Anorexia Nervosa: A Case Study

1. Anorexia Nervosa: A Case Study By: Colleen Shank Sodexo Dietetic Intern April 30, 2014

2. Presentation of Anorexia Nervosa • “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)

3. Presentation of Anorexia Nervosa • “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)

4. 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 changes Psychological changes

5. Presentation of Anorexia Nervosa Two types: • Restricting type • Energy intake is restricted • Binge-eating/purge type • Vomiting • Excessive exercising • Both types suffer from fear of gaining weight

6. Presentation of Anorexia Nervosa 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 The Alliance for Eating Disorders

7. Presentation of Anorexia Nervosa 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 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

8. Presentation of Anorexia Nervosa Physical Signs & Symptoms: • Weight loss • Tiredness • Thinning hair • Hair loss • Dry skin • Swelling of arms/legs • Lanugo • Intolerance to cold

9. Presentation of Anorexia Nervosa 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

10. Presentation of Anorexia Nervosa Psychological Signs & Symptoms: • Not wanting to eat • Fear of weight gain • Extreme exercise • Depression • Preoccupation with food • Lying • Lack of social interaction

11. Presentation of Anorexia Nervosa Tests/Labs: • CBC • Electrolytes • Total protein • Minerals • H/H • Glucose • B12 • Etc. Tests/Labs: • Height, weight, BMI • Look at • Heart • Liver • Kidneys • Bones • Thyroid • Etc.

12. Presentation of Anorexia Nervosa 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

13. Presentation of Anorexia Nervosa 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

14. Presentation of Anorexia Nervosa Treatment: Psychological • Different types of therapy • CBT • IPT • SSCM • Research? Treatment: Psychological • One-on-one • Group • Family • Discover underlying issues

15. Presentation of Anorexia Nervosa 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?

16. Presentation of Anorexia Nervosa MNT: AND Position Paper • “Nutrition intervention, includingnutrition 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”

17. Presentation of Anorexia Nervosa MNT: RDs Role • Assess the patient • Determine nutrition risks • Define nutrition diagnosis • Identify nutrition intervention • Write nutrition prescription • Define nutritional goals

18. Presentation of Anorexia Nervosa 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

19. Presentation of Anorexia Nervosa 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

20. Presentation of Anorexia Nervosa 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

21. Presentation of Anorexia Nervosa Treatment: Nutrition Support • Need for nutrition support depends on needs of the patient • PN should only be used when medically necessary

22. Presentation of C.H. 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

23. 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

24. Presentation of C.H. 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

25. Presentation of C.H. 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

26. Presentation of C.H. 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

27. Presentation of C.H. 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

28. 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 Manor Care: • Labs from February 21, 2014 • Random glucose: 78 • BUN: 12 • Creat: 0.40 • K: 4.2 • NA: 136 • AST: 21 • ALT: 30 • Alkphos: 66 • Total bilirubin: 0.3

29. Presentation of C.H. 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)

30. Presentation of C.H. 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

31. Presentation of C.H. 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

32. Presentation of C.H. 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

33. Presentation of C.H. Manor Care: • Weekly weights • 2/14/14 76.6# • 2/18/14 77.2 # • 2/24/14 77.6# • 3/4/14 82 #

34. Presentation of C.H. 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"

35. Presentation of C.H. 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

36. Update on C.H. • 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#

37. 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. APAhttp://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. 

38. 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.

39. YagerJ, 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.

40. 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. • 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. Am J Psychiatry. 2002;159:1347-1353. DOI:10.1176/appi.ajp.159.8.1347. Accessed April 11, 2014.