1. Anorexia Nervosa: A Case Study
By: Colleen Shank
Sodexo Dietetic Intern
April 30, 2014

2. Presentation of Anorexia Nervosa
“Up to 24 million people of all ages and genders suffer from an eating disorder (anorexia, bulimia and binge eating disorder) in the U.S (The Renfrew Center Foundation for Eating Disorders)”
“Only 35% of people that receive treatment for eating disorders get treatment at a specialized facility for eating disorders” (Noordenbox, 2002)
Some statistics to keep in mind throughout the presentation.

3. Presentation of Anorexia Nervosa
“A review of nearly fifty years of research confirms that anorexia nervosa has the highest mortality rate of any psychiatric disorder” (Arcelus, Mitchell, Wales, & Nielsen, 2011)
“20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart problems” (The Renfrew Center Foundation for Eating Disorders)
Surprising to think that it has the highest mortality rate of psych disorders…then again the complications of AN can be deadly

4. Presentation of Anorexia Nervosa
Overview of how one may suffer from AN:
Body image distortion
Restrictive intake and or binging/purging
Excessive exercise
Severe weight loss
Fear of becoming fat
Physiological changes
Psychological changes
Very much a psychological issue

5. Presentation of Anorexia Nervosa
Two types:
Restricting type
Energy intake is restricted
Binge-eating/purge type
Vomiting
Excessive exercising
Both types suffer from fear of gaining weight
Restricting type- restrict food intake. May only allow oneself to have a certain amount of calories per day. Usually very restrictive and may only have a few hundred calories per day.
Binge-eating/purge type- this could be just eating one thing or binging and eating a large amount of food. Afterwards the person wants to get rid of the food so they exercise excessively or purge.

6. Presentation of Anorexia Nervosa
Diagnosis criteria: DSM-5
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
Intense fear of gaining weight or becoming fat, even though underweight.
Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
Changes made:
Criterion A focuses on behaviors, like restricting calorie intake, and no longer includes the word
“refusal” in terms of weight maintenance since that implies intention on the part of the patient and
can be difficult to assess.
Amenorrhea no longer included- some women do have menstrual cycle, men do not, women on birth control.
The Alliance for Eating Disorders

7. Presentation of Anorexia Nervosa
Types of Questions:
Gender, height, weight
How often one feels, experiences, likes, or avoids certain things
Avoiding foods when hungry, feeling guilty after eating, eat diet foods, etc.
How often one partakes in certain behaviors
Vomiting, binging, and exercising
Screening Tools: EDI-3 Eat-26
Can be given by health Care professionals
Can be accessed online
Can help assess risk
Do not diagnose eating disorders
Important to note that these do not diagnose an eating disorder. They are helpful tools for individuals to see if they or someone they know may be suffering from an eating disorder and may prompt them to seek help.

8. Presentation of Anorexia Nervosa
Physical Signs & Symptoms:
Weight loss
Tiredness
Thinning hair
Hair loss
Dry skin
Swelling of arms/legs
Lanugo
Intolerance to cold
Lanugo: tiny hairs to keep the body warm
These symptoms do not just appear overnight, many of these are caused by the internal damage occurring due to AN which I will get into in upcoming slides.

9. Presentation of Anorexia Nervosa
Internal Changes:
Body systems are affected
Examples: cardiovascular, neuroendocrine, renal, and gastrointestinal systems
Slow heart rate
Anemia
Stomach gets smaller
Constipation
Dehydration
Amenorrhea
Osteoporosis
Hypothermia
Hypotension
These internal changes may not be visible but can affect the outer appearance… dry skin, hair loss, fatigue.

10. Presentation of Anorexia Nervosa
Psychological Signs & Symptoms:
Not wanting to eat
Fear of weight gain
Extreme exercise
Depression
Preoccupation with food
Lying
Lack of social interaction
Believing that you do not want to eat.
Extreme exercise- very excessive…
Lying: denial, lying about how much one has eaten.
Lack of social interaction- especially in adolecent years- friends may not understand what is going on… you focus more on food and yourself than friends.

11. Presentation of Anorexia Nervosa
Tests/Labs:
Height, weight, BMI
Look at
Heart
Liver
Kidneys
Bones
Thyroid
Etc.
Tests/Labs:
CBC
Electrolytes
Total protein
Minerals
H/H
Glucose
B12
Etc.
As mentioned before many of the bodies systems are affected and thus the doctors must look carefully at the body to determine the damage done.
As far as the labs- it is important to look as several things- starvation is the main cause for labs to be abnormal. The labs could still be normal depending on how long the person has been suffering.
Starvation, dehydration, vomiting, can all contribute to abnormal lab values.
Mg, Fe, Zn, Ca, P, K

12. Presentation of Anorexia Nervosa
Examples of Abnormalities:
Abnormal lipoprotein profile
Low zinc
Low vitamin B-12
Alkalosis
Low chloride and potassium
Elevated bicarbonate
Hypomagnesmia
Hypophosphatemia
Lymphocytosis
Low resting metabolic rate
Mitral valve prolapse
As far as the labs- it is important to look as several things- starvation is the main cause for labs to be abnormal. The labs could still be normal depending on how long the person has been suffering.
Starvation, dehydration, vomiting, can all contribute to abnormal lab values.

13. Presentation of Anorexia Nervosa
Treatment:
Requires a team
Physician, Psychologist/Psychiatrist, RD
Not all treatment plans are the same
Everyone needs a treatment plan specific to them
Inpatient, outpatient, both
Not all eating disorders are the same…
there are underlying issues that need to be addressed
Those suffering from AN may have different needs in terms of treatment
Availability to treatment is not always there for some patients

14. Presentation of Anorexia Nervosa
Treatment: Psychological
Different types of therapy
CBT
IPT
SSCM
Research?
Treatment: Psychological
One-on-one
Group
Family
Discover underlying issues
Family- Parents and family members are involved- it is about allowing the patient to have control over eating with the help of the family who encourages the patient.
1. Through 2 studies this type of therapy has shown, “approximately two thirds of adolescent AN patients are recovered at the end of FBT while % are fully weight recovered at five-year follow-up.
CBT- cognitive behavior therapy-
1. focuses on examining the relationships between thoughts, feelings and behavior
therapist and the patient will actively work together to help the patient recover from their mental illness
IPT- focuses on interpersonal issues, which are understood to be a factor in the genesis and maintenance of psychological distress
targets of IPT are symptom resolution, improved interpersonal functioning, and increased social support.
SSCM- Specialist supportive clinical management- The primary goals of SSCM are resumption of normal eating and restoration of healthy weight through the development of a supportive and positive relationship with the therapist.
Research:
Although SSCM was associated with a more rapid response than IPT, by follow-up all three treatments were indistinguishable” 16. As can be seen in this study and the study by Schmidt et al. there are a variety of therapies for patients but more research is needed to determine long-term effectiveness of those treatments.

15. Presentation of Anorexia Nervosa
Treatment: Pharmacotherapy
Not to treat AN specifically
Used to treat underlying issues
Antidepressants, antipsychotics
Olanzapine, Fluoxetine, Prozac, Risperidone
Research?
Can drugs help improve weight gain?
Research:
3rd edition of the Guideline Watch: Practice Guideline for the Treatment of Patients with Eating Disorders
They have determined that “limited evidence for the use of medications to restore weight, prevent relapse, or treat chronic anorexia nervosa”
Olanzapine- improve BMI in outpatient treatment of AN ([F(1, 20)=6.64, p=0.018]). However, the number of participants that completed the entire trial was small (17 out of 23 participants)
Risperidone, on the other hand, did not have an effect on weight improvement in a study completed by Hagman et al
Fluoxetine also did not conclude any benefit in regards to weight restoration for AN patients
More research needed.

16. Presentation of Anorexia Nervosa
MNT: AND Position Paper
“Nutrition intervention, including nutrition counseling by a registered dietitian, is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment across the continuum of care”

17. Presentation of Anorexia Nervosa
MNT: RDs Role
Assess the patient
Determine nutrition risks
Define nutrition diagnosis
Identify nutrition intervention
Write nutrition prescription
Define nutritional goals

18. Presentation of Anorexia Nervosa
MNT: RD Assessment
What is important to assess?
Of course the RD will assess physical signs and symptoms but there are other things that should be included in their assessment of the patient
Current dietary intake
Present eating patterns
History related to foods
Nutrient deficiencies
Supplement use
Risk of refeeding syndrome

19. Presentation of Anorexia Nervosa
Treatment: Current Guidelines
Intake recommendations
Calculating needs
Kcal
Starting point
Increase by kcals
Macronutrients
CHO: 50-55%
PRO: 15-20%
Fat: 25-30%
Micronutrients?
Weight gain
Differences between in and out patient settings
Increase in kcal needs
Calculating needs- equations like Mifflin-Jeor may not be accurate
1. Start with 1200 and then inclrease
kcal every few days
Weight gain:
In- 2-3# per week- RD/staff may have more control
Out # per week- RD/staff have less control
To keep wt gain a pt may eventually require >3,000 kcal per day

20. Presentation of Anorexia Nervosa
Treatment: Refeeding Syndrome
Refeeding a starved patient
Clinical implications
Low Mg, K, P
Thiamine deficiency
Must be aware of the affects
Must follow protocol to help prevent refeeding
Monitor electrolytes and fluids
Glucose intolerance and fluid buildup can also occur
Refeeding: See practice paper- Day one start slow 10kcal/kg/day; Day 2-4 increase by 5kcal/kg/day; Day kcal/kg/day; Day 8-10 increase to 30 kcal/kg/day then increase to full needs

21. Presentation of Anorexia Nervosa
Treatment: Nutrition Support
Need for nutrition support depends on needs of the patient
PN should only be used when medically necessary

22. Presentation of C.H. Basics: Age: 56 Sex: Female
Lives at home with her mother and sister
Dates of hospital stay: January 15, 2014-February 14, 2014
Date transferred to Manor Care: February 14, 2014

23. Presentation of C.H. Hospital Stay:
Dx: FTT secondary to malnutrition, Pancytopenia, Hypothermia related to malnutrition, Bradycardia related to hypothermia, and Hypotension related to dehydration
PMH: Anorexia, Anemia

24. Presentation of C.H. Hospital Stay:
Reason for going to ER: inability to ambulate and weakness
Vital 1.5
3 day calorie count
Labs: Labs: BG 49, HGB 3.7, Creatinine 0.67, BUN 60
Per patient:
Reported that weight loss started several months ago
No menstruation anymore
No diarrhea, blood in the stool
Was on iron pill but stopped taking due to negative side effects
Has struggled with weight since age 11
Vital 1.5- no info on length of TF or rate
Kcal count
Wt loss
Weight struggle: mom and pt state anorexia but they believe dx was not correct…

25. Presentation of C.H. Manor Care:
Admit dx: FTT, (GERD), Refeeding Syndrome, Pancytopenia, and History of intussusception
Her admission note states she was "in an anorexic and malnourished state"
Admit weight 76.6#, Height 62.0”, BMI 14.0
Stage 3 gluteal wound
Left hip wound

26. Presentation of C.H. Manor Care:
No smoking, drinking, drug use history
February 18, 2014
AOA involved
Mother and sister were not allowed to bring in food to patient

27. Presentation of C.H. Manor Care: Plan
Physical and occupational therapy
Continue current diet, supplements, folic acid, MVI, zinc, labs as scheduled
Follow up with GI at the hospital as scheduled
Wound: local care with santyl, daily dressing change/pressure relief, nutritional support

28. Presentation of C.H. Manor Care: Ca: 8.9 Labs from February 21, 2014
Random glucose: 78
BUN: 12
Creat: 0.40
K: 4.2
NA: 136
AST: 21
ALT: 30
Alk phos: 66
Total bilirubin: 0.3
Ca: 8.9
Alb: 3.6
Total pro: 6.3
GFR: >60
WBC: 6.6
RBC: 3.96 L
HGB: 9.3 L
HCT: 31.3 L
MCV: 79.1 L
MCH: 23.4 L

29. Presentation of C.H. Manor Care: Medications
Cholecalciferol 2000 unit po daily
Heparin 5000 units SQ
Folic acid 1mg po daily
MVI po daily
Protonix 40mg po daily
Zinc sulfate 220mg po daily
As needed: Miralax, Colace, Tylenol, MOM, Dulcolax,
Ferrous liquid 220g po daily (added at a later date 3x/week)

30. Presentation of C.H. Manor Care:
On admission was placed on gluten intolerance diet and enhanced food
Prior to RD assessment
Was later changed to a regular diet
No history of Celiac Disease

31. Presentation of C.H. Manor Care: RD Assessment February 19, 2014
Current weight 77.2#, BMI 14.1
Interview
Pt prefers “plain foods”
Pt reports allergy to guar gum
Consumption of meals %
Eats meals slowly (1-1.5hours)
No diarrhea, constipation, steatorrhea, communication, dental/oral, or functional problems noted

32. Presentation of C.H. Manor Care: RD Assessment
Calculated needs (with IBW 110#:
35kcal/kg = 1750kcal/day
1.5g/kg pro= 75g/day
30mL/kg fluid= 1500mL/day
Diet order: Regular diet, Supplement TID
No longer giving enhanced foods due to pt liking plain foods
Recommendations: weekly CMP, CBC, P, Mg, LFTs, iron supplement

33. Presentation of C.H. Manor Care: Weekly weights 2/14/14 76.6 #
2/18/ #
2/24/ #
3/4/14 82 #

34. Presentation of C.H. Manor Care: Med Options Assessment
Mental health evaluation (2 visits)
Main issue: AN
Patient has difficulty with mood functioning, behavioral functioning, and lack of insight
"I am not an anorexic"
"I do eat- I like food but I have a difficult time keeping the weight on"

35. Presentation of C.H. Manor Care: My interaction with C.H Usual intake
3 meals per day (breakfast, lunch, and dinner) as well as snacks in between meals
UBW: #
Since she has been sick she reports her weight has been 85-90#
States she does not usually keep track of weight
Reports she could feel she was losing weight when she started getting sick
Reports when she was taking her iron pill that would help her gain weight
For breakfast she would eat things such as cold cereal with whole milk, fruit, eggs, hot cereal, and orange juice. For lunch she would eat foods including grilled cheese, chicken, sou p, whole milk, fruit juice. Dinner consisted of some of a meat, start, and vegetable with whole milk to drink. Snacks included banana, raisins, and cookies. She also reported that she would usually snack at night.

36. Update on C.H. Was d/c on March 4, 2014
D/c to home with mother and sister
No further info on AOA
Weight at d/c 82#

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