Anorexia Nervosa: A Case Study - PowerPoint Presentation

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Anorexia Nervosa: A Case Study

By: Colleen Shank

Sodexo Dietetic Intern

April 30, 2014

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“Up to 24 million people of all ages and genders suffer from an eating disorder (anorexia, bulimia and binge eating disorder) in the U.S

(The

Renfrew Center Foundation for Eating Disorders)”“Only 35% of people that receive treatment for eating disorders get treatment at a specialized facility for eating disorders” (Noordenbox, 2002)

Presentation of Anorexia Nervosa

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“A review of nearly fifty years of research confirms that anorexia nervosa has the highest mortality rate of any psychiatric disorder” (

Arcelus

, Mitchell, Wales, & Nielsen, 2011)“20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart problems” (The Renfrew Center Foundation for Eating Disorders)

Presentation of Anorexia Nervosa

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Presentation of Anorexia Nervosa

Overview of how one may suffer from AN:

Body image distortion

Restrictive intake and or binging/purging

Excessive exercise

Severe weight loss

Fear of becoming fat

Physiological changesPsychological changes

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Two types:

Restricting type

Energy intake is restrictedBinge-eating/purge typeVomiting

Excessive exercising

Both types suffer from fear of gaining weight

Presentation of Anorexia Nervosa

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Diagnosis criteria: DSM-5

Restriction

of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.Intense fear of gaining weight or becoming fat, even though underweight.

Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current

low body weight

Presentation of Anorexia Nervosa

The Alliance for Eating Disorders

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Screening Tools: EDI-3 Eat-26

Can be given by health Care professionalsCan be accessed onlineCan help assess riskDo not diagnose eating disorders

Types of Questions:

Gender, height, weight

How

often

one feels, experiences, likes,

or avoids certain

things

Avoiding foods when hungry, feeling guilty after eating, eat diet foods, etc.

How often one partakes in certain behaviors

V

omiting

, binging, and exercising

Presentation of Anorexia Nervosa

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Physical Signs & Symptoms:

Weight loss

TirednessThinning hairHair lossDry skinSwelling of arms/legsLanugoIntolerance to cold

Presentation of Anorexia Nervosa

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Internal Changes:

Body systems are affected

Examples: cardiovascular, neuroendocrine, renal, and gastrointestinal systemsSlow heart rate AnemiaStomach gets smallerConstipationDehydration

AmenorrheaOsteoporosisHypothermiaHypotension

Presentation of Anorexia Nervosa

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Psychological Signs & S

ymptoms:

Not wanting to eatFear of weight gainExtreme exerciseDepressionPreoccupation with food

LyingLack of social interaction

Presentation of Anorexia Nervosa

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Tests/Labs:

Height, weight, BMI

Look atHeartLiverKidneysBonesThyroidEtc.

Tests/Labs:

CBC

Electrolytes

Total protein

Minerals

H/H

Glucose

B12

Etc.

Presentation of Anorexia Nervosa

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Examples of Abnormalities:

Abnormal

lipoprotein profile Low zinc Low vitamin B-12 AlkalosisLow chloride and potassium Elevated bicarbonateHypomagnesmiaHypophosphatemia

LymphocytosisLow resting metabolic rate Mitral valve prolapse

Presentation of Anorexia Nervosa

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Treatment:Requires a team

Physician, Psychologist/Psychiatrist, RD

Not all treatment plans are the sameEveryone needs a treatment plan specific to themInpatient, outpatient, both Presentation of Anorexia Nervosa

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Treatment: PsychologicalOne-on-one

Group

FamilyDiscover underlying issues

Treatment: Psychological

Different types of therapy

CBT

IPT

SSCM

Research?

Presentation of Anorexia Nervosa

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Treatment: PharmacotherapyNot to treat AN specifically

Used to treat underlying issues

Antidepressants, antipsychoticsOlanzapine, Fluoxetine, Prozac, Risperidone Research? Can drugs help improve weight gain?

Presentation of Anorexia Nervosa

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MNT: AND Position Paper“Nutrition

intervention, including

nutrition counseling by a registered dietitian, is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment across

the continuum of care”

Presentation of Anorexia Nervosa

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MNT: RDs RoleAssess the patientDetermine nutrition risks

Define nutrition diagnosis

Identify nutrition interventionWrite nutrition prescriptionDefine nutritional goalsPresentation of Anorexia Nervosa

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MNT: RD Assessment

What is important to assess?

Of course the RD will assess physical signs and symptoms but there are other things that should be included in their assessment of the patientCurrent dietary intakePresent eating patterns

History related to foodsNutrient deficiencies

S

upplement use

Risk of refeeding syndrome

Presentation of Anorexia Nervosa

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Treatment: Current Guidelines

Intake recommendations

Calculating needsKcalStarting pointIncrease by 100-200kcalsMacronutrientsCHO: 50-55%PRO: 15-20%

Fat: 25-30%

Micronutrients

?

Weight gain

Differences between in and out patient settings

Increase in kcal needs

Presentation of Anorexia Nervosa

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Treatment: Refeeding Syndrome

Refeeding a starved patient

Clinical implicationsLow Mg, K, PThiamine deficiencyMust be aware of the affects Must follow protocol to help prevent refeedingMonitor electrolytes and fluids

Presentation of Anorexia Nervosa

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Treatment: Nutrition Support

Need for nutrition support depends on needs of the patient

PN should only be used when medically necessaryPresentation of Anorexia Nervosa

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Basics:Age: 56Sex: Female

Lives at home with her mother and sister

Dates of hospital stay: January 15, 2014-February 14, 2014Date transferred to Manor Care: February 14, 2014Presentation of C.H.

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Hospital Stay:Dx:

FTT secondary to malnutrition, Pancytopenia, Hypothermia related to malnutrition, Bradycardia related to hypothermia, and Hypotension related to

dehydrationPMH: Anorexia, AnemiaPresentation of C.H.

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Hospital Stay:

Reason for going to ER: inability to ambulate and weakness

Vital 1.53 day calorie countLabs: Labs: BG 49, HGB 3.7, Creatinine 0.67, BUN 60Per patient:Reported that weight loss started several months ago

No menstruation anymoreNo diarrhea, blood in the stoolWas on iron pill but stopped taking due to negative side effects

Has struggled with weight since age 11

Presentation of C.H.

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Manor Care:Admit dx:

FTT,

(GERD), Refeeding Syndrome, Pancytopenia, and History of intussusceptionHer admission note states she was "in an anorexic and malnourished state" Admit weight 76.6#, Height 62.0”, BMI 14.0

Stage 3 gluteal woundLeft hip wound

Presentation of C.H.

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Manor Care: No smoking, drinking, drug use history

February 18, 2014

AOA involvedMother and sister were not allowed to bring in food to patientPresentation of C.H.

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Manor Care: Plan Physical

and occupational therapy

Continue current diet, supplements, folic acid, MVI, zinc, labs as scheduledFollow up with GI at the hospital as scheduledWound: local care with santyl, daily dressing change/pressure relief, nutritional support

Presentation of C.H.

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Manor Care:

Labs from February 21, 2014

Random glucose: 78BUN: 12Creat: 0.40K: 4.2NA: 136

AST: 21ALT: 30Alk phos: 66

Total bilirubin: 0.3

Presentation of C.H.

Ca: 8.9

Alb

: 3.6

Total pro: 6.3

GFR: >60

WBC: 6.6

RBC: 3.96 L

HGB: 9.3 L

HCT: 31.3 L

MCV: 79.1 L

MCH: 23.4 L

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Manor Care: Medications

Cholecalciferol

2000 unit po dailyHeparin 5000 units SQFolic acid 1mg po dailyMVI po daily

Protonix 40mg po dailyZinc sulfate 220mg po daily

As needed:

Miralax

, Colace, Tylenol, MOM, Dulcolax,

Ferrous liquid 220g

po

daily (added at a later date 3x/week) Presentation of C.H.

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Manor Care:

On admission was placed on gluten intolerance diet and enhanced food

Prior to RD assessmentWas later changed to a regular dietNo history of Celiac DiseasePresentation of C.H.

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Manor Care: RD Assessment

February 19, 2014

Current weight 77.2#, BMI 14.1InterviewPt prefers “plain foods”Pt reports allergy to guar gumConsumption of meals 75-100%Eats meals slowly (1-1.5hours)No diarrhea, constipation,

steatorrhea, communication, dental/oral, or functional problems noted

Presentation of C.H.

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Manor Care: RD Assessment

Calculated needs (with IBW 110#:

35kcal/kg = 1750kcal/day1.5g/kg pro= 75g/day30mL/kg fluid= 1500mL/dayDiet order: Regular diet, Supplement TIDNo longer giving enhanced foods due to pt liking plain foods

Recommendations: weekly CMP, CBC, P, Mg, LFTs, iron supplement

Presentation of C.H.

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Manor Care: Weekly weights

2/14/14

76.6 #2/18/14 77.2

#2/24/14 77.6

#

3/4/14

82

#

Presentation of C.H.

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Manor Care: Med Options AssessmentMental health evaluation (2 visits)

Main issue: AN

Patient has difficulty with mood functioning, behavioral functioning, and lack of insight"I am not an anorexic" "I do eat- I like food but I have a difficult time keeping the weight

on"Presentation of C.H.

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Manor Care: My interaction with C.H

U

sual intake3 meals per day (breakfast, lunch, and dinner) as well as snacks in between mealsUBW: 110-115# Since she has been sick she reports her weight has been 85-90#States she does not usually keep track of weight

Reports she could feel she was losing weight when she started getting sick Reports when she was taking her iron pill that would help her gain weight

Presentation of C.H.

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Was d/c on March 4, 2014D/c to home with mother and sisterNo further info on AOA

Weight at d/c 82#

Update on C.H.

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Sources

Eating Disorder Statistics.

ANAD. http://www.anad.org. Accessed April 20, 2014.Get the Facts on Eating Disorders. NEDA

. https://www.nationaleatingdisorders.org. Accessed March 13, 2014.Anorexia Nervosa. National Association of Anorexia Nervosa and Associated Disorders. http://www.anad.org/. Accessed March 13, 2014.

Feeding and Eating Disorders.

APA

http://www.dsm5.org. Accessed March 13, 2014

DSM-5 Diagnostic Criteria.

The Alliance for Eating Disorders.

http://www.allianceforeatingdisorders.com. Accessed March 19, 2014.The Eating Attitudes Test (EAT-26). Eat-26. http://www.eat-26.com/. Accessed April 3, 2014.Mayo Clinic Staff. Anorexia Nervosa. Mayo Clinic. http://www.mayoclinic.org. Updated January 5, 2012. Accessed March 19, 2014. Anorexia Nervosa. The New York Times. http://www.nytimes.com. Reviewed March 18, 2013. Accessed April 3, 2014.Anorexia Nervosa Biochemical and Nutrient Issues. Academy of Nutrition and Dietetics Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed April 3, 2014. 

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Treatment Basics.

NEDA

. https://www.nationaleatingdisorders.org. Accessed April 4, 2014.Eating Disorders. How can a psychologist help someone recover? APA. https://www.apa.org/. Revised October 2011. Accessed April 10, 2014. Le Grange, D., Lock, J. Family-based Treatment of Adolescent Anorexia Nervosa: The

Maudsley Approach. Maudsley Parents. http://www.maudsleyparents.org/whatismaudsley.html. Accessed April 10, 2014.

DeAngelis

, T. Promising Treatments for anorexia and bulimia.

Monitor on Psychology. March 2002; 33 (3): 38. http://www.library.illinois.edu/learn/research/citation/ama.html. Accessed April 10, 2014.

Schmidt U,

Oldershaw

A, Jichi F, et al. Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial. The British Journal of Psychology. 2012, (201):392-399. DOI: 10.1192/bjp.bp.112.112078. Accessed April 10, 2014. Carter, F, Jordan, J, McIntosh, V. V.W, et al. The long-term efficacy of three psychotherapies for anorexia nervosa: A randomized, controlled trial. Int. J. Eat. Disord. 2011; (44): 647–654. DOI: 10.1002/eat.20879. Accessed April 10, 2014.

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Yager

J, Devlin M, Halmi K, et al. Guideline Watch: Practice Guideline for the Treatment of Patients with Eating Disorders. 3rd ed. APA. 2012. http://psychiatryonline.org/pdfaccess. Accessed April 10, 2014. Mickley D. Medication for Anorexia Nervosa and Bulimia Nervosa.

Eating Disorders Recovery Today. 2004; 2(4). http://www.eatingdisordersrecoverytoday.com. Accessed April 11, 2014.Attia E, Kaplan A, Walsh B, et al. Olanzapine versus placebo for out-patients with anorexia nervosa [Abstract]. Psychological Medicine. 2011; 41(10): 2177-2182.

DOI: http://dx.doi.org/10.1017/S0033291711000390 Accessed April 11, 2014.

Hagman

J,

Gralla

J, Sigel E, et al. A Double-Blind, Placebo-Controlled Study of Risperidone for the Treatment of Adolescents and Young Adults with Anorexia Nervosa: A Pilot Study. JAACAP. 2011; 50(9): 915-924. DOI

:10.1016/j.jaac.2011.06.009.Walsh T, Kaplan A, Attia E, et al. Fluoxetine After Weight Restoration in Anorexia NervosaA Randomized Controlled Trial. JAMA. 2006;295(22):2605-2612. DOI:10.1001/jama.295.22.2605.Ozier A, Henry B. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders. JADA. 2011;111:1236-1241. http://www.eatright.org/ Accessed April 11, 2014.

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Waterhous T, Jacob M. Practice Paper of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorder.

ADA.

2011; 11(8): 1261. http://www.eatright.org/ Accessed April 10, 2014. Parent Toolkit. NEDA. 47. http://www.nationaleatingdisorders.org/sites/default/files/Toolkits/parenttoolkit/. Accessed April 11, 2014.Anorexia Nervosa Nutrition Prescription. Academy of Nutrition and Dietetics Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed April 10, 2014.

Schebendach J. Nutrition in Eating Disorders. In: Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. St. Louis, MO; Saunders Elsevier; 2008: 563-586. Anorexia Nervosa Nutrition Support. Academy of Nutrition and Dietetics Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed April 11, 2014.

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