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].