Anorexia Nervosa in Pediatrics Eva Yuen OHSU Dietetic Intern NUTN 515 April 14th, 2008

Agenda What is Anorexia Nervosa? Treatment Case Study: Q & A First Admission Second Admission Third Admission Q & A

Anorexia Nervosa Eating Disorder Low Body Weight (85% or less of IBW) Refusal to maintain normal body weight Puberty is delayed Denies the dangers of low weight Fear of weight gain Severe body image disturbance Reports feeling fat even when emaciated Excessive dieting, fasting, restricted diet

What is the treatment for anorexia nervosa? Question What is the treatment for anorexia nervosa?

Treatment Medical Monitoring: Psychological Treatment: Nutritional Provider Psychological Treatment: Mental Health Provider Nutritional Rehabilitation: Dietitian

What is the female-to-male ratio in having anorexia nervosa? Question What is the female-to-male ratio in having anorexia nervosa?

Introducing Mr. Kid: Admission Sex: M Age: 15 ½ y.o. Admission Diagnoses: Anorexia nervosa Bradycardia (slow heart rate) Resting heart rate: ~40 bpm (normal: 60-100 bpm) Temperature: 35.6 ۫C

Lab Values Normal Range Admission Na 135-145 mEq/L 139 K 3.5-5.3 mEq/L 4.1 Cl 95-109 mEq/L 104 CO2 content 20-28 mEq/L 29 H Ca 8.6-10.2 mg/dL 9.4 Phosp. 2.7-4.5 mg/dL 3.5 Mg 1.6-2.6 mg/dL 2.5 Gluc. 70-99 mg/dL 66 L PAB 20-40 mg/dL 20 Total, Protein 6.2-8.4 g/dL 6.7 ALB 3.5-5.0 g/dL 4.4 Total, Bilirubin 0.1-1.2 mg/dL 0.9 Alk Phos 120-390 IU/L 68 L AST-(SGOT) 15-41 IU/L 24 BUN 8-20 mg/dL 22 H Creatinine 0.9-1.3 mg/dL 1.1

Diet history (Energy Input) Breakfast: English muffin / Bagel with cream cheese Chocolate milk Lunch: ½ Peanut butter and jelly sandwich Snack: Cereal Dinner: Soup / Spaghetti / Pasta Fruit

Exercise (Energy Output) Walking Hip Hop class Jump rope Skateboard Exercise video tape

Nutrition Assessment Height: 172cm Weight: 45.1 kg (99.5 lbs) IBW: 69 kg (152 lbs) %IBW= 65% BMI: 15.24 (Underweight) Unintentional weight change: ↓ 25 lbs Est. Daily Caloric Needs: 3000 kcal/day Kcal/kg needs: 45 kcal/kg Est. Daily Protein Needs: 45+ g/day Gm/kg needs: 1 g/kg Nutrition Risk Status: High

Nutrition Diagnosis PES Inadequate oral food/beverage intake related to disordered eating pattern as evidenced by significant weight loss in last 3 months.

Eating Disorder Protocol Eating Disorder Diet 3 meals, 3 snacks No non-caloric fluids No fat-free or sugar-free products Maintenance fluids (1cc/kcal minimum) Start kcals at either: Estimated daily intake prior to hospitalization OR 1000 kcals if they were eating less than this ↑ 100-200 kcals/day until consistent weight gain of 0.2 kg/day Plan: 1500 kcal diet + 100 kcal/day 3 meals a day HS snack Calorie counts

Menu Selection Breakfast: Lunch: Dinner: PM Snack: HS Snack: Sausage Patty Granola Applesauce 2% Chocolate Milk Apple Juice Lunch: Fruit & Cottage Cheese Salad Plate Wheat Bagel with Cream Cheese 2% Milk Dinner: Macaroni and Cheese Baby Carrots Peaches PM Snack: Fresh Fruit Cup ½ Peanut Butter Monster Cookie Milkshake HS Snack: Fruit Yogurt Graham Crackers 2% Milk

Short-Term Goals Restoration of a healthful weight Normalization of eating patterns Adequate calorie & protein intake

Calorie Counts Day 1 Day 2 Day 3 Day 4 Day 5 Calories (kcal) 1665 1599 2453 1972 2297 Protein (g) 69 67 96 58 88 Meals 3 Snacks 1 2

Daily Weight Change Weight (kg) Day

Long-Term Goals Self-care management ability Maintain adequate calories intake Maintain/gain weight Increase self-efficacy Positive self-image

Before Discharge Home plan 2500 kcal (3 meals + 2 snacks) Breakfast: 2 oz protein, 3 grains, 2 fruit, 2 fat, 1 cup milk Lunch and Dinner: 3-4 oz protein, 3 grains, 1 vegetable, 2 fruit, 2 fat, 1 cup milk Snack: 1 protein, 1 grain

2nd Admission (2 weeks later) Weight: 43.4 kg (↓ 3.2 kg) Height: 172 cm BMI: 15.8 Temperature: 36.0 ۫C Admitting diagnosis: Anorexia nervosa Severe weight loss Bradycardia Hypothermia

Lab Values Normal Range Admission Na 135-145 mEq/L 136 K 3.5-5.3 mEq/L 4.1 Cl 95-109 mEq/L 105 CO2 content 20-28 mEq/L 23 Ca 8.6-10.2 mg/dL 9.4 Phosp. 2.7-4.5 mg/dL 4.0 Mg 1.6-2.6 mg/dL 2.4 Gluc. 70-99 mg/dL 70 PAB 20-40 mg/dL 20 Total, Protein 6.2-8.4 g/dL 6.5 ALB 3.5-5.0 g/dL 4.4 Total, Bilirubin 0.1-1.2 mg/dL 1.0 Alk Phos 120-390 IU/L 61 L AST-(SGOT) 15-41 IU/L 21 BUN 8-20 mg/dL 25 H Creatinine 0.9-1.3 mg/dL 1.1

Nutrition Diagnosis PES Plan: Inadequate oral food/beverage intake related to disordered eating pattern and food- and nutrition-related knowledge deficit as evidenced by significant weight loss. Plan: 2000 kcal + 100 kcal/day 2500 kcal 3000 kcal 3 meals a day + 2 snacks Calorie counts

Calorie Counts Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Calories (kcal) 2160 2245 2435 2752 2563 2528 2815 2801 2670 Protein (g) 95 75 86 112 120 101 110 92 Meals 3 Snacks 2

Daily Weight Change Weight (kg) Day

Before Discharge Home plan 3000 kcal (3 meals + 2 snacks) Breakfast: 2 oz protein, 3 grains, 2 fruit, 2 fat, 1 cup milk Lunch and Dinner: 3-4 oz protein, 3 grains, 2 fruit, 2 fat, 1 vegetable with added fat, 1 cup milk Snack: 1 protein, 1 grain, 1 fruit

3rd Admission (10 days later) Weight: 43.1 kg (↓ 3.9 kg) Height: 172 cm BMI: 14.6 (Underweight) Temperature: 36.4 ۫C Admitting diagnosis: Anorexia nervosa Severe weight loss Bradycardia Hypothermia

Lab Values Normal Range Admission Na 135-145 mEq/L 136 K 3.5-5.3 mEq/L 3.9 Cl 95-109 mEq/L 104 CO2 content 20-28 mEq/L 25 Ca 8.6-10.2 mg/dL 9.5 Phosp. 2.7-4.5 mg/dL 3.5 Mg 1.6-2.6 mg/dL 2.5 Gluc. 70-99 mg/dL 70 PAB 20-40 mg/dL 21 Total, Protein 6.2-8.4 g/dL 6.8 ALB 3.5-5.0 g/dL 4.5 Total, Bilirubin 0.1-1.2 mg/dL 0.9 Alk Phos 120-390 IU/L 54 L AST-(SGOT) 15-41 IU/L BUN 8-20 mg/dL 25 H Creatinine 0.9-1.3 mg/dL 1.0

Nutrition Assessment Weight: 43.1 kg (↓ 3.9 kg) Height: 172 cm BMI: 14.6 (Underweight) Est. Daily Caloric Needs: 2000-3000 kcal/day Kcal/kg needs: 45+ kcal/kg Est. Daily Protein Needs: 45 g/day Gm/kg needs: 1 g/kg Est. Fluid Needs: 2000 ml/day Nutrition Risk Status: High

Menu Selection Breakfast: Lunch: PM Snack: Dinner: Yogurt Parfaits 2% Milk Orange Juice Lunch: Chicken Caesar with dressing Wheat Roll Margarine Peaches Peanut Butter Milkshake Dinner: Pasta Al Forno Breadstick Steamed Broccoli Chocolate Chip Cookies PM Snack: Fresh Fruit Yogurt Parfait

Am I dealing with disordered eating? Do you spend time wishing parts of your body looked different? Are you unhappy with your reflection in the mirror? Do you skip meals? Do you count the calories or fat grams in anything you eat? Do you exercise so much that you are fatigued? Do you weigh yourself often and find yourself obsessed with the number on the scale? Are you afraid of gaining weight?

References Escott-Stump S, Mahan LK. Krause’s Food, Nutrition, & Diet Therapy. 11th edition. Philadelphia: Elsevier, 2004. ADA. Position of the ADA: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa and other eating disorders. JADA 2006;106(12):2073-2082. Melissa Eckstein-Harmon. Eating disorders: The changing role of nutrition intervention with anorexic and bulimic patients during psychiatric hospitalization. JADA 1993; 93(9):1039-1040 Up To Date. Eating disorders: Treatment and outcome. (2007). http://www.utdol.com/utd/content/topic.do?topicKey=genr_med/9736&view=print Up To Date. Eating disorders: Epidemiology, pathogenesis, and clinical features/ (2007). http://www.utdol.com/utd/content/topic.do?topicKey=genr_med/9522&view=print

Thank You! **Special Thanks to Jessie, Laurel, and June** Questions? Thank You! **Special Thanks to Jessie, Laurel, and June**