anorexia nervosa: a case study by: colleen shank sodexo dietetic intern april 30, 2014

Anorexia Nervosa: A Case Study

By: Colleen ShankSodexo 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 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

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=CRkstKxfGyaT1M&tbnid=2UHUISaiYt9IHM:&ved=0CAUQjRw&url=http://newvoices.org/2014/03/14/anorexia-and-shabbat/&ei=4WNZU-zpMujisASikYCoBQ&psig=AFQjCNFYC1cS7lDQxgjcQuDx1NCYB7tTAQ&ust=1398453357912381

“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)


http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=EAKQ-TPHXaLvnM&tbnid=AOpfLtP3VN3Z7M:&ved=0CAUQjRw&url=http://www.thewhirlingwind.com/2012/10/09/psychosis-a-peek-into-the-pinhole-of-mitt-romneys-mind/anorexia-mirror-1-282x300/&ei=5mRZU_rjEpXTsAS1-IDQCg&psig=AFQjCNFURZtRiKK6BNgpxFVx1M7FAaShgw&ust=1398453851523621


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 changes Psychological changes

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=G37Eel6W7DFsoM&tbnid=2zrtw-KwNYHgyM:&ved=0CAUQjRw&url=http://weheartit.com/entry/37360305&ei=abVRU8S6GrOpsQTe1oC4Aw&bvm=bv.65058239,d.aWw&psig=AFQjCNGvBGBCopF2jNAIAi2TtB6EW2k7yQ&ust=1397949914714190

Two types:1. Restricting type

o Energy intake is restricted

2. Binge-eating/purge typeo Vomitingo Excessive exercising

Both types suffer from fear of gaining weight


http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=gfPhs_7FgYIeBM&tbnid=DCVsOgv48yGZxM:&ved=0CAUQjRw&url=http://thequietvoice18.wordpress.com/2011/07/24/anorexia-a-luxury-disease-heck-no/&ei=s7VRU-aGBKqxsQTSvYDYBQ&bvm=bv.65058239,d.aWw&psig=AFQjCNGvBGBCopF2jNAIAi2TtB6EW2k7yQ&ust=1397949914714190

Diagnosis criteria: DSM-51. 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.

2. Intense fear of gaining weight or becoming fat, even though underweight.

3. 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


The Alliance for Eating Disorders

Screening Tools: EDI-3 Eat-26 Can be given by

health Care professionals

Can be accessed online

Can help assess risk Do 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

Vomiting, binging, and exercising


Physical Signs & Symptoms: Weight loss Tiredness Thinning hair Hair loss Dry skin Swelling of arms/legs Lanugo Intolerance to cold


Internal Changes: Body systems are affected

Examples: cardiovascular, neuroendocrine, renal, and gastrointestinal systems Slow heart rate Anemia Stomach gets smaller Constipation Dehydration Amenorrhea Osteoporosis Hypothermia Hypotension


Psychological Signs & Symptoms: Not wanting to eat Fear of weight gain Extreme exercise Depression Preoccupation with food Lying Lack of social interaction


http://www.google.com/imgres?imgurl=http://images.smh.com.au/2013/05/22/4294364/art-anorexia-620x349.jpg&imgrefurl=http://www.smh.com.au/national/health/feeding-the-soul-gives-new-hope-to-anorexics-20130522-2k1ag.html&h=349&w=620&tbnid=5v0--qmXCZd5BM:&zoom=1&docid=M3jLjIOLswLJfM&ei=zMxRU_7aFtSryATLiIHAAg&tbm=isch&client=firefox-a&ved=0CMIBEDMoUDBQ&iact=rc&uact=3&dur=722&page=3&start=51&ndsp=32

Tests/Labs: Height, weight,

BMI Look at

Heart Liver Kidneys Bones Thyroid Etc.

Tests/Labs: CBC Electrolytes Total protein Minerals H/H Glucose B12 Etc.


Examples of Abnormalities: Abnormal lipoprotein profile Low zinc Low vitamin B-12 Alkalosis Low chloride and potassium Elevated bicarbonate Hypomagnesmia Hypophosphatemia Lymphocytosis Low resting metabolic rate Mitral valve prolapse


Treatment: Requires a team

Physician, Psychologist/Psychiatrist, RD Not all treatment plans are the same

Everyone needs a treatment plan specific to them

Inpatient, outpatient, both


Treatment: Psychological One-on-one Group Family

Discover underlying issues

Treatment: Psychological Different types of

therapy CBT IPT SSCM Research?


Treatment: Pharmacotherapy Not to treat AN specifically

Used to treat underlying issues Antidepressants, antipsychotics

Olanzapine, Fluoxetine, Prozac, Risperidone Research?

Can drugs help improve weight gain?


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”


MNT: RDs Role Assess the patient Determine nutrition risks Define nutrition diagnosis Identify nutrition intervention Write nutrition prescription Define nutritional goals


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 patient Current dietary intake Present eating patterns History related to foods Nutrient deficiencies Supplement use Risk of refeeding syndrome


Treatment: Current Guidelines Intake

recommendations Calculating needs Kcal

Starting point Increase by 100-

200kcals Macronutrients

CHO: 50-55% PRO: 15-20% Fat: 25-30%

Micronutrients?

Weight gain Differences

between in and out patient settings

Increase in kcal needs


Treatment: Refeeding Syndrome Refeeding a starved patient

Clinical implications Low Mg, K, P Thiamine deficiency

Must be aware of the affects Must follow protocol to help prevent

refeeding Monitor electrolytes and fluids


Treatment: Nutrition Support Need for nutrition support depends on

needs of the patient PN should only be used when medically

necessary


Basics: Age: 56 Sex: Female Lives at home with her mother and

sister Dates of hospital stay: January 15, 2014-

February 14, 2014 Date transferred to Manor Care:

February 14, 2014

Presentation of C.H.

Hospital Stay: Dx: FTT secondary to malnutrition,

Pancytopenia, Hypothermia related to malnutrition, Bradycardia related to hypothermia, and Hypotension related to dehydration

PMH: Anorexia, Anemia


Hospital Stay: Reason for going to ER: inability to ambulate and

weakness Vital 1.5 3 day calorie count Labs: Labs: BG 49, HGB 3.7, Creatinine 0.67, BUN

60 Per patient:

Reported that weight loss started several months ago

No menstruation anymore No diarrhea, blood in the stool Was on iron pill but stopped taking due to negative

side effects Has struggled with weight since age 11


Manor Care: Admit dx: FTT, (GERD), Refeeding

Syndrome, Pancytopenia, and History of intussusception

Her admission note states she was "in an anorexic and malnourished state"

Admit weight 76.6#, Height 62.0”, BMI 14.0 Stage 3 gluteal wound Left hip wound


Manor Care: No smoking, drinking, drug use history February 18, 2014

AOA involved Mother and sister were not allowed to bring

in food to patient


Manor Care: Plan Physical and occupational therapy Continue current diet, supplements, folic

acid, MVI, zinc, labs as scheduled Follow up with GI at the hospital as

scheduled Wound: local care with santyl, daily

dressing change/pressure relief, nutritional support


Manor Care: Labs from February

21, 2014 Random glucose: 78 BUN: 12 Creat: 0.40 K: 4.2 NA: 136 AST: 21 ALT: 30 Alk phos: 66 Total bilirubin: 0.3


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

Manor Care: Medications Cholecalciferol 2000 unit po daily Heparin 5000 units SQ Folic acid 1mg po daily MVI po daily Protonix 40mg po daily Zinc sulfate 220mg po daily As needed: Miralax, Colace, Tylenol, MOM,

Dulcolax,

Ferrous liquid 220g po daily (added at a later date 3x/week)


Manor Care: On admission was placed on gluten

intolerance diet and enhanced food Prior to RD assessment

Was later changed to a regular diet No history of Celiac Disease


Manor Care: RD Assessment February 19, 2014 Current weight 77.2#, BMI 14.1 Interview

Pt prefers “plain foods” Pt reports allergy to guar gum

Consumption of meals 75-100% Eats meals slowly (1-1.5hours) No diarrhea, constipation, steatorrhea,

communication, dental/oral, or functional problems noted


Manor Care: RD Assessment Calculated needs (with IBW 110#:

35kcal/kg = 1750kcal/day 1.5g/kg pro= 75g/day 30mL/kg fluid= 1500mL/day

Diet order: Regular diet, Supplement TID No longer giving enhanced foods due to

pt liking plain foods Recommendations: weekly CMP, CBC, P,

Mg, LFTs, iron supplement


Manor Care: Weekly weights

2/14/14 76.6 # 2/18/14 77.2 # 2/24/14 77.6 # 3/4/14 82 #


Manor Care: Med Options Assessment Mental 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"


Manor Care: My interaction with C.H Usual intake

3 meals per day (breakfast, lunch, and dinner) as well as snacks in between meals

UBW: 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


Was d/c on March 4, 2014 D/c to home with mother and sister

No further info on AOA Weight at d/c 82#

Update on C.H.

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anorexia nervosa: a case study by: colleen shank sodexo dietetic intern april 30, 2014

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