Anorexia Nervosa

Page 1

Anorexia Nervosa

Erica Gavey, Dietetic Intern University of Mar yland College Park Children’s National Medical Center Case Study

What is Anorexia? 

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

Physical Signs and Symp toms 

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

Emotional/Behavior al Signs and Symp toms  

     

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

Red Flags 

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

Causes of A .N. 

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

Risk Factors 

Gender

Age

Genetics

Family Hx

Weight Changes

Transitions

Media and society

Sports and other extracurricular activities

Complications of A.N. 

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

Treatment 1.

Getting back to a Healthy Weight

2.

Psychotherapy: individual, family-based, group therapy

3.

Medications: possibly antidepressants

4.

Hospitalizations

Maudsley’s Approach 

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

Case Study

Case Study: L.H. 

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

Case Study: L.H. 

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

Case Study: L.H. ďƒ˜ Growth Charts: Height-for-Age

Case Study: L.H. ďƒ˜ Growth Charts: Weight-for-Age

Case Study: L.H. ďƒ˜ Growth Charts: BMI-for-Age

Case Study: L.H. ďƒ˜ 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

Case Study: L.H.  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)

Case Study: L.H.  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

Case Study: L.H.  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

Case Study: L.H. ďƒ˜ 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

Case Study: L.H. ďƒ˜ Nutrition Goals

1.

Modify Diet

2.

Initiate Enteral Nutrition

3.

Add Oral Supplements

4.

Modify vitamin and mineral intake

Case Study: L.H.  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

Case Study: L.H.  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)

Case Study: L.H. ďƒ˜ 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

Case Study: L.H. ďƒ˜ Recommendations

4. Multivitamin 6. Check Basal Metabolic Panel , Mg and Phos daily 8. Give Neutaphos 10. Regular BM 8. Blind weights Monday and Thursday; goal weight gain 250-300g/day

Case Study: L.H. ďƒ˜ Nutrition Follow-Up: 4/11/2014

Diet Order: -

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)

Case Study: L.H.  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

Case Study: L.H. ďƒ˜ 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

-

No changes to recommendations or PES statement

-

Pt will continue to receive TF at night and will have blind weights on Mondays and Thursdays until d/c

References 1.

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.

2.

Academy of Nutrition and Dietetics. Pediatric Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed April 13, 2014

3.

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

4.

Anorexia nervosa. (2012, January 5). “Definition�. Retrieved April 13, 2014, from http:// www.mayoclinic.org/diseases-conditions/anorexia/basics/definition/con-20033002

5.

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

Thank you!! An y Questions?

Turn static files into dynamic content formats.

Create a flipbook
Issuu converts static files into: digital portfolios, online yearbooks, online catalogs, digital photo albums and more. Sign up and create your flipbook.