The Annual Meeting of the Nutrition Society and BAPEN was held at Harrogate International Centre, Harrogate on 4–5 November 2008
Conference on ‘Malnutrition matters’
Symposium 8: Feeding size 0: the challenges of anorexia nervosa
Managing anorexia from a dietitian’s perspective
Annette Cockfield1*and Ursula Philpot2,3
1The Retreat, York, UK
2Yorkshire Centre for Eating Disorders, Seacroft Hospital, Leeds, UK
3Leeds Metropolitan University, Leeds, UK
Anorexia nervosa has the highest mortality rate of any psychiatric condition and its manage-
ment is complex and multi-faceted, requiring a multidisciplinary team approach. Dietitians are
an important part of the multidisciplinary team, offering objective nutritional advice with the
aim of helping the patient to develop an improved relationship with food. Refeeding patients
with a low body weight requires careful management; nonetheless, refeeding the low-weight
patient with anorexia presents many additional complications, largely of a psychological
nature. Treatment plans need to consider psychological, physical, behavioural and psycho-
social factors relating to anorexia nervosa. Currently, there is no consistent approach and a
paucity of evidence to support best practice for weight restoration in this group of patients.
Tube feeding is utilised at varying BMI in anorexia nervosa, mainly in an inpatient setting.
However, its use should be seen as a last resort and limited to a life-saving intervention. Weight
restoration is best managed by an experienced dietitian within a specialist eating disorders
team, using normal foods. This approach is ideal for nutrition rehabilitation, promoting skills
for eating and normal behaviour and providing a longer-term solution by challenging unhelpful
coping strategies from the onset. Dietitians have a unique mix of skills and knowledge in
numerous areas including nutrition, physiology, psychology, sociology and behaviour change,
which can be applied to support patients with thoughts and behaviours around food, weight and
appetite. Further research is required into the effectiveness of dietetic interventions in eating
disorders in order to establish an evidence base for best practice.
Anorexia nervosa: Tube feeding: Nutrition
Anorexia nervosa is a psychiatric condition that varies in
severity, from mild to severe and chronic cases, resulting
in extreme dieting and starvation(1). With a mortality rate
amongst the highest of all psychiatric illnesses(2), anorexia
nervosa is a life-threatening disorder. Not only does severe
weight loss increase the risk of medical complications, but
other associated behaviours, such as bingeing, purging,
over-exercising and deliberate self-harm, pose a substantial
risk to both physical and psychological health and well-
As a result of its complex nature a multidisciplinary
team approach to the management and treatment of ano-
rexia nervosa is essential. It has been suggested that the
most successful way to achieve recovery in this patient
group is to blend together the expertise of the numerous
members of the multidisciplinary team(3). Dietitians are
becoming increasingly recognised as an important part of
the team, providing a specialist role in assisting patients to
restore a normal body weight, achieve a dietary intake that
meets nutritional requirements and to provide nutrition
education. They have a unique mix of skills and knowl-
edge in areas including nutrition, physiology, psychology,
sociology and behaviour change, which can be applied to
support patients with thoughts and behaviours around food,
weight and appetite.
The present paper will address how patients with ano-
rexia nervosa are managed from a dietitian’s perspective;
from the initial stages of refeeding, through to weight
*Corresponding author: Annette Cockfield, fax +44 113 8123416, email ACockfield@theretreatyork.org.uk
Proceedings of the Nutrition Society (2009), 68, 281–288
gThe Authors 2009First published online 6 May 2009
Proceedings of the Nutrition Society
stabilisation and normalised eating. Considerations such as
the psychological, physical, behavioural and psycho-social
aspects of eating will also be explored.
As the severity of eating disorders can vary, decisions
about treatment plans and settings should be made on an
individual basis. Most patients suffering from anorexia
nervosa can be managed in an outpatient setting and will
not require intensive inpatient treatment. An example of
how patients may be categorised is shown in Table 1.
BMI should not be the only measure of physical or
psychological risk(4). The National Institute for Health and
Clinical Excellence recommends that ‘a physician or pae-
diatrician with expertise in the treatment of medically at
risk patients with anorexia nervosa should be considered
for all individuals who are medically at risk’(5). The
National Institute for Health and Clinical Excellence also
suggests that inpatient treatment should be considered for
the following patients with anorexia nervosa: those whose
disorder has not improved with appropriate outpatient treat-
ment; those whose disorder is associated with high or
moderate risk; those for whom there is a substantial risk of
suicide or severe self-harm(5).
Judgement about the extent of physical risk that a
patient presents is difficult, as there is little evidence to
causally link specific measurable variables such as BMI
with mortality risk, except at extremes. A review of mor-
tality rates and cause of death has found that sudden death
has no clear relationship with length of illness or age(2).
Instead, very low serum albumin and a weight of <60% of
ideal body weight (BMI <12kg/m2) are the best indicators.
However, one of the few long-term studies on mortality, in
which patients were followed up at both 5 and 20 years
post treatment, has found that mortality is unpredictable,
with 40% of deaths in patients classed as ‘poor outcome’
at 5 years follow-up, but surprisingly 40% classed as ‘inter-
mediate outcome’ and one death from the ‘good outcome’
category(6). Of these deaths, 50% were attributed to elec-
trolyte imbalances and 50% to suicide.
In agreement with these findings, it has been claimed
that individual response to starvation is hugely variable(7),
and thus the risk of sudden death is difficult to predict,
relying heavily on clinician judgement together with the
assessment of a range of factors(4): excess exercise+low
weight; blood in vomit; frequent vomiting; laxative abuse;
poor fluid intake; chronic low weight; type of food re-
striction (high protein and low carbohydrate); rapid weight
If inpatient treatment is deemed necessary, it should take
place in a setting that can provide the skilled implement-
ation of refeeding, with careful physical monitoring and in
combination with psycho-social interventions(5).
The first 7–10d of the reintroduction to food poses a sub-
stantial risk of refeeding syndrome and its related com-
plications(5). Medical stabilisation of electrolytes, liver
function tests and the electrocardiogram are a priority.
Thus, initial feeding (7–10d) is aimed at medical stabili-
sation, as opposed to weight gain, as well as building the
patient’s tolerance to an energy intake that will promote
weight restoration. Currently, there is no consistent ap-
proach and a paucity of evidence to support best practice
for weight restoration in this patient group. However, most
inpatient programmes commence refeeding at approxi-
mately 2092–2929kJ (500–700kcal) per d, depending on
body weight and previous intake. Careful management of
electrolyte balance is required, along with the supplement-
ation of vitamins and minerals(5,8).
Weight change during the early stages of refeeding is
unpredictable. Weight may fall as a result of a reduction in
fluid intake in comparison with previous fluid overloading
or over-hydration. Also, weight can drop as a result of a
sudden increase in energy requirements(9), coupled with
the low level of energy consumed at this initial phase.
Weight gain may not occur until 2–3 weeks into treatment.
In contrast, some individuals may gain weight quickly
from the onset for a variety of reasons, e.g. previous de-
hydration, rapid weight loss or obesity. Energy and fluid
prescriptions should be monitored and adjusted frequently
to ensure minimal symptoms of refeeding and a safe rate of
Next, there follows a period of steady weight restoration
until a safer weight is achieved, ensuring a substantial re-
duction in physical risk. Once this outcome is achieved, the
rate of weight gain can be raised to 0.5–1kg/week, which
usually requires a 10460–12552kJ (2500–3000kcal)/week
increase(5). From the authors’ experience (A Cockfield and
U Philpot, unpublished results) intakes can be adjusted to
ensure that adequate weight gain continues by introducing
increments of 837–1255kJ (200–300kcal)/d.
A weight gain of 0.5–1.0kg is recommended(5). There
is a shortage of studies in this area, but two studies have
drawn conclusions that are similar(10,11). These studies
have found that the period of time patients have to main-
tain weight up to discharge predicts time to re-admission;
the more time patients have to maintain their weight, the
slower the rates of re-admission. It has also been shown
that patients who gain weight rapidly (>750g/week) are
more likely to show rapid post-discharge weight loss(11).
Slower weight gains (of 500g/week) result in more sus-
tained weight maintenance. Furthermore, caution is ex-
pressed against forced fast weight gain under inpatient
conditions, and it is suggested that rapid weight gain at
the beginning of treatment, followed by a reduced rate of
weight gain, could increase the chance of later weight
Table 1. BMI and treatment settings for patients with anorexia
BMI (kg/m2) RiskSetting
Outpatient or inpatient
282A. Cockfield and U. Philpot
Proceedings of the Nutrition Society
The National Institute for Health and Clinical Excellence
proposes that through early identification and intervention
patients should be engaged and treated before reaching
severe emaciation(5). However, there are cases for which
an emergency admission is needed because of deteriorating
health and physical risk, and a decision must be made
about where this admission takes place. Since refeeding
patients at dangerously-low body weights (BMI <13.9kg/
m2) is high risk, an admission to a medical ward is often
deemed necessary. Ideally, this admission should be to a
medical ward that is experienced in refeeding patients with
anorexia nervosa, and under the care of a physician with a
special interest in eating disorders. In the absence of this
type of setting a refeeding protocol (Appendix) should be
in place, together with frequent liaison with local specialist
services, or an urgent out-of-area assessment and advice
must be sought. All assessments and events involved in the
refeeding process should be explained to the patient and,
where possible, options and risks discussed in an honest
and supportive way.
Psychological and behavioural considerations
In anorexia nervosa behaviours are used to help manage
unbearable thoughts, beliefs or emotions. In other words,
food restriction, over-exercising and a preoccupation with
food distract the patient from these negative thoughts and
beliefs. Through the repeated use of eating-disorder behav-
iours anorexia nervosa eventually becomes egosyntonic in
nature(12), i.e. it becomes part of the sufferer’s identity.
Weight restoration involves giving up the patient’s coping
mechanism and exposing them to their unbearable thoughts
and feelings. Recovery allows new skills to be learned, so
the individual can stop self-defeating behaviours and
develop self-enhancing ways of coping. For this reason
weight restoration and psychotherapy must be used con-
currently if treatment is to be effective. Thus, refeeding
patients with anorexia nervosa is markedly different from
refeeding patients without an eating disorder and requires a
skilled multidisciplinary team approach.
Irrespective of body weight, rate of weight loss or the
history of the eating disorder, in the absence of any life-
threatening medical complications, any patient with an
eating disorder can restore their body weight with the use
of normal foods, as opposed to artificial nutrition. None-
theless, supported nutrition is essential.
Patients with an eating disorder find eating to promote
weight gain distressing, both physically and psychologi-
cally. As a result of delayed gastric emptying and impaired
gut motility, the consumption of large amounts of food
can be uncomfortable(13,14). Also, with an intense dread
of weight gain and the risk of losing control and their
identity, patients need psychological and emotional support
to eat(12). This process is best managed under the care of a
specialist eating disorders service, where trained health
professionals can put in place sufficient boundaries to
allow patients to begin eating again without coercion.
Some inpatient eating disorder units encourage peer chal-
lenging and support from fellow inpatients with an eating
An individualised initial eating plan is prescribed that
includes foods from all the major food groups, i.e. carbo-
hydrate, protein, fat, vegetables and dairy. This eating plan
is only a baseline and is intended to help the patient start
eating, as opposed to meeting their nutritional require-
ments. The eating plan is also non-negotiable, i.e. the
patient has to consume all foods from the plan and not
leave any of it. This regimen is often enforced by health
professionals, who remain with the patients, supporting
them until all the food has been eaten, irrespective of the
time taken, or other patients stay in the dining room until
all the food has been consumed. What is negotiable is the
choice of the food from the food group. For example, with
protein patients are able to choose whether it is meat, fish
or a vegetarian form of protein. Gradually, the eating
plan is increased to ensure continuing weight restoration.
Patients are also monitored and any nutrient deficiencies
corrected. Over time, a therapeutic and trusting relation-
ship is built up between the patient and the dietitian, which
is an important component for recovery(15). However,
since recovery is not achieved through weight restoration
alone(16), the responsibility for eating, making dietary chan-
ges and establishing a healthy body weight is slowly han-
ded back to the patient.
There is a misconception that patients with an eating
disorder have a good understanding of nutrition, but evi-
dence suggests otherwise. Research into the nutritional
knowledge of these patients shows that their expertise is on
the energy value of foods, with a poor comprehension of
their overall nutritional requirements and how to consume
a healthy balanced meal and/or diet(17). Also characteristic
of the illness itself are faulty ideas and attitudes towards
eating(18). A major part of the nutritional rehabilitation is
to consider psycho-social factors. This process includes
assessing patient’s skills and knowledge in areas such as
meal planning, shopping, cooking and portioning. Patients
with anorexia nervosa often have functional deficits in
relation to these issues. Ability to judge an adequate por-
tion or the components of a balanced meal can be severely
distorted. The dietitian has a vital role in ensuring a normal
range of foods are consumed, establishing normal meal
patterns and portions, reducing the fear of dietary change
and addressing any abnormal beliefs towards food(19).
Further research is required into the effectiveness of die-
tetic interventions in eating disorders in order to establish
an evidence base for best practice.
The frequent use of sip feeds and/or nutritional supple-
ments is not usually helpful. They encourage patients away
from the experience of food, re-enforce their avoidance of
foods and can foster dependency on artificial food sources.
However, there may be cases for which they are helpful
and supportive in the short term, e.g. for weaning off tube
Managing anorexia from a dietitian’s perspective 283
Proceedings of the Nutrition Society
feeding, and as a ‘top-up’ for patients struggling with
satiety and the volume of food required to promote weight
The challenge of refeeding patients with anorexia nervosa
at a very low weight, combined with their psychological
needs, is enormous and a multidisciplinary team assess-
ment is essential. The decision to tube feed is complex and
requires careful planning, i.e. it may be extremely distres-
sing for patients with a history of physical or sexual abuse.
Characteristic of an eating disorder is a reluctance to
accept treatment and ambivalence, i.e. at the same time
wanting to and not wanting to have treatment(12), and thus
tube feeding may be necessary as a last resort. Some in-
dicators for tube feeding are a life-threatening low weight
(BMI <12kg/m2) and/or poor compliance with dietary
intake or (at higher weights) a high physical risk score(20)
with falling weight and non-compliance with oral intake.
There is evidence that supplementary nasogastric feed-
ing may be a useful and acceptable method of weight
restoration. Voluntary use of tube feeding in inpatient set-
tings has been shown to improve weight gain and reduce
length of stay, with no detrimental effects on therapeutic
relationship or treatment-satisfaction scores(13,21). Delayed
gastric emptying and impaired intestinal motility makes
eating difficult and voluntary short-term supplementary
tube feeding may be useful in some individuals, at varying
BMI, in specialist inpatient settings. Nevertheless, refeed-
ing with food teaches skills for eating, promotes normal
behaviour, challenges unhelpful coping strategies and
should be considered the first treatment option for patients
with an eating disorder.
It has been argued that enforced tube feeding damages
the therapeutic alliance(22). Conversely, it has been claimed
that tube feeding in the correct way does not impact on the
therapeutic relationship(23). Most current literature focuses
on tube feeding as a life-saving intervention, used to safely
manage medical risks(5). Working with the patient to sup-
port the reintroduction of food and returning control and
choice at the earliest possible point is crucial in enabling
them to move towards accepting further treatment.
When patients with anorexia nervosa refuse treatment,
even when their health is at risk, issues of patient auto-
nomy can conflict with protection of their best interests.
Healthcare professionals have a moral and legal obligation
to save life, which creates difficult situations in which
patients, their families and health professionals are en-
gaged in struggles around treatment options(12). Where
patients are unwilling to cooperate with refeeding and
weight restoration, involuntary feeding may need to be con-
Patients with anorexia nervosa may refuse treatment
because of: fear of loss of personal identity; fear of loss
of advantages of anorexia nervosa; feeling the choice of
giving up the eating disorder is not theirs to make; needing
to be coerced before they feel able to comply; relative
unimportance of death in comparison with anorexia ner-
The issue of capacity to consent is especially difficult to
assess in anorexia nervosa for many reasons. Patients have
the right to refuse treatment as long as they possess the
capacity to do so, even if their reasons are irrational or
unreasonable. Thus, the legal criterion for capacity focuses
on the patient’s understanding of their illness and its con-
sequences. Patients with an eating disorder often have a
good understanding of the risks involved and the ability to
reason, but still refuse life-saving treatment. Competence is
different from capacity, as it incorporates factors such as
appreciation of information applied to oneself, but is
poorly defined(12). However, competence should be con-
sidered together with capacity, the Mental Health Act
2007(24)and the Human Rights Act 1998(25)when patients
Feeding against the will of the patient should be an
intervention of last resort and is a highly specialised pro-
cedure, requiring expertise in the care and management of
those with severe eating disorders and the associated phy-
sical complications(5). It has been reported that patients
consider their experience of involuntary feeding to be
degrading and an infringement of their human rights, as
well as making them feel imprisoned and punished(12).
However, at a higher body weight these same patients are
pleased that the decision to refuse treatment had been
overridden, thus proving the complexity of assessing capa-
city and competency.
The National Institute for Health and Clinical Excel-
lence states that healthcare professionals who do not have
the specialist experience of managing patients with an
eating disorder, or in times of uncertainty, should seek
advice from an appropriate expert when considering a
Anorexia nervosa is bound up in identity and is often
viewed as more important to the sufferer than its detri-
mental physical side effects or the risk of dying. Weight
restoration is associated with a strong decrease in physical
and cognitive symptoms and is considered essential for
effective psychotherapy(13), which should occur simulta-
because of physical symptoms such as delayed gastric
emptying, early satiety(14)and other behavioural and psy-
chological factors, and thus the setting needs careful con-
sideration. Rapid weight gain and low weight at discharge
are both risk factors for relapse(11). Supported nutrition is
the treatment of choice for anorexia nervosa and tube
feeding is a life-saving intervention and a last resort.
Refeeding must not be undertaken without adequate psy-
chological support and requires a multidisciplinary team
multi-agency approach. Dietitians specialising in eating
disorders are ideally placed to support patients with weight
gain and normalised eating. However, there is a paucity of
research on nutritional interventions in anorexia nervosa.
284A. Cockfield and U. Philpot
Proceedings of the Nutrition Society
The article was jointly researched and written by U. P. and
A. C., who contributed equally. The authors declare no
conflict of interest.
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This protocol has been developed to offer guidelines in the
care of a recently admitted patient with severe anorexia
nervosa (defined as BMI <15kg/m2) for the physicians,
psychiatrists, nursing staff and dietitians involved in the
Most patients with anorexia nervosa should be managed
on an outpatient basis, but if there is a substantial dete-
rioration in their physical condition or mental state, then
inpatient care should be considered.
It is important, before admission, to agree with both the
patient and the care team the aims of the admission, e.g.
admission for weight restoration or management of major
risk of suicide or self-harm.
Nasogastric feeding is associated with substantial phy-
sical risks, including refeeding syndrome. The setting for
tube feeding should be a multidisciplinary team decision,
e.g. if physical risk is high refeeding patients on a medical
ward may be considered. However, staff experienced in
managing patients with an eating disorder should be pre-
sent, which may require mental health nursing staff to
assist patients on the medical ward.
By the nature of their illness these patients require care
from various professionals and regular multidisciplinary
reviews are vital to coordinate this care.
These recommendations are guidelines rather than rigid
rules and have been based on the care offered to patients
within the specialist eating disorder service. However, this
protocol is based on a specialised service and therefore
some of the recommendations may not be possible in other
These guidelines are not intended to replace the liaison
role with the specialist eating disorder service.
Assess patient for nasogastric feeding or oral diet.
Initiate nasogastric feeding if: planned admission for
nasogastric feeding; BMI <12kg/m2and/or poor
Managing anorexia from a dietitian’s perspective285
Proceedings of the Nutrition Society