MNT in a Residential Eating Disorder Treatment Facility

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

21. 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

22. 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

23. 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

24. 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

25. Nutrition-Focused Physical Assessment

26. Anthropometric Data • Weight • Height • BMI

27. 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

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

29. 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!

30. 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

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

32. 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

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

34. 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

35. 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

36. 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

37. Presentation of G.V. Anorexia Nervosa

38. 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

39. 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”

43. The Renfrew Center 5.29.2013

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

46. 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)

47. 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

48. 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

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

50. 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