Eating disorders

Sheila Turner Sheila retired from her post as Community dietetic lead a year ago and continues to provide and develop a private dietetic service within a residential clinic for women and adolescents.

eAting diSorderS: CASe StUdy

this case study is based on my experiences with several patients, although there was one who features more strongly. Details have been altered to preserve the confidentiality of the patients concerned, as well as giving an authentic overview of the challenges of in-patient treatment for people who are seriously ill with restrictive eating disorders.

Patient: Female, aged 23. Median weight: 63.3 kg with fat 21 per cent or more. Diagnosis: Restricting type of anorexia nervosa of seven years duration. Medication: Mirtazapine, Forceval Liquid, Movicol, ADCal, initially thiamine and strong B for 10 days. Treatments: • Initial 17-day assessment with refeeding, treatment for physical health and key worker sessions. • At day 17 review, decision to add CBT and Body Image Therapy at BMI 15. • Weekly review in multidisciplinary meeting. Family therapy added after four months.

Extracts from Dietetic Reports

March Admission to specialised residential clinic for treatment of eating disorders. Admission was from a community service where there was a diet plan, but she had been able to follow that and most of her admitted intake was salad and some starch. Weight had been managed by restriction of food, physical activity and some purging, although purging was limited by her financial position where she would be unable to afford to waste the food. Laxatives x 2 a week claimed to be for constipation. Some superficial cutting, but not contemplating self-harm at admission. blood sugars low normal and urea high normal, other electrolytes within normal range. big fear food was cheese and “anything greasy”. vegetarian. Although the refeeding risk was limited by her previous intake, it was planned that she would start on quarter portions and no snacks, milk at bedtime. If the refeeding risk had been higher, she would have started on 20 percent of 1,400 kcals, including milk, so would have been offered about the amount she was prepared to eat. 16.3. one meal increased to half, but very little being eaten. 17.3. breakfast and tea now half. Eating a bit better, but refusing anything sweet including jam on toast. 18.3. All meals to half. Accepting all eight drinks.

20.3. beginning sequential increase to full portions under guidance of key nurse. Refusing yoghurt. 1.5. Spends all her time thinking about food and much of contact time arguing against increase or even current amount. Keeps talking about her fear of grease and noncompliance about cheese. Monosyllabic and easily offended. finds it difficult to socialise with other patients 5.6. Managing full diet apart from problems with cheese and compound dishes like lasagne. Still focusing on fat especially in cooked meals. Introduced savoury snacks of 250 to 300 kcals – rather limited without cheese. Still determined to avoid sweet foods because she “does not deserve nice things”. Will sometimes eat yoghurt and banana. To try dried fruits. 15.7. Patient agreed to try mindfulness with a sweet food of her choice along with myself and her support key worker. July Continuing to gain weight on full portions with two savoury snacks. very slow with some non-compliance and some inadequate snacks. As planned, reluctantly tried mindfulness using yoghurt raisins. Achieved four raisins and felt she may have enjoyed them a bit. bMI 13.8 (kg/m2) Weight 35kg (Ht =1.59m) fat 3%

Wt 34.5kg Urea now normal No signs of refeeding syndrome Wt 36.5kg bMI 14.4 (kg/m2) fat 3%

Wt 38.3kg, bMI 15.1 (kg/m2),fat 3.5% Allowed to use stairs and offered five minutes activity a day

Wt 40.3kg bMI 15.9 (kg/m2)

July/Aug Tried mindfulness again with support worker, but very reluctant to try any other foods, aim to try chocolate at some point. bMI over 16 and therefore home leave and short periods of meaningful activity have been introduced. Allowed to go on trips with other patients to do craft or visit cinema etc. Wt 42kg bMI 16.6 (kg/m2) fat 5.9%

Sept Unable to eat either raisins or banana at home in her single flat. Eating too little altogether because she feels she has no money for food. Starting to make plans to re-enter education, but realises she needs to step up recovery to start this year. Initial motivation to change, but problems with finance and continued difficult disordered thoughts gradually wore motivation away again. Unfortunate interactive event with a perceived breach in confidentiality by a support worker led to increased non-compliance. oct-Dec Returned to clinic to complete treatment. Activity and home leave in relation to improvement in weight and psychological health. Discharged before Christmas into care of community team. Still having problems with cheese and sweet foods, but able to manage a diet that is nutritionally adequate and maintains weight. Wt 40kg bMI15.1 (kg/m2) fat 4%

Wt increased to 46kg bMI 18.1(kg/m2) fat 15%

REfLECTIoNS • Treatment for prevention of refeeding syndrome. History given at assessment a few days before admission would have indicated that there would be little risk of refeeding.

However, the value of diet assessment face to face as soon as possible after admission was shown by the reported diet and weight loss for those few days. Although her safety would have been fairly assured because of her lack of ability to eat, this would confirm our policy of offering a quarter portion of the first meals and refeeding protocol vitamins until a clearer picture, including admission blood tests, is obtained. In this case, there was indication of dehydration rather than water loading, so there wasn’t the false higher BMI due to excess water that we often see. Refeeding would be at 20 percent of assumed BMR of 40 cals per kg. If the patient is compliant, this is increased each day so that at five days they will be taking around three half portions of meals and a glass of milk, depending on initial weight. • Allowing changes from set plan for her anorexic problems around sweet foods. It is

hard to say whether she would have managed sweet things better if encouraged more strongly to take them from the beginning. It would have been easy for me to prescribe them in the diet, but her argumentativeness would probably have led to inconsistency in support workers’ enforcing of the menu, which would have made it harder still to get her to a BMI where she was able to engage in therapy. The challenge of cheese and determination to stick with the vegetarianism that developed with her illness, seemed to be the limit of everyone’s negotiations. • Mindfulness. The mindfulness trial seemed to work in that she ate something outside her rigid plan at a time when she would not usually eat. She was able to participate in much the same way as the very heavy people did with whom I have tried this, but her thoughts were of course around eating something and more quickly rather than the contrary. It was good that the support worker managed to repeat the exercise and found that this deflected her from continuing to argue round in circles about her diet plan.

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