Mini Case Study:Anorexia Nervosa

Wendy AndersonDecember 3, 2012

Anorexia Nervosa• Chronic disorder in eating behavior, body perception, and weight

loss that is an outcome of disturbances in the multifaceted interrelationships between biological, psychological, and social development

• Weight loss not related to any medical or physical illness nor the result/side effect of any medications

• Root of food restriction to the point of starvation is an abnormally low self-esteem coupled with a variety of possible psychiatric and/or psychosocial issues

Nutrition Intervention

• It is the position of the Academy of Nutrition and Dietetics that 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.

• Ozier, Amy D; Beverly W. “Position of the Academy of Nutrition and Dietetics: Nutrition Intervention in the Treatment of Eating Disorders.” Journal of the Academy of Nutrition and Dietetics 111.8 (2011): 1236-1241.

Goals of Nutrition Therapy• Assist in medical stabilization• Weight stabilization• Aid in symptom management• “Normalized” eating

Types of Anorexia• Restricting Type:• The patient does not engage in binge eating or purge behaviors

• Binge-eating/purging• The patient regularly engages in binge eating or purging behavior

Anorexia Nervosa Diagnosis• 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, restricting

Medical Complications• Amenorrhea• Estrogen deficiency• Electrolyte imbalances• Osteoporosis• Abnormal thermoregulation• Anemia, dehydration• RBC dysfunction• Encephalopathy• Disruption in renal and gastric functioning• Cardiac abnormalities• Anxiety, Depression

Physical Observations/ Nutritional Assessment• Low body weight: 85% recommended BW• Lanugo and brittle hair• Cyanosis of hands and feet• Dry skin• Bradycardia and Hypotension• EKG abnormalities• Mitral valve prolapse• Orthostatic hypotension• Decreased GI motility (constipation; laxative abuse)• Depression• Scars or bruises on fingers that indicate purging

Not just about being THIN…

General Information• KS is a 15yo Caucasian Female admitted 10/31/12• Chief Complaint: “I am losing weight.”• Height: 4’ 11” (149.9 cm)• Weight upon admission (10/31/12): 80.2 lbs. (36.38 kg)• UBW: 105 lbs.• % UBW: 76%• BMI: 16.2 (Underweight)• Menarch at age 10• Fallopian tube cyst (2/2010)• Frequently experiences headaches

Social/Personal Data• KS has a twin sister and 3 older sisters• She lives with her parents and twin sister• Twin sister has h/o ED behaviors• Tenth grader (good student)• Denies experimentation with tobacco,

alcohol, & illicits• Hobbies: Photography and Family

Hospital Course• KS seen as outpatient at JHH: Plan to consume 3,000

calorie diet• Weight loss continued; pt admitted 10/31• KM diagnosed w/ Anorexia Nervosa (Restricting Type)• Eating Disorder > 14 protocol, started on 1500 calorie diet• Inpatient individual and group therapy, occupational therapy,

social work support• KS’s Growth Chart: She was below the 25th % percentile prior

to the onset of anorexia• 25th percentile based on age as

goal weight • GWR: 106-110 lbs

Why start at 1500 kcals???• Refeeding Syndrome

• Initial stage of refeeding may cause: - Hypophosphatemia - Hypokalemia - Hypomagnesemia - Vitamin (eg, thiamine) and trace mineral deficiencies - Volume Overload and Edema

** Pts weighing < 70% of IBW require hospitalization for initial stage of nutritional replenishment

Weight Progression• October 31st – November 6th : 80.2 85.4 lbs. (+5.2 lbs. for

week)• November 7th – 13th : 85.7 93.3 lbs. (+ 7.6 lbs. for week; 3500 kcals)• November 14th – 20th : 93.4 97.2 lbs. (+3.8 lbs. for week)• November 21st – 27th: 97.6 101.5 lbs. (+ 3.9 lbs. for week; 3500

kcals)• November 28th – 30th: 101.5 101.1 lbs. (-.4 lb.)• Net Gain: 20.9 lbs. in one month • GWR: 106 – 110 lbs.

Common Nutrition Diagnoses/PES Statement• Inadequate oral intake (NI-2.1)• Inadequate fluid intake (NI 3.1)• Malnutrition (NI-5.2)• Disordered eating pattern (NB-1.5)

• PES StatementInadequate energy intake (NI 1.4) related to intentional weight loss for “bikini season” as evidenced by 25 lb. weight loss.

Program Guidelines• Pt not told GWR until have reached middle of GWR• Pt does not see weights unless at mid GWR• While on weight gain, no exercising outside of walks; started

at day 3• 3 meals/day• No food dislikes allowed• Start selecting menu items and portions (exchanges) at 3500

calories after instruction by RD.• Pt loses selection privileges if repeatedly choosing only low

calorie items despite the need to choose “risky” foods.

KS’s Caloric Advancement• BMI: 16.2• 1500 calories, low salt• Completed meals and no edema 2000 calories on day 3• Completed meals and no edema 2500 calories on day 5• Completed meals and no edema 3000 calories on day 7• Completed meals and no edema 3500 calories on day 9

• If KS not finishing meals on time, vomiting, w/ edema or gaining over 3.5 lbs./week, advance every 72 hrs.

• Middle GWR reached calories lowered by 500 every other day

Medications• MVI: 1 Tablet PO daily routine • Psyllium Enteral: 2 wafer PO Bid (laxative)• Simethicone Enteral: 80 mg PO Bid (reduces bloating and pain

caused by gas)• Docusate Enteral: 200 mg BID (stool softener)

Common Abnormal Lab Values• Elevated cholesterol and/or nml-high LDL levels• Low zinc and Vitamin B-12• Alkalosis• Low chloride, potassium and sodium• Hypomagnesia and Hypophosphatemia• Leukopenia (Decreased WBC)• Thrombocytopenia (Decreased Platelets)• Low Glucose• Increased Alkaline Phosphatase and Aspartate

Aminotransferase• Serum albumin may be masked by dehydration, usually wnl

Patient Rounds• November 14th :

Psychiatrist: “ How are you doing today?”

KS: “ I am feeling better about my body, and I want to have my normal body again. I don’t want to feel that I

am getting so fat…this is very hard.”

Psychiatrist: “It would be helpful to turn it to more positive talk. You are doing great. You are gaining the appropriate amount of weight,

participating in group…we are proud of you.”

Nutritional Education• Family meeting on 11/14 • Met with mother, KS and her twin sister• 60 minute meeting• Portions (caloric exchange pattern) explained for KS’s current

diet prescription (3500 calories)• 3 regular meals daily following exchanges• Avoidance of diet foods• KS was quiet and slightly withdrawn. Told in

rounds she would not be able to go home for Thanksgiving

• Twin sister very involved in meeting• Mother concerned about following protocol at

home

Specific Goals : Anorexia• Increase overall intake• Weight- gain or preventing further loss• Meal guidelines• Incorporate fear foods• Improve recognition of physical cues• Decrease measuring, calorie counting• Education• Medical complications• Address distortions about food and eating

Final Nutritional Assessment• Ht: 4’ 11”• Wt: 101.1 lbs. (November 30th)• BMI: 20.4 • UBW: 105 lbs.• % UBW: 96%

• Pt is currently on 3500 calories• Bone scan indicates no evidence of osteopenia (low bone

mineral density) or osteoporosis

Conclusions• KS is stepping down to Day Hospital today• KS is very excited• KS’s concern: Her twin sister will be a “trigger” for her upon

eventual d/c and return to home• Plan to speak with family and request twin sister enter

treatment• Pt told: She is her OWN PERSON, and to to do what she is

supposed to do to stay healthy.

Questions?

References• Academy of Nutrition and Dietetics. Anorexia Nervosa. Nutrition

Care Manual. http://nutritioncaremanual.org• Mahan LK, Escott-Stump S, and Raymond JL. Krause’s Food and the

Nutrition Care Process. St. Louis, MO: Elsevier, 2012.• The Johns Hopkins Hospital Treatment Protocol: Eating Disorders

Inpatient Service and Day Hospital• Ozier, Amy D; Beverly W. “Position of the Academy of Nutrition and

Dietetics: Nutrition Intervention in the Treatment of Eating Disorders.” Journal of the Academy of Nutrition and Dietetics 111.8 (2011): 1236-1241.