the tissue lost during starvation. Individuals commonly experience elevated body temperature as energy intake may be converted into heat, rather than solely used to build tissue. This paradoxical symptom makes recovery even harder. Additionally, many patients with anorexia nervosa engage in excessive exercise 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. The 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/dayDay 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 2,000–2,500Day 15–21: 2,500–3,000 calories/dayDay 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 is 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. 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 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:
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: Although nutritious, these foods can contribute to early fullness and prevent weight gain.Eating frequency: Instead of eating three times per day, increase to six times per day.Portion size: Serve larger portions for each meal.Supplement with liquid nutrition: Products like Ensure Plus and Boost Plus provide 350–360 calories per 8 ounces. This could prove very helpful for caloric density. Liquid nutrition in this form is recommended immediately as a replacement for skipped or unfinished meals or snacks.
Overcoming Weight Restoration Challenges
Since a primary symptom of the disorder is a 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 expertise in the treatment of eating disorders. 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.
A Word From Verywell
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 are indeed possible.
