TABLE 1.

High-Caloric Refeeding Algorithms in 3 Specialized Units

	Sydney, Australia (adolescents)11,13	Prien, Germany (adults)2	University of California, San Francisco (adolescents)6
Population	Age, mean (SD) [range]: 14.8 (1.5) [12–18] y BMI, mean (SD) [range]: 15.2 (5.1) [9.5–21] kg/m2 %mBMI, mean: 78.4, SD and range not reported	Age: mean (SD) [range]: 23.8 (5.3) [18–47] y BMI: mean (SD) [range]: 11.5 (0.9) [9.5–13] kg/m2 Exclusion: age >40 years, chronic renal failure, heart insufficiency	Age: mean (SEM) [range]: 16.1(0.4) [9–20] y BMI: mean (SEM) [range] 16.2 (0.5) [range not reported] %mBMI: mean (SEM): 79.8 (2.1) [range not reported] Patients <60% median BMI (by US Centers for Disease Control and Prevention data) are excluded from high-caloric refeeding due to concerns of medical fragility and are refed via low-caloric refeeding
Food intake	Started with 2,400 kcal and nasogastric tube feeding, which reduces according to a standardized protocol Initial intake was lower in patients with a BMI of <12 kg/m2 Weight gain goal: >1 kg/wk	Starting with 2,000 kcal/day orally, spread over 3 meals and adjusting energy intake to achieve weight gain of 0.7–1 kg/wk This caloric intake can subsequently be increased meal by meal or with additional snacks in between the three main meals. Usual, stepwise increases (by 200 kcal per step) are from 2,000 kcal to 3,000 kcal and from 3,000 kcal to 4,000 kcal. Managing exercise and nonexercise physical activity along with caloric intake is important in order to normalize both. The general aim is to steadily maintain weight gain of 700 to 1,000 g/wk. If weight cannot be increased with 4,000 kcal, excessive exercising seems likely. In this case, additional increase of meals risks reinforcing purging behavior, thus potentially harming patients. Management of physical activity should go hand in hand with the management of caloric intake and weight restoration. This approach requires obligatory resting time and support to perform alternative activities and regulation of anxiety and emotions	Started with 1,764 ± 60 kcal (1,400–2,400) with 6 meals per day; high-calorie liquid formula [oral)] to replace refused calories in meals kcal increased 122 ± 8 per day; no weight gain goal Currently, there is a fixed kcal/d starting point for all patients
Fluids	The use of continuous nasogastric tube feeds assisted in providing the fluid and calories to reestablish circulation	Care is taken not to use fluid replacement per se, as cardiac failure can be induced, by volume overload, in patients with protein calorie malnutrition Circulatory changes are corrected slowly; the adaptive physiological changes producing a low-volume, low-pressure circulation are corrected over several days to 1 week Diuretics are used with caution	Fluid balance calculated daily as the difference between total intake and output recorded over 24 h All beverages were weighed and measured before serving; free water was restricted to 1 L/d Intake represents beverages only (no intravenous fluids); output represents urine only, using bedside commode
Vital signs	Monitored either continuously over 24–48 hours, then every 4–6 hours until normal vital sign and electrolytes have been consistently recorded for 72 hours	Measurement of blood pressure, heart rate, and detection of edema Monitoring of vital signs during the first 3–4 weeks for patients with BMI up to 13 kg/m2	Heart rate and blood pressure were assessed with continuous cardiac monitoring, and temperature was measured orally. Postural changes in heart rate and blood pressure were assessed starting with supine measurements (after 5 min in position), followed by standing measurements (after 2 min in position)
Supplements	To prevent refeeding syndrome, oral phosphate (SANDOZ phosphate, 500 mg) is supplemented to correct serum phosphate levels >1.0 mmol/L The dose is adjusted empirically from serial measurements of serum phosphate Serial measurements of electrolytes, blood sugar, and urine pH continue daily until levels are maintained within normal ranges. Urinalysis included measure of specific gravity indicating hydration and pH reflecting metabolism	Phosphate (PH; REDUCTO spezial 602 mg/360 mg equivalent of 612 mg PH twice per day, 0-1-1) and thiamine (200 mg, 1-0-0) when initial BMI is >13 kg/m2 is given prophylactically over 2 wk after admission when beginning re-nutrition in order to prevent RS. After 2 weeks, PH supplementation is adjusted based on measurements of serum PH. Serial measurements of electrolytes, blood sugar on a daily basis for the first week, then weekly for 4 wk and continued according to normalized ranges	Electrolytes were measured daily to monitor refeeding risk Low serum phosphate (>3.0 mg/dL) or declining trend was supplemented in packets of 250 mg phosphate Daily multivitamin with minerals, 500 mg calcium carbonate twice per day, and zinc sulfate or zinc acetate once per day
Body temperature	Maintained above 35.5°C, for example by providing continuous caloric intake and/or increasing environmental temperature or using overhead heating or heated waterbeds in hypothermic patients	Maintained by clothes and heated rooms
Mental state	Should be assessed daily for mood symptoms as well as the development of delirium, associated with the RS		Psychiatric evaluation upon admission
Further monitoring	Containment of exercising or purging behaviors	Containment of exercising or purging behaviors	Bedrest
Usual treatment after initial refeeding phase and discharge criteria	After an average admission of 28 days, patients are supported to continue a meal plan of 2,700–3,500 kcal/d Following medical stabilization (using criteria established by the Society for Adolescent Medicine,11) patients are transitioned to oral intake only. Discharge occurs after ongoing weight gain has been established through oral feeding both in the hospital and during leave for family meals outside the hospital Weight gain after discharge is typically supported through family-based therapy	The average duration of stay in the special ward to treat extreme AN is 2 months. After the initial refeeding phase, the weight target remains at 700–1,000 g/wk, and nutrition is adjusted to achieve this goal, with a maximum meal plan of up to 4000 kcal/d. After discharge from the unit, patients are transferred to a less intensive, inpatient setting, are moved to a residential home, allowed to return home and receive outpatient psychotherapy or receive daypatient treatment The German medical system allows for a length of inpatient treatment as required to achieve weight recovery and improvement of eating behavior. Apart from these weight recovery aspects, the most common discharge criteria are discontinuation of therapy decided by adult patients (28% among extremely underweight patients, 11% among all patients with an eating disorder as main diagnosis), substance abuse, excessive therapy-offending behaviors, contiunous lack of motivation, or therapy decision	Length of stay was 11.9 ± 1.0 days Patients are discharged home with medical/nutritional care and psychoptherapy in our outpatient program or in the community Discharge criteria are based on the reversal of published vital sign instabilities (Society for Adolescent Medicine, Position Statement, 201511: 1) heart rate ≥ 45 beats/min for 24 hours; 2) normotension (>90/50 mm Hg) 3) temperature ≥35.6°C 4) orthostatic heart rate increase in HR ≤35 beats/min 5) orthostatic BP decrease in systolic BP of ≤20 mm Hg or in diastolic BP of >10 mm Hg 6) ≥75% of mBMI

Note: BMI = body mass index; %mBMI = percent median BMI; BP = blood pressure; HR = heart rate; PH = phosphate; RS = refeeding syndrome; SEM = standard error of the mean.