Is there evidence to support omitting weight restoration goals in the treatment of severe and enduring anorexia nervosa?

Weight Restoration Goals in Severe and Enduring Anorexia Nervosa

Current evidence does not support omitting weight restoration goals in the treatment of severe and enduring anorexia nervosa (SE-AN), as the American Psychiatric Association (APA) explicitly recommends that all patients with anorexia nervosa who require nutritional rehabilitation have individualized goals set for weekly weight gain and target weight. 1

Evidence-Based Recommendations for Weight Restoration

The 2023 APA Practice Guideline for the Treatment of Patients with Eating Disorders provides clear recommendations regarding weight restoration in anorexia nervosa:

• APA recommends (1C) that patients with anorexia nervosa who require nutritional rehabilitation and weight restoration have individualized goals set for weekly weight gain and target weight 1
• APA recommends (1B) that adults with anorexia nervosa be treated with eating disorder-focused psychotherapy, which should include normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects of the disorder 1

These recommendations apply to all patients with anorexia nervosa, including those with severe and enduring forms of the illness.

Considerations for Severe and Enduring Anorexia Nervosa

While weight restoration goals remain important, the approach may need modification for patients with SE-AN:

• Research suggests that treatment for SE-AN may benefit from a flexible, patient-centered approach that focuses on enhancing quality of life and maintaining medical stability while still addressing weight concerns 2
• A 2023 observational study found that even in patients with an average of 19 years of eating disorder symptoms, 69.2% remained weight stable or showed an increase in BMI with treatment that focused on quality of life 2

Treatment Approaches for SE-AN

For patients with severe and enduring anorexia nervosa:

1. Maintain weight restoration goals but with flexibility:

   • Set realistic, individualized weight targets
   • Focus on medical stability as a primary concern
   • Consider slower weight gain targets compared to acute cases

2. Adapt psychological approaches:

   • Modified cognitive behavioral therapy (CBT) approaches may be beneficial 3
   • Balance weight restoration goals with quality of life improvements
   • Address chronic illness management strategies

3. Monitor for medical complications:

   • Regular assessment of electrolytes, especially phosphate levels 4
   • Cardiac monitoring, particularly in severely underweight patients 1
   • Comprehensive metabolic panels 1

Common Pitfalls to Avoid

• Completely abandoning weight goals: This approach is not supported by current guidelines and may lead to continued medical instability 1
• Setting unrealistic expectations: Overly aggressive weight restoration targets may increase treatment dropout in chronic cases 5
• Focusing exclusively on weight without addressing quality of life: This may reduce treatment engagement in long-standing cases 3

Clinical Decision Algorithm

1. Assess chronicity and severity:

   • Duration of illness (>3-7 years often considered "enduring")
   • Previous treatment attempts and responses
   • Current medical stability

2. Set appropriate weight restoration goals:

   • For all patients: Establish minimum weight targets for medical stability
   • For SE-AN: Consider more modest initial weight goals with gradual progression
   • Individualize weekly weight gain expectations (typically 0.5-2kg/week in inpatient settings) 4

3. Implement multidisciplinary treatment:

   • Medical monitoring for complications
   • Specialized psychotherapy addressing both eating behaviors and quality of life
   • Nutritional rehabilitation with appropriate monitoring for refeeding complications

The evidence strongly supports maintaining weight restoration goals as part of comprehensive treatment for all patients with anorexia nervosa, including those with severe and enduring forms, while adapting approaches to enhance engagement and quality of life.