Table 3.

Benefits and adverse effects of four feeding methods

Food only feeding
Benefits	Adverse effects
• It teaches skills for eating, promotes normal behaviour, and challenges unhelpful coping strategies [39];	• Less energy is delivered from food when compared with nasogastric feeding [9].
• Patients experience the amount of food necessary for weight gain and weight maintenance [40];
• Food makes hospital meal management home-like and realistic, which exposes patients to a situation which is anxiety-provoking, and gives them confidence at managing meals at home [41].
High-energy liquid supplements
Benefits	Adverse effects
• Supplements can meet the high-energy requirements required for weight gain in a smaller volume than food [7,42];	• The frequent use of supplements encourages patients away from the experience of food, re-enforces their avoidance of food and can foster dependency on artificial food sources [39].
• They are helpful as a “top-up for patients struggling with satiety and the quantities of food required to promote weight gain [39,40];
• It can be seen as a type of medicine [43].
Nasogastric feeding
Benefits	Adverse effects
• More comfortable for the patient with less pain, physical discomfort and abdominal distension than large amounts of food [33,34,38].	• It interferes with the fragile alliance between the patient and treatment team [44];
	• The patient may feel disempowered and embittered towards the treatment team, which may have an impact on future personal and professional relationships [45];
• A helpful strategy aiding recovery:
o It transfers the responsibility of weight gain from the patient to the treatment team [46];
		• It is invasive, frightening, unpleasant and mirrors the dynamics of trauma [27,39];
o If placed upon admission, it “medicalises” the treatment, and reduces the “power struggle” between the patient and clinicians [34].
	• There is an emotional toll on staff treating involuntary patients [18];
• Opinions from patients and carers:	• Not helpful for long term recovery:
o Nasogastric feeding was seen as necessary by some patients because they believed they lacked the physical or psychological capacity to eat [47];	o Patients may demonstrate an inability to maintain adequate intake and weight gain once the tube is removed [9,46];
o Parents recognized it as a last resort that was required to keep their child alive [27];	o Force feeding in low weight patients achieved little in relation to remitting illness or suffering [48];
o It reduced the pressure patients perceive is being placed on them to eat and temporarily relieves responsibility for adopting improved eating behaviours [47]	o Patients tamper with the tube by adjusting the control, decanting the feed into other containers when unobserved, biting, and removing the tube [27,32,33,40,48].
	• Medical complications i.e. aspiration [49]; nasal bleeding and nasal irritation [9,18,33]; reflux and sinusitis [9,32];
	• The tube may not be inserted properly which is more likely when patients have one inserted against their will [40];
	• Opinions from patients and carers:
	o It disguised the consumption of food [47];
	o Patients become emotionally attached to and physically reliant on nasogastric feeding, and were anxious about the tube being removed [47]
	o Used as a form of punishment and seen as a strategy that doctors used to assert their control [47];
	o It was easier to avoid nutrition rehabilitation [47];
	o “NG feeding becomes enmeshed as an integral and valued sense of patients personal identity or if it becomes entwined with a desire to preserve a public status as an anorexic” which may contribute to the patient valuing AN more highly than recovery. It is a personal and public signifier of AN [47];
	o “….my lasting memory of being fed by a tube was that it was very very intrusive” [27];
	o Two parents believed that the tube was kept in for too long, which made the reintroduction of solid foods more difficult [27].
Parenteral nutrition
Benefits	Adverse effects
• It requires minimal patient cooperation [31].	• It may reinforce a tendency to focus only on physical symptoms rather then the psychiatric implications of AN [31];
	• Sabotage occurs by pouring solutions into the sink and removing the device [8,31];
	• It cannot teach patients anything about eating, food choice or portion size, or to perceive their bodies more accurately [31].
	• Medical complications i.e. infections, arterial injury, cardiac arrhythmias (from placement), changes in vascular endothelium, hyper-osmolarity, and hyperglycaemia [44]; hypophosphataemia and hypokalemia [8];
	• More medically intensive [31,44,50];
	• Financial cost [8,44].