Ethical aspects of this study were reviewed and approved by the Human Research Ethics Committee at the Ashikaga Red Cross Hospital. This study was performed after obtaining informed consent from all participants upon admission. For a patient below the age of 18 years, informed parental consent was also obtained. Diagnosis was based on criteria in the ICD-10, and each patient was diagnosed by two of the three psychiatrists (MF, AK, and TT), each of whom had > 10 years of experience in psychiatry at the time of the study. Participants were recruited from the neuropsychiatric unit in Ashikaga Red Cross Hospital during the period from April 1999 to March 2018. Among 96 admissions with eating disorders that were managed in our unit (F50.0, anorexia nervosa; F50.2, bulimia nervosa), only those with a body mass index of < 16 (68 admissions) were included to investigate refeeding hypophosphatemia, which are considered severe malnutrition among patients with anorexia nervosa [6 (link)]. The five patients who discharged themselves from the hospital against medical advice or declined repeated blood tests were excluded. Thus, 63 admissions met the abovementioned criteria and were included in this study. Consecutive admissions with recurrences of anorexia nervosa were included as separate admissions [2 (link), 4 (link)] because weight and nutritional status, and thus risk of refeeding syndrome, changed with each admission [2 (link)]. In this study, among a total of 37 patients, all of whom were Japanese, 12 had two or more consecutive admissions, which adds up to a total of 63 admissions. However, considering a potential bias toward a correlation, analyses were repeated using only 37 independent patients.
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