What to Expect During the Refeeding Process

Eating disorder recovery usually involves several treatment interventions. Refeeding, or the refeeding process, is used in treatments with other effective strategies to treat patients who are recovering from disordered eating. Nutrition rehabilitation and weight restoration are the first components of the refeeding process and is taken very seriously to avoid symptoms of refeeding syndrome1. Clinicians and the multidisciplinary team work alongside one another to ensure that the refeeding plan is easy to understand, safe and individualized. During the refeeding process, an individual may experience the usual symptoms of mechanical eating, those being gastrointestinal discomfort, increased satiation, body fluid fluctuations and re-established hunger cues. An individual may also experience feelings of psychological discomfort and may regress by engaging in self-defeating behaviours throughout the process of mechanical eating1. The refeeding process will teach individuals in recovery about normalized eating, restore hunger cues, improve their relationship with food and adopt new eating patterns. 

The refeeding process is used in collaboration with other treatments and therapy programs. It is important that the individual manages their stress throughout the varying metabolic changes and weight restoration processes. The goal for an individual in recovery is to achieve their setpoint body weight through mechanical eating and nutrition therapy. This process involves consuming a surplus of energy that the body is not used to and during this change, physiological changes can occur. The body may endure a shift in fluid balances, electrolytes and hormones as the body is working to repair itself and moving away from a state of starvation. The body also shifts from being in a catabolic state to an anabolic state, now using energy and nutrients to build and repair tissues and vital organs2. Weight gain will occur as the body moves from a dehydrated and malnourished state to a hydrated and nourished state. Changes in lean body mass, water retention and body fat are normal and need to occur in order for someone recovering from an eating disorder to reach their setpoint body weight3.  Uncertainty is something that individuals may face as they can experience a fluctuation in weight in result of the extra energy and nutrients that they are now consuming. This is a normal part of the process. Some symptoms reported pertain to the gastrointestinal tract which include bloating, diarrhea and abdominal discomfort4. This is due to the expansion of the abdomen and digestive processes that are being repaired. Digestion remains slow in the first stages of the refeeding process, which is why most patients experience bloating and/or gas4.  The bloating sensation will be reduced as our body gets used to normal eating. Some patients also report constipation while refeeding. Eating more fibre and water can improve this symptom over time4.

Mechanical eating is a way of eating to normalize eating behaviours and restore hunger cues. This integrated eating strategy is used to treat most eating disorders, including anorexia nervosa, bulimia nervosa and binge eating disorder5. It is a structured way of eating three meals and two ot six snacks daily according to an individualized timely schedule5. The idea is to eat every few hours to keep your body engaged, channel hunger cues and adopt normalized eating behaviours. Throughout eating disorder recovery, working with a Registered Dietitian can help individuals to establish a mechanical eating plan that is tailored to their lifestyle, levels of comfort and readiness for change1.

The refeeding process may also trigger psychological discomfort. This can due to the fact that individuals recovering from an eating disorder are undergoing cognitive restructuring and learning how to adopt normalized eating behaviours and cope with the many changes in their body. Eating disorder thoughts may increase as mechanical eating goes against unrealistic health ideologies and food rules that were once followed. Individuals usually experience anxiety in many form such as stress, nervousness and varying emotions of uncertainty and unpredictability3. If the individual has begun to engage in self-defeating behaviours, it is important to remember to be kind to their future selves and to not allow feelings of guilt or shame cloud their thoughts and goals for recovery.  Regression is a normal part in recovery and can be treated by remembering why one started on the path to recovery in the first place.  Don’t allow oneself to get stuck in the past; move on, find self-acceptance and work towards progression. 

 Recovery is a slow process that is not linear; it is very common for people to take steps backward before moving forwards. By trusting the process and working towards a goal with your family and healthcare team, the process can be much more manageable and comfortable. It is important that the individual in recovery is comforted by their support system and is actively talking about their emotions, fears and concerns with their healthcare team.  At this time, a sense of security and reassurance will help the individual to progress and reach further stages in recovery. 

Eating intuitively can be the ultimate goal in the recovery process but this can not be reached without first tackling refeeding. 


References

1) Mehler, P. S., Winkelman, A. B., Andersen, D. M., & Gaudiani, J. L. (2010). Nutritional rehabilitation: practical guidelines for refeeding the anorectic patient. Journal of nutrition and metabolism,625782. doi:10.1155/2010/625782

2) Mascolo, M. (2018) Refeeding Patients with Anorexia Nervosa: What Does Research Show? In Eating Disorder Hope. Retrieved from https://www.eatingdisorderhope.com/information/anorexia/refeeding-patients-with-anorexia-nervosa-what-does-research-show

3) Winkler, J., Alperovitz, D. (2015). The body’s response to adequate fuel in anorexia. In Eating Disorders Catalogue. Retrieved website: https://www.edcatalogue.com/the-bodys-response-to-adequate-fuel-in-response-to-anorexia/

4) Nutrition in Eating Disorders. (n.d.). 2016. In Nova Scotia Health Authority. Retrieved from http://www.nshealth.ca/sites/nshealth.ca/files/patientinformation/0308.pdf

5) Grave, R. D. (2005). A multi-step cognitive behaviour therapy for eating disorders. In European Eating Disorders Review, 13, 373–382. doiI: 10.1002/erv.671

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