By Colleen Shank Sodexo Dietetic Intern April 30 2014 Up to 24 million people of all ages and genders suffer from an eating disorder anorexia bulimia and binge eating disorder in the US ID: 908933
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Slide1
Anorexia Nervosa: A Case Study
By: Colleen Shank
Sodexo Dietetic Intern
April 30, 2014
Slide2“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
Slide3“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
Slide4Presentation 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
Slide5Two types:
Restricting type
Energy intake is restrictedBinge-eating/purge typeVomiting
Excessive exercising
Both types suffer from fear of gaining weight
Presentation of Anorexia Nervosa
Slide6Diagnosis 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
Slide7Screening 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
Slide8Physical Signs & Symptoms:
Weight loss
TirednessThinning hairHair lossDry skinSwelling of arms/legsLanugoIntolerance to cold
Presentation of Anorexia Nervosa
Slide9Internal Changes:
Body systems are affected
Examples: cardiovascular, neuroendocrine, renal, and gastrointestinal systemsSlow heart rate AnemiaStomach gets smallerConstipationDehydration
AmenorrheaOsteoporosisHypothermiaHypotension
Presentation of Anorexia Nervosa
Slide10Psychological Signs & S
ymptoms:
Not wanting to eatFear of weight gainExtreme exerciseDepressionPreoccupation with food
LyingLack of social interaction
Presentation of Anorexia Nervosa
Slide11Tests/Labs:
Height, weight, BMI
Look atHeartLiverKidneysBonesThyroidEtc.
Tests/Labs:
CBC
Electrolytes
Total protein
Minerals
H/H
Glucose
B12
Etc.
Presentation of Anorexia Nervosa
Slide12Examples 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
Slide13Treatment: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
Slide14Treatment: PsychologicalOne-on-one
Group
FamilyDiscover underlying issues
Treatment: Psychological
Different types of therapy
CBT
IPT
SSCM
Research?
Presentation of Anorexia Nervosa
Slide15Treatment: 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
Slide16MNT: 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
Slide17MNT: RDs RoleAssess the patientDetermine nutrition risks
Define nutrition diagnosis
Identify nutrition interventionWrite nutrition prescriptionDefine nutritional goalsPresentation of Anorexia Nervosa
Slide18MNT: 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
Slide19Treatment: 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
Slide20Treatment: 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
Slide21Treatment: Nutrition Support
Need for nutrition support depends on needs of the patient
PN should only be used when medically necessaryPresentation of Anorexia Nervosa
Slide22Basics: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.
Slide23Hospital 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.
Slide24Hospital 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.
Slide25Manor 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.
Slide26Manor 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.
Slide27Manor 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.
Slide28Manor 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
Slide29Manor 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.
Slide30Manor 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.
Slide31Manor 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.
Slide32Manor 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.
Slide33Manor 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.
Slide34Manor 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.
Slide35Manor 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.
Slide36Was 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.
Slide37Sources
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.
Slide38Treatment 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.
Slide39Yager
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.
Slide40Waterhous 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.
Robb A, Silber T,
Orrell
- Valente J, Valadez-Meltzer A, et al. Supplemental Nocturnal Nasogastric Refeeding for Better Short-Term Outcome in Hospitalized Adolescent Girls With Anorexia Nervosa.
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2002;159:1347-1353. DOI:10.1176/appi.ajp.159.8.1347. Accessed April 11, 2014.