Anorexia Nervosa Mimi Huang - PowerPoint Presentation

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Anorexia Nervosa

Mimi HuangKaiser Oakland Medical CenterOakland, California

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Introduction

Overview of Anorexia NervosaMedical Nutrition Therapy for Anorexia Nervosa

Description of patientNutrition Care PlanAssessmentDiagnosisIntervention

Monitoring and Evaluation

Summary and Conclusion

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Objectives

What is Anorexia Nervosa?What are the complications related to AN?What is Medical Nutrition Therapy for AN?How to apply Nutrition Care Plan for patient?

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DSM IV Criteria for Eating Disorder/ Diagnosis

Anorexia Nervosa (AN)Fear of weight gainRefusal to maintain body weight or minimal normal weight

Obsession with staying thinAmenorrhea (will be removed in DSM5 as this criteria cannot be applied to males)Subtypes of ANBinge eating/ Purging: During an episode, person has active binge eating or purging behaviors such as self induced vomiting, abuse of laxatives, diuretics, or enemas.

Restricting: During an episode, person

does not

engage in active binge eating or purging behaviors such as self induced vomiting, abuse of laxatives, diuretics, or enemas.

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Behavioral Symptoms

Restrictive food intakeObsession with exercisingObsession with dietingWeight loss progression

 irritable, moody, socially withdrawn, isolated.

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Health Complications of Anorexia Nervosa

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Medical Nutrition Therapy

Eating disorders (ED) are psychiatric illnessesNutrition Goal: restore patient’s weight to >/=90% ideal body weight. Feeding methods

Oral feedingEnteralParenteralRefeeding SyndromeSeverely malnourished patients are at riskStart at 50% of needs and advance as tolerated

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Medical Nutrition Therapy

Estimated Nutrition Needs: MacronutrientsCalories: 30-40kcal/kg/day (~1000-1200 kcal in severely low-weight pts)Weight restoration Hospitalized patients: 2-3# / week

Outpatient treatment programs: 0.5-1# / weekProtein: No recommendation for eating disordered population. Fat: 1.5-9.6g/day of w-3 fatty acidsFluids: 1ml/kcal or MD’s order

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Medical Nutrition Therapy

Estimated Nutrition Needs: MicronutrientsSupplementationNiacinB12

Folic AcidThiamineZincVit DCalciumMultivitamins

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Patient Description

Name: MWAge/Sex: 38 year old White FemaleSocial Hx: Lives alone in apartment. Sister lives nearby whom she visits often. Pt denies smoking and drinking. She has a history of being in and out of outpatient eating disorder programs.

Dx: Admitted for rehydration/refeed and inpatient psych treatment of Anorexia Nervosa.Pmhx: Thiamin deficiency, Vit B6 Deficiency, chronic abdominal pain, eating disorder, vitamin D deficiency, laxative abuse, recurrent major depression, moderate PCM, borderline personality disorder, n/v, abnormal wt loss, hypokalemia, moderate dehydration, orthostatic hypotension,

nontraumatic

acute kidney injury.

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Nutrition Assessment

AnthropometricsHeight: 5'4 (1.62m) Admit Weight: 52.3kg (115#) IBW

: 54.5kg (120#) 95.8%IBWBMI: 19.9 kg/m2 (normal)Weight Hx:10/31/14 52.3kg (115#)

10/21/14 53.4kg (117#)

10/10/14 52.7kg (116#)

08/26/14 57.5kg (126#)

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Nutrition Assessment: Biochemical Data

Biochemical

Data 

Reference Range

10/21/14

10/23/14

Reason

Na (mEq/L)

133-145

140

140

WNL

K (

mEq

/L)

3.5-5.3

3.5

3.4 (L)

Dehydration, Vomiting, Diarrhea , Poor intake

Cl (mEq/L)

100-111

96 (L)

105

Dehydration, Vomiting, Restricted Salt Diet

BUN (mg/dL)

7-27

32(H)

15

Hypovolemia, Dehydration, Kidney Disease

Creat (mg/dL)

<=1.11

1.27 (H)

0.96

Hypovolemia, Dehydration, Kidney Disease

Corrected Ca

8.5-10.36.96 (L) Kidney failure, Vit D Deficiency, Mg Deficiency, Low serum ALB.

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Nutrition Assessment: Biochemical Data

Biochemical Data

 

Reference Range

10/21/2014

10/23/2014

Reason

Mg (mg/dL)

1.7-2.3

2.0

1.9

WNL

Phos (mg/dL)

2.7-4.5

2.3 (L)

2.2 (L)

Poor nutrition intake,

Vit

D deficiency

Gluc (mg/dL)

60-159

127

112

WNL

ALB (g/dL)

3.7-5.7

5.3 (H)

--

Dehydration

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Nutrition Assessment: Medications

Medication

Rationale

Drug/Nutrient Interaction

 

 

 

Vitamin B Complex

Supplement to replete, treats pernicious anemia.

Caution with folate supplementation as it may mask pernicious anemia.; May cause diarrhea.

Clonazepam

antianxiety,

antipanic

, muscle relaxant

Limit caffeine to <400,g/day, avoid grapefruit/related citrus; Increase appetites.

Lexapro

Treat anxiety and depression

Take with food, avoid tryptophan supplement; increases appetite, may cause n/v/d.

Pepcid

Antiulcer, antigerd, antacid

Limit caffeine intake; take 2 hrs before/after Fe Mg supplement. Lowers Fe and Vit B12 absorption.

Tenex

Antihypertensive, ADHD treatment

Avoid grapefruit/related citrus; insure adequate hydration; avoid natural licorice.

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Nutrition Assessment: Medications

Medication

Rationale

Drug/Nutrient Interaction

 

 

 

K-

Phos

Phosphorus supplement to replete

Avoid Calcium and

Vit

D supplements, Take Fe, Mg, Zn supplements 2hrs before/after, avoid high oxalate/

phytate

foods; insure adequate hydration.

Multivitamin

Supplement to replete

 

Zofran

Anti nausea

Abdominal pain, constipation, diarrhea.

Thiamin Mononitrate

Supplement to replete

Nausea, alcohol inhibits absorption.

Lovenox

Anticoagulant

Derived from Pork, avoid with pork allergy.

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Nutrition Assessment

Food and Nutrition History:Pt reports that she has small frequent meals at home. Did not specify types of food she eats.Estimated Nutrition Needs:Calories:

1500-1700kcal/day (28-32 kcals/kg/day admit wt) Protein: 52-65gm protein/day (1.0-1.2gm/kg/day admit wt) Fluid

:

1500-1700

(1ml/kal)

Diet Order: Regular w/ Nutrition Supplement Boost Vanilla 2x BID w/ meals.

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Nutrition Diagnosis

Altered nutrition-related laboratory values (NC-2.2) related to inadequate intake, as evidenced by Low K, Cl, Ca, Phos values.Disordered eating pattern (NB-1.5) related to anorexia nervosa as evidenced by

pt hx of induced vomiting and restrictive eating patterns.

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Nutrition Intervention

Goal #1: Maintain weight within +/-5% of IBWIntervention: Nutrition education and counseling on appropriate body size and adequate nutrition intake.Goal #2: To eat =/>75% of meals and nutrition supplements daily.Intervention: Provide meal plan appropriate for pt’s nutrition needs.

Goal #3: To improve biochemical values to WNL in one week.Intervention: Continue supplementation of Vit B, Thiamine, K-Phos, and MVI.

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Monitoring and Evaluation

Lab

 

Ref

Range

10/21/14

10/23/14

11/15/14

11/18/14

11/20/14

Na (mEq/L)

133-145

140

140

136

136

140

K (mEq/L)

3.5-5.3

3.5

3.4 (L)

4.5

4.1

4.3

Cl (mEq/L)

100-111

96 (L)

105

106

102

103

BUN (mg/dL)

7-27

32 (H)

156107Creat (mg/dL)

<=1.11

1.27 (H)

0.96

0.92

0.96

0.90

Ca (mg/dL)

8.5-10.3

8.0 (L)

--

8.4

9.0

8.3

Corrected Ca

8.5-10.3

6.96 (L)

--

7.9 (L)

8.5

7.8(L)

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Monitoring and Evaluation

Lab

 

Reference Range

10/21/14

10/23/14

11/15/14

11/18/14

11/20/14

Mg (mg/dL)

1.7-2.3

2.0

1.9

1.9

2.0

2.1

Phos (mg/dL)

2.7-4.5

2.3 (L)

2.2 (L)

3.3

5.1

2.6 (L)

Gluc (mg/dL)

60-159

127

112

135

112

132

ALB (g/dL)

3.7-5.7

5.3 (H)

--

4.6

----

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K and Cl labs are WNL from nutrition and supplementation.

Phos labs improved to WNL with K-Phos supplementation however on 11/20 dropped to 2.6mg/dl.Calcium levels are fluctuating however there is an overall improvement of corrected Ca 6.96mg/dl --> 7.8mg/dl.

Monitoring and Evaluation

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PO intake for the last 3 days was ~50%, and pt reports to drinking half of nutrition supplement Boost.

Recent weight 54.9kg (11/18/14), increased ~6# since her last weight and was very upset, says that she will "lose it anyway" at home, assuming either by laxative abuse, restrictive eating, or emesis.Pt seems to understand what appropriate body size means and adequate nutrition intake however still have paranoia over weight gain and body image.

Monitoring and Evaluation

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Summary

Eating disorders are psychiatric illnesses, a interdisciplinary team of health care professionals is needed for treatment.The Goal of Nutrition Intervention with ED is to replete and restore the weight of an individual within >/=90% of IBW.

Patient Progress:Pt biochemical, weight, nutrition status was improved.Pt has had a long history of eating disorder, was discharged to go home, not outpatient program.

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References

American Psychiatric Association (APA). (1994). Diagnostic and Statistical Manual of Mental Disorders 4th ed. American Psychiatric Association,

American Psychiatric Association (APA). (2013). DSM-5: Feeding and eating Disorders. American Psychiatric Publishing,Journal of the American Dietetic Association (JADA). (2011). Position of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders. J Am Diet Assoc., 111

, 1236-1241. doi:10.1016/j.jada.2011.06.016

National Institute of Mental Health (NIMH).Eating disorders. Accessed 11/30/2014. Retrieved from 

http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml

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References

Reiter, C. S., & Graves, L. (2010). Nutrition Therapy for Eating Disorders. Nutrition in Clinical Practice, 25(122) doi:10.1177/0884533610361606Waterhous

, T., & Jacob, Melanie A. (2014) Nutrition Intervention in the Treatment of Eating Disorders. Practice Paper of the American Dietetic Assosication. Retrieved from http://feast-ed.org/Portals/0/Documents/Practice_Paper_Nutrition_Intervention.pdf

Winston AP. (2012). The Clinical Biochemistry of Anorexia Nervosa.

 Annals of Clinical Biochemistry, 49

, 132-143. doi:10.1258/acb.2011.011185

Image from: http://www.womenshealth.gov/publications/our-publications/fact-sheet/anorexia-nervosa.html