Can higher-calorie feeding protocols for patients with eating disorders admitted to an adult hospital ward be safely implemented to reduce the length of stay? A scoping review

Background: Hospital admissions for individuals with eating disorders are increasing, yet adult inpatient nutritional restoration often relies on conservative low-calorie refeeding to avoid refeeding syndrome (RFS). Evidence from younger populations suggests that higher-calorie refeeding (HCR) may be safe and more efficient, but data from adults are limited. This scoping review mapped the extent, characteristics and safety of HCRs (≥1500 kcal/day) for people with eating disorders admitted to adult hospital wards. Methods: Five electronic databases were searched from July 2025 for studies published from January 2012–June 2025. Eligible studies included adults with a diagnosed eating disorder or mixed-age samples treated in adult wards, who underwent HCR on admission. The primary outcomes were RFS markers, particularly refeeding hypophosphataemia; the secondary outcomes were length of stay (LOS), weight gain and change in body mass index (BMI). Three reviewers independently screened the records and charted the data, and the findings were synthesised descriptively. Results: Of the 778 records identified, 11 studies met the inclusion criteria. Most of these studies involved retrospective cohorts, with three quasi-experimental before–after designs, which were performed in adult specialist or general inpatient settings across several countries. Together, they described 4,874 patients exposed to HCR, usually starting at 1,500–2,000 kcal/day and advancing as tolerated. Definitions and monitoring of RFS vary widely. No study reported deaths or clinically defined RFS attributable to HCR. Biochemical hypophosphataemia affects up to approximately one-third of patients, is usually mild and is managed with electrolyte supplementation. Four studies reported LOS; two reported shorter admissions and faster weight gain with HCR than with lower-calorie protocols did. Conclusions: Across observational studies, initiating HCR for people with eating disorders in adult hospital wards appears feasible and can be delivered without an obvious increase in clinical RFS while potentially reducing the LOS and enhancing weight restoration when combined with close monitoring and supplementation. Heterogeneity in RFS definitions, refeeding protocols and outcome reporting, and the absence of randomised trials limit confidence in these findings. Prospective studies using standardised RFS criteria and clearly defined HCR and comparator protocols are needed to guide adult-focused practice and policy. Trial registration: Not applicable.