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MNT in a Residential Eating Disorder Treatment Facility

MNT in a Residential Eating Disorder Treatment Facility. Aly Brown Sodexo Dietetic Internship July 30, 2013. Purpose. Explore the psychological and physical intricacies of EDs Large part of treatment is nutrition What is the role of the RD?. Agenda. Eating Disorders Classifications

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MNT in a Residential Eating Disorder Treatment Facility

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  1. MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013

  2. Purpose • Explore the psychological and physical intricacies of EDs • Large part of treatment is nutrition • What is the role of the RD?

  3. Agenda • Eating Disorders • Classifications • Causes • Prevalence • Treatment • Recovery • Anorexia Nervosa • Medical Nutrition Therapy • Presentation of Patient • Summary

  4. Background Information • Eating Disorder (ED) Classifications: • Anorexia Nervosa (AN) • Bulimia Nervosa (BN) • Binge-Eating Disorder (BED) • Eating Disorder Not-Otherwise-Specified (EDNOS) • Diagnostic criteria established by American Psychiatric Association (APA); criteria published in Diagnostic and Statistical Manual of Mental Disorders (DSM)

  5. Potential causes • Neurochemical and psychological disorders • Anxiety disorders (most prevalent) • Genetics • Interpersonal • Physical or sexual abuse • Sociocultural • Media, peers

  6. Prevalence ~24 million people 1 in 10 receive treatment Highest mortality rate of any mental illness

  7. Treatment • Hospital, residential treatment facility, or private office • Inpatient • Cornerstone for ED treatment • Outpatient • Medically stable to be discharged from an inpatient setting, yet still requires structure to continue with treatment • DTP, PHP, IOP

  8. Pharmacological Treatment • Fluoxetine (Prozac) used for BN • Only FDA approved medication for treatment of ED • SSRI often used for depression • Not a cure; alleviates some of the symptoms • No pharmacological evidence for AN • Medications only indicated in severe circumstances • Must be used in combination with psychotherapy

  9. Non-Pharmacological Treatment • Psychotherapy • Family-based treatment (FBT) • Cognitive behavior therapy (CBT)/ Behavior Therapy (BT) • Dialectical behavior therapy (DBT) • Medical • Nutrition • Alternative (Yoga, spirituality, religion)

  10. Recovery • Not instantaneous • Facilitated with long-term treatment • Stages of change:

  11. Anorexia Nervosa • DSM-5 Criteria for Diagnosis: • Not maintaining normal weight for age and height • Intense fear of gaining weight or being overweight • Disturbance in body weight or shape • Denial of the seriousness

  12. Characteristics of AN Perfectionist Meticulous Fear of growing up Dependent Introverted Obsessive-compulsive Trust issues Self denying Socially insecure Overly rigid thinker

  13. Warning Signs • Dramatic weight loss • Preoccupation with weight or food • Refusal to eat certain foods • Excessive exercise • Withdrawal from friends and activities • Development of food rituals

  14. Consequences

  15. Minnesota Starvation Study • Association between psychological disturbances and starvation • Subjects developed AN-like thoughts and behaviors • Psychological disturbances disappeared when re-nourished

  16. Hormonal adaptation in anorexia nervosa. [Reproduced with permission from Jayasinghe et al.: BJOG 115:304–315, 2008 (52).] FLI, Free leptin index; sOB-r soluble leptin receptor; IGFBP1&2, IGF-binding protein 1 and 2. Hormonal adaptation in AN

  17. Medical Nutrition Therapy In a Residential Eating Disorder Treatment Facility

  18. Role of the Registered Dietitian (RD) • Main Goals: • Weight restoration • Determine target weight • Determine energy needs • Customize a healthy eating plan • Correct disordered thoughts about food and eating • Well supported as an essential component of treatment • Collaborate with multi-disciplinary team

  19. Where to start • Take focus away from calorie counting • All nutrition prescriptions are individualized • Educate • Identify possible barriers • Motivational Interviewing • Encourage and applaud minute accomplishments

  20. Nutrition Screening • Clinical indicators for ED risk • Unintentional weight loss • ≥5% in one month • ≥10% in 1-6 months • Unintentional weight change ≥ 10% in the past 3 months • Decreased appetite • < Half usual food intake in past 7 days • Mini Nutritional Assessment to assess for malnutrition

  21. AssessmentPatient History • Reason for seeking care • Medications • Supplement or vitamins • Menstrual history • ED related treatment history • Chronic disease states • Family health history • Oral health history, • Psychiatric history • Socioeconomic status • Living situation • Social and medical support • History of recent crisis • Activity level • Meal preparation. • Religious or cultural dietary practices • Alcohol or drug use/abuse

  22. AssessmentFood and Nutrition-Related History • Food habits (rituals, preoccupations) • Eating patterns • Restrictions and “fear foods” • Preferences • Intolerances/allergies • Obtained by: • 24-hour recall, food frequencies, or food records

  23. AssessmentLaboratory Data and Procedures Mandatory: • Electrolytes • EKG • Complete blood count with differential • Blood urea nitrogen (BUN) and creatinine • Blood glucose • Calcium • Liver function tests . Optional • Cholesterol • Thyroid function tests • Chest or abdominal X-rays • Electromyography (EMG) • Examination of muscle enzymes (CPK) • Computed tomography (CT) • GI endoscopy • Magnetic resonance imaging (MRI) scans of the head • Body Composition

  24. Nutrition-Focused Physical Assessment

  25. Anthropometric Data • Weight • Height • BMI

  26. Diagnosis • Sample PES statement • Inadequate oral intake related to limited food acceptance due to psychological issues as evidenced by weight less than 75% ideal body weight and food recall consumption meeting less than 25% calorie needs • Diagnosis may be hard to accept for many patients

  27. Intervention • Should target the problem decided upon from diagnosis • Nutritional intervention should be timely and appropriate • Immediate interventions: • Determining target weight • Developing nutrition prescription

  28. InterventionDetermining Target Weight • Adolescents • CDC growth curve charts • BMI • McLaren method • Moore method • Use previous height/weight percentiles • IBW calculation • Resumption of menses • Highest pre-ED weight Weight goal for adolescents is often a moving target!

  29. InterventionNutrition Prescription • Calories: • REE x AF (1.2-2.0) • 40-50 calories per kilogram + 500 calories for anabolic energy needs • Begin with: • 600-1,000 calories per day • Advance by: • 300-400 calories every three to four days • May need up to 4,000-5,000 calories per day

  30. Nutrition PrescriptionMacronutrients • Protein: • 15-20% total daily caloric intake • Carbohydrate: • 50-60% • Fat: • 30%

  31. Nutrition PrescriptionWeight & Fluid • 2-3 pounds weight gain per week • Fluid: • 30-40 mL per kilogram per day • Measure fluid intake and output • Monitor weights for fluid retention or “water loading” • EN or PN • Most severe circumstances

  32. Sample Meal Plans *Fluid: ≥8 cups per day

  33. Other Nutritional Issues • Constipation • Avoid bulky foods, increase fiber, and maintain adequate hydration • Low bone density/osteopenia/osteoporosis • Calcium: 1,000-1,500 mg per day • Vitamin D: 600-1,000 IU • Weight gain

  34. General Meal Guidelines • Earn privilege to choose food • Cannot bring anything that could be used to hide food • Prohibited behaviors include: overuse of condiments, using the restroom during meals, using food rituals • Fill out a food diary of their meals along with portion sizes and exchanges • Write how they are feeling before or after each meal

  35. Monitoring and Evaluation • Refeeding syndrome • Monitor associated labs for appropriate amount of time • Daily or every other day for the first 7-10 days, then biweekly • Be aware of symptoms such as altered mental status • Weight/Growth chart trends • Food intake- meet 100% estimated needs

  36. Presentation of G.V. Anorexia Nervosa

  37. Presentation of G.V.Social history • 15-year-old white female • Home-schooled • Lives at home with parents and 6 siblings • Does not feel sense of autonomy • No structure to meals • Poor relationship with father and older sister

  38. ED Onset & Diagnosis • Onset: 11 years old • Started with older sister wanting GV to diet with her • GV: “I couldn’t diet as good as her”  began restricting and exercising • 3 hours a day of exercising + 400-1,000 calories per day • Diagnosis: Anorexia Nervosa (Age 12) • Also diagnosed with Obsessive-Compulsive Disorder • Height: 57.5”

  39. The Renfrew Center 5.29.2013

  40. Admitting Diagnoses • AN • OCD • Malnutrition • Dental enamel erosion • Osteopenia • Orthostatic • Bradycardic

  41. Day OneAssessment • 57.5” • 85.5 pounds (90% goal) • Goal weight = 95 pounds • BMI: 18.2 • Lost 6.5 pounds in 6 months • Abnormal Labs: Chol 223 H, AST 34 H, ALT 27 H, T4 0.7 L Calorie needs: 2,000-2,300 kcals per day (40-47 kcals/weight in kg + 500 kcals anabolic energy needs) Fluid needs: ~1,560 mL per day (weight in kg x 40 mL) Protein needs: 54-62 g per day (1.4-1.6 g/kg)

  42. Day OneDiagnosis Inadequate energy intake (NI-1.2) related to anorexia nervosa as evidenced by estimated energy intake meeting only 25-43% of estimated calorie needs

  43. Day OneIntervention • Start at “Meal Plan A” – 1,700 calories • Increase to “Meal Plan B” in 5 days – 2,000 calorie • Goals: • 48 ounces of Gatorade daily until blood pressure within normal range • Complete 100% of meals for six consecutive days • Weight gain of 1-2 pounds per week

  44. Day OneMonitoring & Evaluation Monitor weight, labs, eating patterns, meal intake, and behavioral symptoms

  45. Day FiveAssessment • 85.9 pounds (+0.4 pounds since admission) • “Meal Plan B” = 2,000 calories • Restricted food Day Two; 100% meal compliance since • Caught exercising Day Two • Abnormal labs: BUN/Cr ratio 33 H, BUN 21 H

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