Erica Gavey, Dietetic Intern University of Maryland College Park Children’s National Medical Center Case Study April 17, 2014
Eating disorder that causes people to obsess about their weight and the food they eat
Attempt to maintain a weight that's far below normal for their age and height
May starve themselves or exercise excessively
Thinness = self-worth
Severely restricting the amount of food they eat
Extreme weight loss Thin appearance Abnormal blood counts Fatigue Insomnia Dizziness or fainting A bluish discoloration of the fingers Hair that thins, breaks or falls out Absence of menstruation Constipation Dry skin Intolerance of cold Irregular heart rhythms Low blood pressure Dehydration
Irritability Refusal to eat Denial of hunger Depressed mood Social withdrawal Excessive exercise Afraid of gaining weight Reduced interest in sex Preoccupation with food Flat mood (lack of emotion) Lying about how much food has been eaten Possible use of laxatives, diet aids or herbal products
Skipping meals Making excuses for not eating Eating only a few certain "safe" foods, usually those low in fat and calories Adopting rigid meal or eating rituals, such as cutting food into tiny pieces or spitting food out after chewing Cooking elaborate meals for others but refusing to eat Repeated weighing of themselves Frequent checking in the mirror for perceived flaws Complaining about being fat Not wanting to eat in public
Unknown Biological Genetic tendency towards “perfectionism, sensitivity and perseverance” Predisposition of depression; low serotonin levels
Psychological OCD qualities
Extreme perfectionism; they will never be thin enough Vulnerability
Environmental Cultures emphasis on thinness
Success and self worth= thinness Celebrities and models with “perfect bodies” Peer pressure
Gender Age Genetics Family Hx Weight Changes Transitions Media and society Sports and other extracurricular activities
Death Anemia Heart problems, such as mitral valve prolapse, abnormal heart rhythms and heart failure Bone loss, increasing risk of fractures later in life In females, absence of a period In males, decreased testosterone Gastrointestinal problems, such as constipation, bloating or nausea Electrolyte abnormalities, such as low blood potassium, sodium and chloride Kidney problems
1.
Getting back to a Healthy Weight
2.
Psychotherapy: individual, family-based, group therapy
3.
Medications: possibly antidepressants
4.
Hospitalizations
Family-based Treatment of Adolescent Anorexia Nervosa
Phase 1: Weight Restoration
Phase 2: Returning Control Over Eating to the Adolescent
Phase 3: Establish Healthy Adolescent Identity
16 ½ y.o female with bradycardia secondary to anorexia nervosa
Previous Admission: 3/11/2014 for weight-loss
Family Hx: mental health issues; mom currently has altered mental state and grandmother passed away of dementia
Social Hx: Lives with aunt, grandfather, sister, and mom is in and out of picture; recent of death of grandma.
NKFA
3/11/2014 Height: 164 cm; 50-75th%ile Weight: 45 kg; 5-10th%ile BMI:16.94; <5th%ile
4/08/2014 Height: 165 cm; 50-75th%ile
Weight: 42.2 kg; <5th%ile BMI: 15.5; <5th%ile
Ideal Body Weight 56.1 kg; IBW based on BMI at 50th%ile
ď&#x192;&#x2DC; Growth Charts: Height-for-Age
ď&#x192;&#x2DC; Growth Charts: Weight-for-Age
ď&#x192;&#x2DC; Growth Charts: BMI-for-Age
ď&#x192;&#x2DC; Medications
Medication
Reason Given
Amount Given
Multivitamin
Nutrition Supplement
1 tab daily
Polyethylene Glycol 3350
Laxative
17 gm, BID
Potassium PhosphateSodium Phosphate
Refeeding Syndrome
1 packet, TID
Lab Values Lab
Normal Range
4/9/2014
4/11/2014
Sodium
133 – 143 mmol/L
134
140
Potassium
3.3 – 4.7 mmol/L
4.0
4.2
Chloride
97 – 107
104
105
CO2
16 – 25
28 (H)
27 (H)
Blood Glucose
65 – 115
65
65
BUN
7 – 21
30 (H)
21
Creatinine
0.5 – 1.1
1.1
0.8
Calcium
9.3 – 10.7
8.2 (L)
8.4 (L)
Albumin
3.8 – 5.6
N/A
N/A
Phosphorous
3.1 – 5.5
2.7 (L)
2.5 (L)
Magnesium
1.6 – 2.5
2.0 (L)
2.0 (L)
Estimated Energy Needs
Estimated Fluids/Day 1,944 mL/day (46.07 mL/Kg/day ) Fluids per Holliday-Segar Estimated Calories/Day 2,785.2 Kcal/day (66 Kcal/Kg/day) Estimated Protein/Day 71.74 gm/day (1.7 gm/kg/day) Calories and protein based on DRI x 1.5 for IBW; increased nutrient needs related to nutrition rehabilitation
Nutrition Assessment: 4/9/2014
Pt stated: - “following” 1800kcal/day diet PTA - prepared own food, only wanted to eat healthy foods - “surprised” to have lost weight; says she feels better since last visit - feels less guilty when it is a plate of healthy food - remains physically active
ď&#x192;&#x2DC; Nutrition Diagnosis
Increased nutrient needs related to nutrition rehabilitation and malnutrition as evidenced by 100 gram weight loss/day over past 28 days, BMI <2nd%ile; dropped 1%ile over past month
ď&#x192;&#x2DC; Nutrition Goals 1. 2. 3. 4.
Modify Diet Initiate Enteral Nutrition Add Oral Supplements Modify vitamin and mineral intake
Nutrition Intervention:
Dislikes: No Pork, No Red Meat, No White Bread
4/9/2014: Started on a 1200 kcal diet (Standard Menu); 3-400kcal meals/day Diet was transitioned to 1800kcal/day PO diet (3-400 kcal meals/day and 2- 300kcal snacks/day) Nutren 1.5 @ 40mL/hr; advance by 20ml q 4 for 8 hours until goal rate of 100mL/hr is reached (by 3rd day) Nightly TF: 10pm-6am This provides: 1200kcal/night
If pt doesn’t consume meal; Boost is supplemented
Nutrition Intervention: 4/10/2014: Diet advanced to 2100 kcal/day PO diet (3-600kcal meals/day, 1-300kcal snack/day) - Nutren 1.5 at goal rate of 100mL/hr
4/11/2014: Diet advanced to 2400 kcal/day PO diet (3-600kcal meals/day, 2-300kcal snacks/day)
4/12/2014- 4/14/2014: Saturday:
Diet advances to 2700 kcal/day PO diet ( 3-700kcal meals/day, 2-300 kcal snacks/day) Sunday and Monday:
Diet advanced to 3000 kcal/day PO diet (3-750kcal meals/day, 2- 350-400 kcal snacks/day)
ď&#x192;&#x2DC; Recommendations
1. Continue eating disorder diet: 1200 kcal/day: 400 kcal/meal x 3; advance when appropriate 2. Continue oral nutrition supplements, PRN 3. Continue overnight enteral nutrition support via NG tube
ď&#x192;&#x2DC; Recommendations
4. Multivitamin 5. Check Basal Metabolic Panel , Mg and Phos daily 6. Give Neutaphos 7. Regular BM 8. Blind weights Monday and Thursday; goal weight gain 250-300g/day
Nutrition Follow-Up: 4/11/2014 Diet Order: ď&#x192;&#x2DC;
PO: 2400kcal/day: 600kcal/meal x 3 + 300kcal/snack x 2 - Oral nutrition supplements: Boost as uneaten meal calorie replacement - Nutren 1.5 at 100mL/hr x 8 hours; this provides 19mL/kg/day, 29kcal/kg/day, and 1.2 g protein/kg/day - This provides: 87kcal/kg/day (3600 kcal/day) -
Nutrition Follow-Up: 4/11/2014 Weight : -
4/10/2014: New weight: 41.4kg down 0.8 kg since admission, averaging ~400 grams per day
I/O’s: -
-
1 BM on 4/9 and 3 BM on 4/10 4/8--4/9/14: I: 877mL, O: 1060mL 4/9--4/10/14: I:1500mL, O:3100mL 4/10--4/11/14: I: 1940 mL, O: 2910mL
ď&#x192;&#x2DC; Plan of Care -
Next f/u with R.D. will be on 4/15, if pt continues to tolerate PO diet and regains wt; pt will be transferred to another facility
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No changes to recommendations or PES statement
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Pt will continue to receive TF at night and will have blind weights on Mondays and Thursdays until d/c
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Walsh BT, et al. Eating disorders. In: Longo DL, et al. Harrison's Online. 18th ed. New York, N.Y.: The McGraw-Hill Companies; 2013. http://www.accessmedicine.com/content.aspx?aID=9100636. Accessed Apr. 12, 2014. Academy of Nutrition and Dietetics. Pediatric Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed April 13, 2014 Ranzenhofer LM, et al. Eating disorders. In: South-Paul JE, et al. Current Diagnosis & Treatment in Family Medicine. 3rd ed. New York, N.Y.: The McGraw-Hill Companies; 2011. http://www.accessmedicine.com/content.aspx?aID=8150394. Accessed April 14, 2014 Anorexia nervosa. (2012, January 5). â&#x20AC;&#x153;Definitionâ&#x20AC;?. Retrieved April 13, 2014, from http://www.mayoclinic.org/diseases-conditions/anorexia/basics/definition/con20033002 Grang, D. L., & Lock, J. (n.d.). Maudsley Parents. - family-based treatment for eating disorders, anorexia nervosa, and bulimia nervosa. Retrieved April 14, 2014, from http://www.maudsleyparents.org/whatismaudsley.html