MARSIPAN Medical assessment Alastair Forbes Norwich Medical School University of East Anglia

England

Starvation Humans well adapted Intermittent food consumption Continuous energy expenditure

Starvation Stores of Carbohydrate Fat (and protein) Reduced expenditure

Starvation Survival ?

Marasmus vs Kwashiorkor

Starvation Stores of Carbohydrate and fat Calorific value Muscle sparing

Starvation Insulin lower Glucagon & catecholamines higher Glycogenolysis & lipolysis Free fatty acids & ketones

Starvation <72h Energy mainly from glycogenolysis for ~24h at rest Thereafter from gluconeogenesis Brain adapts to ketones Effects on appetite

Starvation >72h No glycogen Glucose from gluconeogenesis Never from free fatty acids Amino acids become glucose source Negative nitrogen balance 200g muscle/day

Starvation >72h Ketones support brain & muscle Some muscle sparing effect

Starvation >72h Change in body composition Classic Keys study % diet for 24 weeks

The Minnesota experiment

Starvation 24 weeks 23% loss of weight 71% loss of fat 24% cell mass loss Basal Metabolic Rate 60% of baseline Various mechanisms

Common Still 30-40% on admission Worsens during admission Malnutrition in hospitals

Several tools What do they do ? Are they feasible in practice ? Are they valuable ? Are they relevant to eating disorders ? Nutrition screening

Albumin and nutritional status Highly relevant to prognosis Many different clinical contexts Unrelated to nutritional status??

Albumin and nutritional status David Blaine 2003 Starved for 44 days – water only

Albumin and nutritional status David Blaine 2003 Starved for 44 days – water only Weight 96.0 to 71.5kg = -25.5%; BMI 28.3 to 18.9 Jackson JM ‘06

Albumin and nutritional status Albumin at 44 days ……

Albumin and nutritional status Albumin at 44 days …… 52.9 !

Special aspects in Eating Disorders (ED) Usually thought of as simple (!) starvation Probably not actually true

Special aspects in ED Usually thought of as simple (!) starvation Probably not actually true Metabolic aspects from pharmacological manipulation – especially laxatives and diuretics Inflammatory aspects from immunosuppression and element of infection

Special aspects in ED Usually thought of as simple (!) starvation Probably not actually true Deception in Anorexia Nervosa (AN) – Water-loading before weighing – Extra weights concealed in clothing

Special aspects in ED Usually thought of as simple (!) starvation Probably not actually true Deception in AN – Water-loading before weighing – Extra weights concealed in clothing Exercise in AN – Overt – Microexercise

Special aspects in ED Bulimia also complex Nutrition risk may be under-recognised

Assessment in ED Simple anthropometry Weight and BMI – challenge/threat Nutrition screening tools – depend on former Do other tests contribute?

Assessment in ED – other tests When BMI >16 no special concerns Similar to other malnourished patients No special tests needed But important to agree assessment strategy

Assessment in ED – other tests When BMI >16 no special concerns Similar to other malnourished patients No special tests needed But important to agree assessment strategy For example – weekly weighing

Assessment in ED – other tests When BMI <16 concerns increase Cardiovascular instability Significant immunosuppression Possibility of added self-induced metabolic upset

Assessment in ED – other tests When BMI <16 - and increasingly critically as it falls lower Must assess cardiac and electrolyte status Postural hypotension (Wikipedia emphasis) Should assess muscle function but often refused Assume high risk if refused

Assessment in ED with BMI <<16 ECG/EKG - and preferably echo Serum electrolytes Magnesium Phosphate Liver function tests Micronutrients (but assume abnormal)

Assessment in ED with BMI <<16 ECG/EKG and preferably echo Bradycardia Long QTc >450ms

Assessment in ED with BMI <<16 Look ! - QTC 477

Assessment in ED with BMI <<16 Long QTc >450ms

Assessment in ED with BMI <<16 Other functional tests Spirometry Stand from crouch Sit Up Squat Stand (SUSS) test

SUSS Scoring (Sit-up and Squat-Stand tests separately) 0: Unable 1: Able only using hands to help 2: Able with noticeable difficulty 3: Able with no difficulty

MARSIPAN Medical treatment in adults

Assessment in ED Simple anthropometry Weight and BMI Nutrition screening tools Laboratory tests Psychological status

“Non-assessment” in ED Emergency admission Unplanned transfer Additional problems

“Non-assessment” in ED Emergency admission Unplanned transfer Additional problems Liaison with EDU and team May need to be initiated – Previously unknown – Deliberate geographical displacement

Planning management in ED Decisions needed on strategy Life-saving Part of continuing care plan Mixture

Planning management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion …

Planning management in ED What will the treatment be ? … Nutrition evidently but …

Planning management in ED “Food is not the issue”

Planning management in ED “Food is not the issue” Multidisciplinary approach crucial Remember “peripheral players”

The hospital cleaner

Planning management in ED What will the treatment be ? Food Oral supplements Tube feed Parenteral feed

Planning management in ED How much ? Enough Harris-Benedict equation (etc) Unreliable when low BMI Indirect calorimetry

Planning management in ED How much ? Enough Harris-Benedict equation (etc) Unreliable when low BMI Indirect calorimetry Calories as basis for other nutrients

Planning management in ED Which constituents ? Complete balanced regimen Obvious – but ….

Planning management in ED Which constituents ? Complete balanced regimen Obvious – but …. Easier to achieve with artificial feed

Planning management in ED Micronutrients Critical and potentially life-saving / losing

Planning management in ED Micronutrients Critical and potentially life-saving / losing Especially thiamine = vitamin B1 Deficiency likely Demands increased Risk of permanent damage

Ophthalmoplegia Thiamine deficiency

Scurvy Vitamin C deficiency

Acrodermatitis enteropathica Zinc deficiency Dermatol On Line

Planning management in ED How quickly ? Difficult decision Practical and influenced by risk of refeeding syndrome Multidisciplinary approach Influenced by severity of starting position

Planning management in ED Which route ? If the gut works use it

Planning management in ED Which route ? If the gut works use it If the mouth works use it

Planning management in ED Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues

Planning management in ED Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues Nasogastric tube feed often needed Gastrostomy very rarely appropriate

Planning management in ED Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues Nasogastric tube feed often needed Gastrostomy very rarely appropriate Parenteral nutrition – “never”

Planning management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion …

Planning management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion …

Active management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion with the patient

Active management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion with the patient Negotiation

Active management in ED Start

Active management in ED Start Careful monitoring Good initial progress

Active management in ED Start Careful monitoring Good initial progress Stop – all sorts of reasons

Active management in ED Start Careful monitoring Good initial progress Stop – all sorts of reasons Renegotiate

Targets in ED management Needed to some extent Always contentious Weight / BMI not ideal

Targets in ED management Needed to some extent Always contentious Weight / BMI not ideal Rule of engagement ! Never punitive

Discharge planning in severe ED Starts at admission Close and frequent liaison with psychological (EDU) team In-patient review

Discharge planning in severe ED Starts at admission Close and frequent liaison with psychological (EDU team In-patient review Often can and should be staged Use of day-care facility In-patient transfer not always needed

Medical withdrawal in ED When will the treatment be stopped ? How much has to be done first ? Which constituents can be omitted ? Micronutrients still important ? How quickly can this happen ? Which route can be avoided ? Discussion with the patient Negotiation

PatientDoctor

Active management in ED This is not an easy area!

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