Jennifer JoynerCheryl RedGroup 3CS125/25 Good Job!

Nutrition Clinic11/23/11 12:00 p.m.

A: Patient Paris Marshall was brought in to ER after losing consciousness in local gym class. She reports having been hospitalized before due to dehydration. Paris states she experiences a lot of stress at work as an attorney and has a problem dealing with food and eating; she copes by restricting diet, purging, and using laxatives. Pt smokes 1 pack of cigarettes and drinks 1/2 -1 bottle of wine per day. Pt complains of easy bruising/bleeding, gastric pain, and heartburn. She self-reports food intolerances of all meats, dairy, and desserts.

34 yo female Admit Dx: AN with purge tendenciesPt admitted with risk of refeeding syndrome and hepatic and cardiovascular compromises due to several abnormal components of CMP test, dehydration, and bradycardia. Pt shows signs of malnutrition/anemia with mild edema in abdominal area, emaciated appearance, brittle nails, dry tenting skin, and lanugo. Pt also has erosion of dental enamel, tonsillar hypertrophy, and scratches on posterior pharynx.

Ht: 68 in wt: 115 lb BMI: 17.5 (underweight)Current Diet order: none listedBP: 90/60 mm Hg HR: 50 bpm RR: 18 bpmLabs- Pre-alb: 14.5 Na: 148 K: 3.0 Mg: 1.7 LDH: 680 T3: 70 Hgb: 10 WBC: 4.6EER: 2191 kcal for BMI 20 Est PRO: 75 g Pt PO intake from 24-hr diet recall is 184 kcal and 8 g of PRO.Current meds: multivitamin q.d. PO, OTC laxative q.o.d.

Pt Hx: Amenorrhea for 2 yrs; cold in past 2 wksFamily Hx: Father- HTN

D: Disordered eating pattern (NB-1.5) RT Anorexia w/ purging AEB pattern of chronic dieting and purging, misuse of laxatives, excessive alcohol intake, and excessive physical activity.

Altered CMP and CBC laboratory values (NC-2.2) RT dehydration, liver and cardiac compromise AEB increased liver panel, electrolyte imbalance, anemia, and leukopenia.

I: ND-1.2 Modify diet initially with 5-6 small meals containing 1500 kcal/day with 20% PRO, 50% CHO, 30% fat, and 10 g of fiber PO. Pt is at risk for refeeding syndrome, organ failure, and gastroparesis. Recommend a low salt diet and avoid IV fluids to reduce edema. Vegetarian diet is discouraged.

ND- 3.2.1 Vitamin and mineral supplements PO that meets 100% RDA excluding iron during initial phase of weight restoration. E-1.1 Purpose of the nutrition education is to help patient with constipation management, establish and accept a healthy eating pattern with nutrient-dense foods to reach target weight range of 132-135 lbs (20-21 BMI), and understand the negative impacts heavy alcohol consumption and purging/laxatives have on the body and organ systems.RC-1.3 Coordination of care with a psychologist to help pt with stress management and food acceptance issues.

M&E: FH-1.1.1 Monitor Energy/ nutrient intake from all sources, FH-5.2.1 Avoidance of food, FH-5.3.2 Purging behavior, AD- 1.1.2 Wt, BD- 1.2 Electrolyte and renal profile, and BD-1.5.2 Glucose daily.Recommend ECG to monitor heart function in relation to bradycardia and electrolyte fluctuations, and U/S of the liver to assess dysfunction or tissue damage so that diet can be modified if necessary.Evaluate CBC and CMP labs in 3 days. Recommend adjusting EER as medically needed.

SignatureJennifer Joyner Cheryl Red

Questions

1. Describe the diagnostic criteria for AN, BN, and BED. Include types and discuss type you believe Paris presents with. Provide examples to support your rationale.

Anorexia Nervosa DSM IV- Refusal to maintain body weight at or above a minimally normal weight for age and height through weight loss leading to maintenance of body weight less than 85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.- 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.- In post-menarche females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. -Symptoms include: cachectic body appearance, lanugo, cold intolerance, hair and nails that are dry & brittle.Restricting Type: during the current episode of AN, the person has not regularly engaged in binge eating or purging behavior through self-induced vomiting or the misuse of laxatives, diuretics, or enemas.Binge-Eating/Purging Type: during the current episode of AN, the person has regularly engaged in binge eating or purging behavior through self-induced vomiting or the misuse of laxatives, diuretics, or enemas.-Additional symptoms for this type can include scratches on the pharynx and dental enamel erosion.

Bulimia Nervosa DSM IV- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: eating, in a discrete period of time (within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances, and a sense of lack of control over eating during the episode (feeling that one cannot stop eating or control what or how much one is eating).- Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.- The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.- Self-evaluation is unduly influenced by body shape and weight.- The disturbance does not occur exclusively during episodes of AN.-Symptoms can include: Russell sign (scarring of dorsum of hand from stimulating the gag reflex in purging type), enlargement of the parotid gland, and dental enamel erosionPurging Type: during the current episode of BN, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemasNon-purging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Binge Eating Disorder DSM IV- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: eating, in a discrete period of time (within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances by feeling that one cannot stop eating or control what or how much one is eating. - The binge-eating episodes are associated with three (or more) of the following:

1. eating much more rapidly than normal 2. eating until feeling uncomfortably full 3. eating large amounts of food when not feeling physically hungry 4. eating alone because of being embarrassed by how much one is eating 5. feeling disgusted with oneself, depressed, or very guilty after overeating

- Marked distress regarding binge eating is present. - The binge eating occurs, on average, at least 2 days a week for 6 months.-Symptoms: Due to lack of compensatory behaviors for binge eating episodes, weight and BMI will usually fall in the overweight (or obese) category.

Paris exhibits AN with purging. She has amenorrhea. She weighs 82% of her IBW and has a current BMI of 17.5 (underweight). Paris shows many physical signs like having dry skin with lanugo, brittle nails, emaciated appearance, and mild abdominal edema. Her enlarged parotid glands and dental enamel erosion suggests self-induced vomiting. Her diet recall indicates a very restricted diet. She self-reports food intolerance of meats, dairy, and desserts. She admits she has a hard time coping with stress and finds self-control in restricting her intake. She openly states she uses laxatives every other day. She exercises excessively, too. Her biochemical data shows that she is malnourished and possibly anemic. Her HR, BP, RR, CMP and CBC labs all match up to the complications of anorexia. It is apparent she’s had a chronic pattern of disordered eating.

2. Describe the common psychological, socioeconomic, and environmental characteristics of an individual with AN.

Psychologically those with EDs are perfectionists and compulsive. They have body image distortion, inflexible thinking, overly restrained emotional expression, limited spontaneity, are people pleasers, critical of selves, have poor coping skills, and low self-esteem. They can also have depression, anxiety, and substance abuse problems.Onset is usually in adolescent/ young adult years; later onset is usually the result of an adverse life event. It more commonly occurs with females, and they usually have amenorrhea.ED usually occurs with Caucasian, middle to upper class women. Families of AN individuals tend to hold high expectations, are rigid with rules and standards, have difficulty resolving conflict, and convey high levels of hostility.

3. What does research indicate about the possible role of genetics in ED?

There also seems to be a genetic disposition that puts one at risk to having ED, making AN a heritable personality; there has been a study on twins to validate this suggestion. There was a difference along the genome in single-nucleotide polymorphisms OPRD1, CHD10, and CHD9. Others suggest copy number variants on chromosome 13, 1, or 10 to be a genetic contributing

factor for one’s predisposition to AN. Basically, AN can run in families just like Schizophrenia can.

4. How does BN differ from BED?

They both eat during a discrete period of time and have a lack of control over eating during the binge eating episode, but persons who have BN will purge through use of laxatives, excessive exercise, or self-induced vomiting.

5. What is the long term prognosis for AN, BN, and BED?

2/3 of AN patients will continue to have severe weight preoccupations; 50% will require rehospitalization within 1 year of having inpatient treatment. 30-85% of BN patients will have relapse. Adolescents generally have better outcomes than adults. BED patients have a higher lifetime prevalence of depression, substance abuse, and personality disorders.

6. Describe the medical consequences associated with AN, BN, and BED.

First, they can be life threatening. Eating disorders are devastating disorders that affect the quality and productivity of life, and relationships with others. Prolonged AN causes heart rate and blood pressure changes risking heart failure. It also causes osteoporosis, muscle wasting, dehydration, kidney failure, and hair loss; however, the body will grow lanugo in efforts to stay warm. BN can cause heart failure too because of electrolyte and chemical imbalance from dehydration from purging. There is a potential for gastric and esophageal rupture, tooth decay from stomach acid, chronic bowel irregularities, peptic ulcers, and pancreatitis. AN can cause this too if purging is present. BED can cause high BP, high Cholesterol, high TG levels, type II DM, and gallbladder disease.

7. Define starvation, binge eating, and purging.

Starvation- a state of extreme hunger resulting from lack of essential nutrients needed for the maintenance of life over a prolonged period of time.Binge eating- uncontrolled ingestion of large quantities of food in a discrete interval, often with a sense of lack of control over the activity.Purging- (medical definition) the use of vomiting, diuretics, or laxatives to clear the stomach and intestines after a binge.

8. Describe the metabolic response to voluntary starvation. Compare Paris’s signs and symptoms to the metabolic response to starvation.

Glucose is the main source of fuel for the body. When that is all consumed by the brain, muscles, and RBCs, the liver and muscle start to break down glycogen stores into glucose. This happens when insulin circulation drops and levels of glucagon and epinephrine rise, releasing high levels of glycogen. The liver then sends that glucose to other areas of the body while the muscle uses it for itself. Blood glucose levels rise and stimulates the release of insulin, which allows the tissues to take up the glucose. Glycogen stores can provide glucose for about 6 hrs. After that TG from

adipose tissue are broken down into glycerol and free fatty acids by lipolysis. Fatty acids can be used as a direct source of energy after undergoing beta oxidation for tissues except for the brain. Glycerol can be used by the liver to make glucose and sent to the brain. Fatty acids will be the metabolic fuel for 2-3 days and the brain will continue to use any glucose that still remains. Once that is all exhausted the body uses ketone bodies (which are short derivatives of fatty acids) made through ketogenesis, and these can pass through the blood-brain barrier and fuel the brain; after 2 or 3 days of fasting, the liver starts to synthesize ketone bodies from fatty acid catabolism. By day 4 the brain is using up 70% of the ketones and drops its glucose requirements from 120 g/day to 30 g/day. The liver can use glycerol to make about 20 g of glucose and then the 10 g deficit from the original 30 g starts to come from the body’s own protein such as alanine and lactate. Amino acids soon start to get released into the bloodstream which can be converted into glucose by the liver. This is muscle wasting- the body is now in starvation mode. When fat reserves are completely used up all that is left to use is protein. The body will start to take the protein from functioning organs such as the liver, heart, and kidney for energy and the tissue will lose weight and its ability to function properly. Cardiac arrhythmia or arrest can occur because of tissue degradation and electrolyte imbalances. The subsequent changes in the sympathetic nervous system and metabolism of thyroid hormones lower the body’s BMR. Body temperature also decreases. Even during refeeding the liver can be stuck in gluconeogenesis and ketogenic state, and glucose levels will continue to rise. Insulin levels continue to stay low and glucagon levels are high inhibiting glycolysis. The glucagon/insulin ratio promotes glycogen breakdown. So there is an excess of glucose in the blood and the liver keeps making it. Glucose is excreted in the urine. The lack of insulin leads to the uncontrolled breakdown of lipids and proteins. A large amount of Acetyl-CoA is produced to make ketone bodies. The ketones overwhelm the kidneys, pH levels drop, dehydration occurs, and coma can be the ending result.

In Paris’s situation she exhausted glucose and glycogen stores, and shows signs of being in starvation mode by the wasting of her muscles made apparent by her emaciated appearance. Starvation has caused her to have poor organ functioning. This in turn, could raise glucose levels when refeeding is initiated. Paris has electrolyte imbalance and is dehydrated. Her protein levels are low. Her TG and cholesterol levels are high because the anorexia lowered her thyroid hormone which is responsible in helping to break down lipids. She also has bradycardia. She is in a risky state for cardiac problems, and liver and kidney failure.

9. To be successful, treatment of ED must include a team approach among physicians, RD’s, and psychologists. Describe the role of each in treatment.

The RD does the nutrition intervention, meaning he/she prescribes a diet best suited to their medical diagnosis or which will help improve their health whether it is weight loss, blood glucose control, lowering LDL levels, etc. Basically, they prevent and treat illnesses by promoting healthy eating habits and recommend dietary modifications. The physician treats the medical conditions by promoting, maintaining, or restoring health by diagnosing, obtaining, evaluating lab tests, physical status, and assessing progress. They treat the disease or injury, and can treat with drugs/medications. The psychologist improves and treats mental health; they also help keep the patient from harming his/her self. By utilizing these three professionals, the team can more effectively and efficiently treat a patient; the team approach provides better care to the patient.

10. Why might it be necessary to include a psychiatrist as a member of the treatment team?

The psychiatrist aids the patient for the same reason as the dietitian or physician, to be of assistance to the patient and to treat them and help them improve their health; for the psychiatrist his purpose it to assess, treat, and improve mental health, and he may do so with drug treatment if needed. The patient’s issue or problem can be best addressed from all angles.In Paris’s case, she can get medical treatment by her physician for her liver functioning and have her heart monitored to prevent any organ failure; the dietitian prescribes a diet suitable for her to restore a healthy weight without jeopardizing her organ systems during initial refeeding; the psychiatrist can address the underlying problem for her anorexia which seems to be her poor coping skills to stress and prescribe a drug for anxiety to help her maladaptive behaviors to food. He can also help her face her food issues and help her accept treatment to a healthier weight.

11. Briefly, what are the primary nutrition therapy goals for acute diagnosis of AN? How will these goals change as treatment progresses?

1) Stabilization of medical condition2) Initial weight gain – should be 2 to 3 lbs/week (inpatient) or 0.5 to 1 lb/week (outpatient)3) Monitor for refeeding syndrome, which can lead to serious complications or sudden death4) Controlled weight gain – calories are increased incrementally for controlled weight gain5) Late treatment – calorie requirements should be 70 to 100 kcal/kg/body wt/day. Can range from 3000 to 4500 kcal/day, depending on the patient.6) Have client understand healthy eating patterns and apply them to her behavior

-As treatment progresses, calorie intake will increase significantly.

12. What are the primary nutrition therapy goals for BN?

1) Weight maintenance – the number of calories will depend on whether the patient is hypometabolic and needs fewer calories than the DRI.2) Achieve proper macronutrient distribution (15-20% PRO, 50-55% CHO, 30% fat)3) Normalize eating patterns – aim to eliminate binging and purging episodes early 4) Refrain from weight reduction diets until pt’s wt and eating patterns have normalized

13. What are the primary nutrition therapy goals for BED?

-Patients with BED can be more complicated to treat than those with AN or BN. Weight loss is usually the primary nutrition therapy goal, as well as a restoration of a normal eating pattern. There is some evidence that weight-loss treatments are an effective form of treatment for BED patients. Other evidence indicates that cognitive behavioral therapy and psychotherapy can be more successful than weight loss after two years.

1) Nutritional counseling to educate pt on healthy nutritional habits2) Dietary management to normalize intake and eating patterns3) Weight loss if needed4) Psychotherapy to address and manage underlying issues behind bingeing behavior

14. Describe prevention strategies that could reduce a person’s risk of developing AN, BN, or BED.

Many eating disorders are rooted in childhood or adolescence. Prevention strategies focus on forming healthy body image and food patterns very early in a child’s life. 1) Decrease social pressures – focus on personality instead of weight; teach children early not to worry about weight.2) Decrease family issues – examine cultural and familial attitudes toward weight and appearance; be aware of the influence parental attitudes have on children’s attitudes3) Decrease individual factors – feelings of inadequacy, perfectionism, or other negative beliefs should be addressed with counseling 4) Explore how you look at food – don’t use it as a reward or punishment, don’t categorize foods as inherently “good” or “bad”, and don’t relate behavior to food (being “bad” when you eat too much)

15. What are the typical differences in body weight between someone with AN and someone with BN?

-The AN patient is underweight, usually due to intake of less than 1,000 calories per day. Body weight is less than 85% of the expected or desired body weight.

- BN patients typically fall in the normal weight range, despite episodes of bingeing and purging.

16. Calculate and interpret Paris’s BMI.

-Paris’s BMI is 17.5, which is classified as underweight.

17. What would be an appropriate weight for her in 1 month? In 3 months? In 1 year? Describe the rationale for choosing the weight values you did.

-A weight gain of 2 to 3 lbs/week is the target for Paris:-1 month: 123 lbs (this is based on inpatient weight goals; we anticipate that Paris will be discharged from the hospital during this time, so the weight gain could slow once she is released)

-3 months: 127 lbs (based on 0.5 lb/week gain recommended for controlled weight gain phase)-1 year: 132 lbs or more (this is Paris’s DBW, and should be achievable after one year of treatment)

18. Calculate the outpatient treatment energy requirements for Paris.

-1,569 to 2,092 kcal/day (based on initial treatment phase of 30 to 40 kcal/kg body weight/day)

19. Using her 24 hr recall, calculate this pt’s current energy and protein intake.

184 kcal, 8 g PRO; with a bottle of red table wine 813 kcal and <9 g of PRO.

20. List any nutrition problems within the intake domain using the appropriate diagnostic term.

-Inadequate energy intake (NI-1.4)-Excessive alcohol intake (NI-4.3)-Malnutrition (NI-5.2)

21. Evaluate Paris’s lab results.

She appears to be anemic by her low Hct and Hg values, and raised LDH (hemolytic anemia). Strenuous exercise can raise LDH and CPK values. Dehydration has impaired Paris’s water homeostasis due to the malnutrition/purging from vomiting and laxatives; she shows electrolyte disturbance through raised Na+, and lower K+ and Mg. Low T3, transferrin, total PRO, albumin, and pre-albumin indicate malnutrition.Alcohol can raise LDH ( * pt has normal platelet count), lower Mg+, raise CPK (from withdrawal), and increase bilirubin. The higher end of normal T-cell values possibly indicates tissue (liver) damage. Increased lymphs indicate hepatitis. Leukopenia can be from alcoholic hepatitis and malnutrition. Functional liver problems as in alcoholic hepatitis can raise glucose levels, lower transferrin, lower PRO and albumin levels, increase AST and ALT, and increase bilirubin (Paris is at higher end of normal). AST/ALT values are not 2 or greater.Her ALP is raised which is present in liver disease and is associated with increased bili, AST, and ALT- her ALP then is being released into the bloodstream by the liver.Her TG levels are high and her LDL and Chol are at high end or normal. This can be a result of her malnutrition impairing thyroid functioning to help breakdown lipids through its hormone T3. Possible kidney problems can be indicated form low PRO, high glucose, high AST, and high LDH.*However, since Paris is dehydrated her labs need to be retested, especially her glucose, lipid, and liver panel. It has been determined that Paris is anemic and malnourished. She has leukopenia, decreased thyroid function, and has electrolyte imbalances; she has been in starvation mode for a while. Her high intake of alcohol has possibly resulted in alcoholic

hepatitis. She is at risk for refeeding syndrome and organ problems for the heart, liver, and kidney, which needs to be monitored closely.

22. During nutritional repletion, Paris should be monitored closely for refeeding syndrome. What are the characteristics of refeeding syndrome?

-Refeeding syndrome results from beginning feeding in a patient who is in a starved, catabolic state. Many metabolic events occur, and it’s characterized by the following:

Biochemical Clinical

Hypophosphatemia (resulting in reduced levels of ATP for cells and decreased cellular oxygen transfer)

Congestive heart failure

Hypomagnesmia SeizuresHypokalemia Muscle fatigue of the diaphragm (and

resulting respiratory failure)Glucose intolerance Hypoxia in the tissuesThiamin deficiency Dysfunction of RBCs and WBCs

23. Why was the EKG ordered?

-The patient exhibited bradycardia of 50 bpm, as well as a low BP of 90/60. Her heart and cardiovascular system have been compromised by the malnutrition.

24. Identify a minimum of five questions that the dietitian would ask regarding Paris’s purging behaviors.

1) How often does she purge?2) How soon after eating or drinking does she purge?3) Are there typical events that precede her purging (was she particularly stressed at work, had an argument with a friend, etc.)?4) How often does she use the laxatives?5) How often does she exercise, and at what intensity?

25. Paris asks you for a list of “good” foods to eat and “bad” foods to avoid. What should you tell her?

-I’d explain to her that foods are not inherently “good” or “bad”; all foods can be part of a balanced diet. I would suggest that during her treatment, she focus on energy- and nutrient-dense foods and try to limit foods with little or no nutritional value, like diet sodas.

26. From the information gathered, list possible nutrition problems within the behavioral-environmental domain using the appropriate diagnostic term.

-Food- and nutrition-related knowledge deficit (NB-1.1)-Harmful beliefs/attitudes about food- or nutrition-related topics (NB-1.2)-Disordered eating pattern (NB-1.5)

27. Select two high-priority nutrition problems and complete PES statements for each.

-Disordered eating pattern (NB-1.5) RT anorexia nervosa AEB pattern of chronic dieting and purging, misuse of laxatives, excessive alcohol intake of ½ to 1 bottle of wine daily, and excessive physical activity.

-Excessive physical activity (NB-2.2) RT harmful attitudes regarding body composition and physical activity AEB loss of consciousness during exercise class and high level of physical activity relative to caloric intake

-Inadequate energy intake (NI-1.4) RT calorie intake lower than caloric needs AEB 24-hour dietary recall intake of ~ 184 kcal and pt-reported restriction of food

- Excessive alcohol intake (NI-4.3) RT lack of knowledge of reasonable amounts of alcohol consumption AEB pt-reported consumption of ½ to 1 bottle of wine each day and extremely low kcal consumption

28. For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology).

-Disordered eating pattern (NB-1.5) RT anorexia nervosa AEB pattern of chronic dieting and purging, misuse of laxatives, excessive alcohol intake of ½ to 1 bottle of wine daily, and excessive physical activity.

-Ideal goal: Restore normal eating patterns and food-related behaviors -Intervention: -Nutrition Education – Purpose of the nutrition education (E-1.1) -Collaboration/referral to psychologist (RC-2.1)

-Excessive physical activity (NB-2.2) RT harmful attitudes regarding body composition and physical activity AEB loss of consciousness during exercise class and high level of physical activity relative to caloric intake

-Ideal goal: Restore healthy attitudes about appropriate exercise in relation to caloric intake-Intervention:-Collaboration/referral to psychologist (RC-2.1)

-Inadequate energy intake (NI-1.4) RT calorie intake lower than caloric needs AEB 24-hour dietary recall intake of ~ 184 kcal and pt-reported restriction of food

-Ideal goal: Increase kcal intake to recommended level and maintain weight-Intervention:-Modify distribution, type, or amount of food and nutrients (ND-1.2)- Nutrition Education – Purpose of the nutrition education (E-1.1)

- Excessive alcohol intake (NI-4.3) RT lack of knowledge of reasonable amounts of alcohol consumption AEB pt-reported consumption of ½ to 1 bottle of wine each day and extremely low kcal consumption

-Ideal goal: Have patient refrain from alcohol consumption until eating patterns have normalized and weight restored; then consume alcohol sparingly-Intervention:-Priority modifications (E-1.2) to focus patient on restoring nutritional status and eating patterns before consuming alcohol

29. When should you schedule your next counseling session with Paris?

-I would check in with her in the hospital 2 to 3 days after feeding is initiated, and adjust her intake if needed. The next counseling session should be scheduled within a couple of days after she is discharged from the hospital.

30. What parameters can be used to measure Paris’s response to treatment?

-Anthropometric: weight gain, skinfold assessments-Biochemical: prealbumin, potassium, phosphate, sodium, magnesium, ALP, AST, vitamin and mineral levels not already listed, Hgb, Hct, glucose-Clinical: EKG results, BP, RR, HR, eventual return of menses-Dietary: assess daily kcal intake, variety of foods consumed, eating patterns

31. What would you assess at this follow-up counseling?

-We would monitor the pt’s lab values such as her electrolyte and liver panels, Hct and Hgb levels, results of EKG, weight gain (if any), adequacy of feeding and pt’s tolerance of it (GI

distress, etc.). We would also assess pt’s attitudes toward the changes and general emotional state.

32. What medical conditions warrant residential or inpatient treatment?

-Bradycardia (<40 bpm)-Tachycardia (>110 bpm)-Drop in BP of 20 mmHG-Lack of ability to maintain core body temperature

33. Compare three eating disorder treatment facilities (e.g., discuss treatment options, treatment model, and the facilities’ professional staff).

-Center for Eating Disorders - Alexian Brothers Behavioral Health Hospital – Elk Grove Village, ILhttp://www.alexianbrothershealth.org/services/abbhh/ourservices/eating-disorders/treatment/

-The facility treats all eating disorders. Their model is based on “Self-regulation Theory”, which combines aspects of CBT (Cognitive Behavioral Therapy), DBT (Dialectical Behavioral Therapy), Family Systems Therapy, Motivational Interviewing, and Solution-Focused Therapy.

-They provide treatment options at all levels. This includes inpatient care, a partial hospital day program (which ranges from 6-8 hours per day in the hospital up to 5 days per week), an intensive outpatient day program (which ranges from 2-3 hours per day in the hospital up to 5 days per week), extended care, and individual therapy.

-The approach includes nutritional education and intervention, medication management, weekly support groups, spirituality, and even Tai Chi.

-Treatment team: MDs, RDs, Case Managers (Masters level), RNs, Expressive Therapists, Chaplains, Teachers, School Liaisons

-The facility also coordinates care with other conditions, including self-injury, anxiety, substance abuse, addictions, and school anxiety/refusal.

-Association of Professionals Treating Eating Disorders Clinic (APTED) – San Francisco, CAhttp://www.edrcsv.org/index.php/resources/treatment-professionals/treatment-centers/183-apted.html

-This facility is outpatient only, and will refer patients to higher levels of care.

-The treatment philosophy includes psychodynamic psychotherapy with CBT and DBT where appropriate. Some other types of therapy used include Art Therapy, Couples Therapy, Family Therapy, Group Therapy, Individual Therapy, Support Groups, nutritional counseling, and acupuncture.

-Treatment team: Licensed therapists, nutritionists, RDs, and licensed acupuncturists.

-La Ventana Treatment Programs – San Francisco, CAhttp://www.laventanaed.com/

-Treatment includes an outpatient program called the Partial Hospitalization Program. The facility is located near transitional housing for patients who wish to attend the 6-day per week of PHP. This treatment includes individual, family, and group psychotherapy, nutritional counseling, and a supervised meal and snack program.

-Also available is the Intensive Outpatient Program (IOP), which focuses on developing coping skills to replace eating disorder symptoms. Patients are able to choose between 3-6 days per week of treatment. The same types of treatments are offered as in the PHP. In the group setting, treatment focuses on DBT, CBT, Art Therapy, Interpersonal Process, Body Awareness, and Relapse Prevention.

-Treatment team: Doctorate Level Clinical Psychologists, Masters Level Psychologists, Licensed Marriage & Family Therapists (LMFT), RNs, and RDs.

References

Pritts, S.D. MD & Susman, J. MD. 2003. Diagnosis of eating disorder in primary care. Jan 15:67 (2) 297-304. University of Cincinnati College of Medicine. American Family Physician.

http://www.benthamscience.com/cnf/sample/cnf5-1/D0003NF.pdf

Royal College of Psychiatrists London. Guidelines for the nutritional management of anorexia nervosa. Council Report CR130, July 2005. http://www.rcpsych.ac.uk/files/pdfversion/cr130.pdf

http://intensivecare.hsnet.nsw.gov.au/five/doc/refeeding_syndrome_R_n_rpa.pdf

http://labtestsonline.org/

http://www.nutritionmd.org/health_care_providers/psychiatric/eating_disorders_nutrition.html

Nutrition Intervention in the Treatment of Eating Disorders, American Dietetic Association Practice Paper, Journal of ADA, Aug. 2011.

Prevention of Eating Disorders, National Eating Disorder Information Centre, Toronto, ON.

http://www.pbs.org/perfectillusions/eatingdisorders/preventing_strategies.html

American Psychiatric Association (APA). Practice guideline for the treatment of patients with eating disorders. 3rd ed. Washington (DC): American Psychiatric Association (APA); 2006 Jun. http://guideline.gov/content.aspx?id=9318