What conditions must exist to initiate nasogastric (NG) feeding in the eating disorder patient?

Woods: My tube-feeding criteria is any 1 of the following:

• The patient is less than or equal to 85% ideal body weight (IBW).
• The patient has experienced greater than 1 month severe restriction (less than 500 calories per day) prior to admission.
• A 3-day calorie count reveals intake below maintenance/gain calories.
• The patient is severely restricting fluid intake and needs the NG tube to maintain hydration status.

I explain to the patient that the tube is not because she can't or won't eat. The tube is a tool to help with weight restoration so she can learn to eat normally.

Many patients will say that their biggest fear is that if they started eating, they would never know when to stop. Using the tube, I can reassure the patient that she can learn to eat normally and the tube will take care of the additional energy needed to get her to her healthy weight. Most patients are quite relieved to learn they do not need to eat the large volume of food required to restore weight but can just focus on eating normally.

Runyan: The time to consider using an NG tube is when a patient's body is so severely depleted of nutrition that his or her health is at risk and when the patient's psychological resistance to accepting oral food intake is hindering weight restoration. A patient's freedom to refuse medical interventions frequently poses the most difficult hurdle when an NG tube is recommended. For patients for whom an NG tube is recommended, the elicitation of strong emotional responses is to be expected. Individuals with anorexia fear several things related to refeeding in general. Initially, they describe their fear in terms of becoming fat (larger than their current weight).

This statement has some personal truth to it, yet it is important to seek the deeper meaning. The term fat generally is a concept covering up a core of control to avoid a deeply felt shame and fear. When challenged, the control factor reveals itself in the realm of severe anxiety.

Anxiety is suppressed within the body, and for those with anorexia, the areas in which it is manifested in are the stomach (knots or nausea in the gut) and the head (obsessive thinking or worry). These tensions can be expressed outwardly in the form of intense rage toward those promoting use of the NG tube or a physical anxiety attack. Both the rage and anxiety attack are uncharacteristic in comparison with their regular demeanor when physically healthy. They are also personally disturbed by their reactions. It is important for clinicians to note that patients may explain their avoidance of using the NG tube as taking the "easy" way out of malnutrition. A fair response to such a statement is that if the patient could manage the oral intake on his or her own accord, then he or she would have done so prior to the NG tube recommendation.

A second retort may include the truth that will power alone seldom releases a person from their fear and shame, particularly when severely malnourished.

Pearle Lamb: I believe that enteral feeding needs to be considered in the setting of severe malnutrition when an individual demonstrates an ongoing struggle to consume enough solids or liquids to improve his or her nutritional status.

In many instances, initiating tube feedings when the body mass index (BMI) falls to 16.5 or less is a reasonable standard of practice. Poor meal compliance over a 24- to 48-hour time frame can be used to assess the individual's ability to tolerate the meal plan and, in some cases, their motivation. In many cases, evidence of dehydration, orthostasis, or electrolyte abnormalities dictate intravenous repletion before initiating enteral feeding. The case for enteral feeding is clearly strengthened when an individual expresses food phobias and verbalizes fear of weight gain yet appears motivated to achieve and maintain recovery. In some cases, enteral feeding is appropriately initiated when patients present closer to IBW, but after periods of rapid weight loss, food or liquid refusal, or prolonged dieting. In still others, gastrointestinal (GI) abnormalities leading to malabsorption may require enteral feeding in eating disordered individuals. For example, postbariatric patients may present at higher weightsbut have equally poor nutritional status as an individual with a very low BMI.

Once decided, how would you proceed?

Woods: Again, patient education is the key. Many patients do not realize the amount of kilocalories they will need to restore weight. It is not uncommon for an adolescent with anorexia nervosa to require more than 4000 kcal/d to restore weight at the rate of 2 to 3 lb/wk, which is the recommended rate of weight gain in an in-patient setting. This is approximately double the typical maintenance kilocalories a teenage girl would need to maintain her healthy weight. Eating disorders are about an abnormal relationship with food. It is important during the treatment phase that we don't promote that abnormal relationship by requiring the patient to eat twice what would be normal.

That would be reinforcing overeating. If we set up the patient to eat that volume, then when she is at her healthy weight, her meal plan is cut in half, and she can feel as if she were put on a diet.

This approach of refeeding with the NG tube is well accepted by patients. It is not a forced feeding, and it is not instead of eating. They eat normally during the day, and while they are sleeping, they are given their tube feeding as prescribed by the registered dietician (RD).

Runyan: NG tubes require a high level of medical supervision. They are most frequently used in an inpatient acute care setting (hospital) or a highly equipped medically staffed residential care facility.

The use of an NG tube seems to have the best psychological results when it is described as a supportive resource rather than a punitive resource. Patients appear to be more cooperative with the NG tube placement when educated using visuals presented by medical staff members trained to work with this population.

Education regarding how the NG tube will be used is helpful for the patient. They should know if the NG tube will be placed for the entire time it takes them to reach an identified safe weight or if it will be used on an as-needed basis. It helps for them to know when the food solution will be infused. Some treatment settings place the solution during the day and others during the sleeping hours of the night. On an individual basis, it may be beneficial for the patient to know if the calories placed in the solution are part of the general nutrition prescription (maintaining ideal body weight + weight gain) or prescribed only for weight gain. When possible, it is best to have the medical staff members who are suggesting the NG tube's use be present to comfort the patient when it is placed.

Pearle Lamb: The presence of the above criteria should generate a discussion about nutrition support, enabling the patient and family to discuss options with the team. Verbal and written communication about the tube can eliminate some of the anxiety that patients and families experience. The team can review the goals of the feeding, the process, and the expected outcomes before dropping the tube and ordering the formula.

A complete medical, psychosocial, and nutritional assessment is crucial to determine the appropriate tube feeding and rate of infusion. Selecting the appropriate enteral feeding should be determined based on the patient's nutritional needs and volume requirements. In the setting of severe malnutrition or if renal status is compromised, administering nutrition at a slower rate is recommended. Good clinical care necessitates frequent checking of lab values and repletion of critical labs to avoid signs and symptoms of refeeding syndrome. Frequent monitoring of tube-feeding tolerance is required before ramping up to the goal rate. Oral feeding may or may not be added to the tube feeding regimen, depending upon tolerance and motivation.

Following a protocol for enteral feeding is advisable. Some of the concerns to be addressed include consent forms, nursing protocols, medication regimens and standardized practices for tube insertion to facilitate ease of placement.

What conditions make a tube feeding counterproductive or contraindicated?

Woods: The dietician and the physician need to work closely together on this. The patient may have an anatomical abnormality of the nose, which makes it difficult to safely insert an NG feeding tube. The patient may have anorexia binge-purge type and be hypokalemic.

Because of stimulation of the reninangiotensin system, the patient may be more vulnerable for fluid overload and refeeding edema, so this needs to be watched closely, and the tube feeding may need to be delayed until the fluid shifts occur. A patient with refeeding syndrome or electrolyte disturbance needs to have these issues corrected before being aggressively refed.

The patient may have psychiatric issues that would place her at risk to tamper with the tube to inflict self-injury, so this could be a limiting factor. Also, some patients have a need to be sick and "the worst case," so the NG tube becomes a badge or honor and negatively reinforces the sick role. In this situation, the therapist can help the patient work through these cognitive distortions.

Runyan: When a patient is managing their caloric intake as prescribed by the attending physician or RD, it is important to allow this opportunity for selfmanagement. Unless the NG tube is absolutely required based on medical necessity, usurping the patient's courageous efforts could instigate more resistance, with a resulting longer period of time for weight restoration.

The most basic focus of treatment is weight restoration. The closer to an IBW a person becomes, the more their emotional states balance and thinking clears.

The treating professionals also get a better idea of the patient's baseline psychological functioning. Outside of medical necessity, it does not really matter how a person obtains the necessary amount of calories to restore weight. It really becomes a personal tolerance issue. If a patient can tolerate the physical and psychological discomfort with oral intake, then this is the best solution. If the patient cannot tolerate oral caloric intake, then the NG tube most likely is the best resource for success. The closer a patient gets to ideal body weight, the more effective psychological counseling becomes.

Pearle Lamb: Enteral feeding is contraindicated in the setting of GI obstruction or other medical conditions that require gut rest. Total parenteral nutrition or even peripheral parenteral nutrition may be the better option in such cases. Individuals with trauma histories may refuse the tube initially, but education about the nutritional goals often supports the enteral feeding process. In some eating disodered individuals who present with Axis II traits, enteral feeding may reward aspects of the eating disorder. I wonder about secondary gain with enteral feeding on an eating disorders unit. I have some concerns that enteral feeding might be a reward to those who seek the nurturing attention of the staff in an eating disorders inpatient setting.

What evidence-based research have you used to shape your clinical practice?

Woods: Unfortunately, there are not large controlled studies for many issues in the eating disorder field. According to an article published in 2007 in Clinical Nutrition by Rigaud et al, there are only 10 published articles on the use of NG feeding in anorexia nervosa. One of those papers, which was based on work done at Remuda Ranch and published by the Journal of Parenteral and Enteral Nutrition in 2003, indicated that use of the NG feeding tube was efficacious, safe, and well received in the ED population. See the reference below.

Zuercher JN, Cumella EJ, Woods BK, Eberly M, Carr JK. Efficacy of voluntary nasogastric tube feeding in female patients with anorexia nervosa. J Parenter Enteral Nutr. 2003;27:268-276.

Runyan: A good resource for evidence based research regarding NG feeding was completed by Remuda Ranch Treatment Centers for Anorexia and Bulimia. I have added the basics of the project below.

My opinion based upon working with patient who use an NG tube and those who don't, is that the end result of weight gain one over the other is negligible.

It is only a matter of how best the patient can manage the physical and psychological discomfort of the increased nutrition. If they want to do it with a NG tube, then treatment will most likely be less uncomfortable than with oral intake.

I have had a few discussions with physicians who have worked with this population for decades and their opinions have supported the slower weight gain (1 lb weekly) via oral intake. Their opinion has been that the slower the weight gain the patient experiences less intense psychological conflict, fewer power struggles and the more committed the patient is to the physical restoration obtained.

Of course the research jury is still out on these opposing view points and their actual outcomes. Nutritional aspects of eating disorders: the Remuda review. Christian Journal of Eating Disorders. 2003;2(2).

Background: Remuda staff recently completed a scientific investigation of nasogastric (NG) tube feeding in anorexia. The study will be published in the July 2003 issue of the Journal of Parenteral and Enteral Nutrition. The study includes detailed instructions on the use of NG tubes with patients who have anorexia. Copies of the study may be obtained from Remuda Ranch by calling 1-800- 445-1900, ext. 4501.

The study included 381 female inpatients with a DSM-IV diagnosis of anorexia nervosa, both subtypes. 155 patients received tube feeding and oral refeeding; 226 received oral refeeding alone. Recovery from the psychological aspects of anorexia was measured by change in Eating Disorder Inventory-2 scores between admission and discharge. Patient satisfaction with treatment was measured using a Patient Satisfaction

Questionnaire completed at discharge. Repeated measures and multivariate analyses were performed.

Controlling for severity-of-illness and caloric intake differences between patients with and without tube feeding, patients who received tube feeding gained significantly more weight per treatment week than those who received oral calories alone. Patients who received tube feeding for at least half their length of stay gained 1 kg. (2.2 lbs.) per week versus 0.77 kg. (1.7 lbs.) per week for patients receiving oral refeeding alone. Tube fed patients evidenced no differences in recovery from anorexia's psychological aspects, satisfaction with treatment, or medical complication frequency-suggesting that tube feeding does not have negative psychological or medical consequences for patients.

Conclusions: In residential psychiatric treatment settings where intensive therapeutic interventions and appropriate medical monitoring can manage potential psychological and medical risks, tube feeding's weight gain benefits may be a viable and safe option in treating anorexia.

I am not aware of literature regarding psychological interventions or counseling related to the use of an NG Tube feeding. Literature on this topic would be very helpful and very likely well received by counseling professionals.

Having had discussions with psychological professionals it seems that there is a significant division between those who support its use vs those who are not supportive of it. Some counseling professional's believe that severely malnourished patients are for the most part less capable of making a rational decision for Refeeding due to the malnourishment's exacerbation of obsessive psychological conflicts. Other professionals side with the idea that a patient can decide for themselves what is best for their nutritional intake. My opinion it related to which approach would best suit the individual for weight restoration in the most expeditious manner with the most comfort possible. My personal approach with the patient is to ask these questions as we determine the course of treatment; "What are the obstacles that have prevented weight restoration and maintenance? Have those obstacles been removed? If not, why not? Under your current conditions described, what is in your (patient) and your family's best interest taking into consideration your past efforts and progress or lack of progress?" If the treatment team determines the use of an NG Tube is in the patient's best interest, then all of the discussions, questions and answers are weighted to motivate the patient's agreement to use the NG Tube.

There is also a divide within the medical community on how to implement the NG tube's use. Some use it as a punitive resource by placing and removing each meal when a 100% of the prescribed calories are not ingested. Others medical professionals choose to leave the NG tube in place with clear definitive education and goals for the patient. My opinion is that patients are more comfortable and less disturbed psychologically and physically when the NG tube is left in place until they reach the goals identified by the treatment team.

Pearle Lamb: There are a few good studies that demonstrate improved outcomes after implementation of enteral feeding.

Most of the literature to date consists of case reports and smaller scale studies using nasogastric tubes. At our center we communicate with clinicians at other programs, identifying potential risks and benefits of various treatment options. Some useful references which have shaped our interventions are listed below:

Diamanti A, Basso MS, Castro M, et al. Clinical efficacy and safety of parenteral nutrition in adolescent girls with anorexia nervosa. J Adolesc Health. 2008;42:111-118.

Potack J, Chokhavatia S. Complications of and controversies associated with percutaneous endoscopic gastrostomy: report of a case and literature review. Medscape J Med. 2008;10(6):142.

Rigaud D, Brondel L, Poupard AT, Talonneau I, Brun JM. A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: a 1-year follow-up study. Clin Nutr. 2007;26:421-429.

Robb A, Sliber TJ, Orrell-Valente JK. Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa. Am J Psychiatry. 2002;59:1347-1353.

Tan J, Hope T, Stewart A, Fitzpatrick R. Competence to make treatment decisions in anorexia nervosa: thinking processes and values. Philos Psychiatr Psychol. 2006;4:267-282.

Zuercher JN. Efficacy of voluntary nasogastric tubefeeding in female inpatients with anorexia nervosa. J Parenter Enteral Nutr. 2003;27:268-276.

What are the potential risks and complications for tube feeding?

Woods: The patient is at risk for sinusitis from prolonged use of the NG tube. Patients say that for the first couple of days, the tube is stiff and causes slight discomfort, but this resolves. The patient is at risk for aspiration at night. For this reason, we use a wedge pillow to have the patient sleep at a 45-degree angle.

In my 12 years at Remuda Ranch, I have had one case of aspiration out of thousands of patients who have chosen to accept the NG tube. There is an increased risk of refeeding syndrome if the feedings are not properly managed by the medical staff and RD. In my experience, I have not seen increased problems with the use of an NG tube in the properly selected patient being managed carefully medically and with a multidisciplinary team.

Runyan: The greatest risk to a patient is when IBW restoration is not achieved. Psychological and emotional disturbances remain intact. Psychological interventions have limited success under these conditions. When the malnutrition remains, the possibility of poor life function and death are realities.

Patients who refuse NG tube feeding will state that its use will cause them undue psychological damage. They also give the idea that because of the NG tube's use, their recovery is based on false efforts and therefore not likely to remain. I see these arguments as resistance and denial. They are refusing because of core problems of severe shame, significant fear, and defensive control. The rationalizations do not hold up under scrutiny, especially because they have not restored weight under their own devices up to the point of the NG tube recommendation.

Pearle Lamb: There are multiple risks associated with enteral feeding any patient, whether or not he or she has an eating disorder history. Some of these risks and complications include abdominal distension and pain, peritonitis, leukocytosis, infection, sepsis, gastroparesis, and GI complications. Refeeding syndrome is widely recognized as a potential risk, although it can be managed with careful electrolyte monitoring and repletion as needed. Delayed gastric emptying may complicate the course of feeding, especially in individuals with very low weight or in cases of laxative abuse.

Dehydration can occur when the tube feeding is not supplemented by adequate free water to meet the patient's fluid requirement. Poor tolerance to the feeding may require a trial of several feedings before finding the most effective formula.

Despite the risks, I believe that enteral feeding dramatically improves outcomes due to the acceleration of nutritional rehabilitation and noted improvements in mental status.

Is there special training or education that you know of that prepares the clinician for caring for the eating disordered patient who may need a tube feeding for nutrition support?

Woods: The clinician needs to understand basic fluid and electrolyte management. Refeeding syndrome and its prevention must be thoroughly understood.

Nursing staff members monitoring the patient need to understand the process. The psychological issues and understanding of how to coach the patient through fear that may be a part of weight restoration are required of all team members.

Runyan: The best training a clinician can obtain is by working in an acute care setting or a qualified residential care setting that uses the NG tube as a means for refeeding. With direct patient care involvement, the clinician will experience the manifestations of resistance and resolve of patients. Working in these settings for an extended period with a multitude of patients, the clinician will be prepared to manage most circumstances patients present in an individually tailored manner unique to their needs.

Pearle Lamb: Perhaps the best training is the certified nutrition support clinician, who addresses all forms of nutrition support in the medical and psychiatric setting. Hospital-based training in an inpatient unit can go a long way toward building proficiency in enteral feeding the high-risk patient. General medical training provides the basis for much of the clinical management of enteral feeding; however, an understanding of behavioral medicine is imperative to establish trust with an individual undergoing treatment of an eating disorder.

Dietetic internships that provide rotations in an eating disorder inpatient setting provide opportunities for learning under supervision.

Brenda K. Woods, MD, FAAFP, is the Director of Medical Services at Remuda Ranch, the nation's largest treatment center exclusively dedicated to women and girls with eating disorders and related issues. Dr Woods' role at Remuda Ranch is to oversee the medical, psychiatric, and psychological care of patients at Remuda's inpatient facility in Virginia. Over the years, she has directed the medical care of thousands of patients with eating disorders.

Dr Woods has been affiliated with Remuda Ranch since 1997, serving as director of primary care medicine for 6 years before assuming the role of medical director. Prior to coming to Remuda, she had 9 years of private practice experience with emphasis on women's health, adolescent, and pediatric medicine. Dr Woods is a member of the VA Academy of Family Physicians, the American Academy of Family Medicine, the Academy for Eating Disorders, and the International Association of Eating Disorder Professionals.

She is board certified with the American Academy of Family Physicians and Awarded Degree of Fellow with the American Academy of Family Physicians. She also has earned a certificate of added qualification in adolescent medicine.

Dr Woods acquired her bachelor of science degree at Indiana Wesleyan University. She received her doctor of medicine degree from the Indiana University School of Medicine. Her internship was with the Department of Obstetrics and Gynecology at Indiana University, and she completed her residency in family medicine at Community Hospitals Indianapolis.

Dr Woods enjoys working with physicians and other health care professionals in helping them recognize and treat eating disorders in their practice.

Buck Runyan, MS, LMFT, LPC, CEDS, is the Chief Operations Officer for Discovery Practice Management's Eating Disorder Division. Buck has been involved in the treatment of eating disorders since 1994. He treats adolescents and adults within residential care, partial hospital, intensive outpatient, and private practice settings. Professionally, Buck holds the administrative position as the chief operations officer for Discovery Practice Management's Eating Disorders Division. He has also been the founding program director of the Remuda Ranch Adolescent Center; program director for the Remuda Ranch adult treatment center in Wickenburg, Arizona; and program administrator for the San Bernardino County Mental Health Court dualdiagnosis day treatment programs. He founded Eating Disorder Recovery Services (EDRS), his private practice, in 2000.

Through EDRS, Buck has developed comprehensive outpatient treatment programs for eating disorders, self-injurious behavior, and gastric surgery assessment and counseling programs. Buck regularly trains multidisciplinary professionals by lecturing on a local, regional, and national basis. He remains active with the International Association of Eating Disorder Professionals California Division (California) as the founding president. He remains credentialed in California as a marriage and family therapist and in Arizona as a licensed professional counselor and a certified eating disorder specialist. Buck was formally educated at California Baptist University, completing a master of science degree in counseling psychology in 1992.

Roberta Pearle Lamb, MPH, RD, LDN, brings broad clinical experience in treating, counseling, and coaching eating disordered individuals and other medically high-risk populations. She serves as director of nutrition services at Walden Behavioral Care, including developing and integrating nutrition services at multiple levels of care on Walden's Eating Disorders service (since 2005). As the director of Walden's Mastering Balance Program, an integrative treatment program for treating binge disorder and night-eating syndrome, Ms Pearle Lamb has applied her understanding of the factors that cause and complicate overeating and appetite dysregulation to program development in the most underserved area of eating disorders. She also maintains a private practice in Wellesley, Massachusetts. Previously, Ms Pearle Lamb worked as a clinical dietitian at the Massachusetts General Hospital Weight Center.

She worked as a consultant dietitian at the UCLA Medical Center in Los Angeles, California, and at the Cedars Sinai Medical Center Weight Loss Program, also in Los Angeles. Ms Pearle Lamb earned her bachelor of science degree in foods, nutrition, and dietetics from New York University in 1982 and her master's degree in public health with nutritional science specialization from UCLA in 1984.

She serves on the American Dietetic Association (ADA) Standards of Practice Committee for Eating Disorders (expected publication of new standards in the Journal of the American Dietetic Association, 2011) and serves as the eating disorders resource professional in the ADA's Behavioral Health Nutrition practice group (term 2007-2010).