As a professor of pediatrics at the University of California, San Francisco, Andrea Garber BS’92 PhD’99 conducted a groundbreaking study concerning a very vulnerable group: patients hospitalized with anorexia nervosa, an eating disorder that often proves fatal. It is most prevalent among teenage girls and young women.

Garber and her team discovered that the standard “refeeding” protocol used in hospitals nationwide—that is, the necessarily careful reintroduction of food to patients who have been starving themselves—was too low in calories and was in fact causing patients to continue losing weight even during longer hospital stays. The phenomenon had been long observed, but Garber’s study, published in 2012 and based on the largest cohort of its kind, was the first to actually prove it.

What makes this work so critical?

Anorexia nervosa is the most deadly psychiatric illness. It has a mortality rate of 5 to 6 percent, which is the highest among all psychiatric diagnoses, and the recovery rates are really low. Studies that are using the absolute best forms of treatment and psychotherapy still show that maybe only 30 percent at the lowest— but at the highest, half—of patients are recovered at one year. So we absolutely need to develop better treatments.

What protocols do you think will be more effective?

In a new five-year study, we are testing a higher-calorie refeeding protocol, starting at 2,000 calories per day and advancing quickly by 200 calories per day. We’ll compare this to a group receiving a lower-calorie protocol, starting at 1,400 calories per day and advancing slowly by 200 calories every other day. This lower-calorie diet is in fact a little higher than the traditional recommendation to start at 1,200 calories.

Why have such low-calorie diets been used with anorexia patients?

For safety. “Low and slow” refeeding is believed to minimize risk for the refeeding syndrome, which was first documented around the time of World War II. It’s characterized by life-threatening shifts in fluids and electrolytes that can occur when nutrition is reintroduced in starved patients. At UCSF and our collaborating site at Stanford, we are set up for a high degree of medical management and we can carefully monitor for any signs of refeeding syndrome. The main one is electrolyte shifts, which our physicians check every day and correct as needed with supplements. A key question is, how much medical intervention is needed to keep higher-calorie refeeding safe? That’s important to know before disseminating these protocols to other settings, such as residential treatment facilities.

Do these protocols have implications for patients after hospital discharge?

We’re looking very closely at relapse rates. Forty percent of these young people relapse within one year of their first hospitalization. If higher-calorie refeeding gives us shorter hospital stays, but these kids end up coming right back, then we’ve undone any potential benefit of that shorter stay. While the higher-calorie refeeding seems promising in terms of faster weight gain and shorter hospital stay, there are many unanswered questions about potential long-term benefits, long-term risks and the overall effect on recovery.