Transcript Slide 1

+
MNT in a Residential Eating
Disorder Treatment Facility
Aly Brown
Sodexo Dietetic Internship
July 30, 2013
+
Purpose

Explore the psychological and physical intricacies of EDs

Large part of treatment is nutrition

What is the role of the RD?
+
Agenda
Eating Disorders
I.





Classifications
Causes
Prevalence
Treatment
Recovery
II.
Anorexia Nervosa
III.
Medical Nutrition Therapy
IV.
Presentation of Patient
V.
Summary
+
Background Information
 Eating Disorder





(ED) Classifications:
Anorexia Nervosa (AN)
Bulimia Nervosa (BN)
Binge-Eating Disorder (BED)
Eating Disorder Not-Otherwise-Specified (EDNOS)
Diagnostic criteria established by American Psychiatric Association
(APA); criteria published in Diagnostic and Statistical Manual of
Mental Disorders (DSM)
+
Potential causes
 Neurochemical and

psychological disorders
Anxiety disorders (most prevalent)
 Genetics
 Interpersonal

Physical or sexual abuse
 Sociocultural

Media, peers
+
Prevalence
~24 million people
1 in 10 receive treatment
Highest mortality rate of any mental illness
+
Treatment

Hospital, residential treatment facility,
or private office

Inpatient

Cornerstone for ED treatment
 Outpatient
• Medically stable to be discharged from an inpatient setting, yet still
requires structure to continue with treatment
• DTP, PHP, IOP
+
Pharmacological Treatment

Fluoxetine (Prozac) used for BN

Only FDA approved medication for treatment of ED

SSRI often used for depression

Not a cure; alleviates some of the symptoms

No pharmacological evidence for AN

Medications only indicated in severe circumstances

Must be used in combination with psychotherapy
+
Non-Pharmacological Treatment

Psychotherapy

Family-based treatment (FBT)

Cognitive behavior therapy (CBT)/ Behavior Therapy (BT)

Dialectical behavior therapy (DBT)

Medical

Nutrition

Alternative (Yoga, spirituality, religion)
+
Recovery

Not instantaneous

Facilitated with long-term treatment

Stages of change:
Precontemplation
Contemplation
Preparation
Action
Maintenance
+
Anorexia Nervosa
 DSM-5 Criteria for




Diagnosis:
Not maintaining normal weight for
age and height
Intense fear of gaining weight or
being overweight
Disturbance in body weight or shape
Denial of the seriousness
Characteristics of AN
Perfectionist
Meticulous
Fear of growing up
Dependent
Introverted
Obsessive-compulsive
Trust issues
Self denying
Socially insecure
Overly rigid thinker
+
Warning Signs
 Dramatic weight

loss
Preoccupation with
weight or food
 Refusal to eat certain
foods
 Excessive exercise

Withdrawal from friends
and activities
 Development
rituals
of food
+
Consequences
Physical
Internal
Psychological
Lanugo
Cardiac complications
Anxiety
Brittle nails
Reduced bone density
Depression
Growth retardation
Thinning hair, falls out easily
Muscle wasting
Amenorrhea
Blotchy, yellow skin Digestive dysfunction
Social withdrawal
Irritability
Food fixation
+
Minnesota Starvation Study

Association between
psychological disturbances and
starvation

Subjects developed AN-like
thoughts and behaviors

Psychological disturbances
disappeared when re-nourished
+
Hormonal adaptation in AN
+
Medical Nutrition Therapy
In a Residential Eating Disorder
Treatment Facility
+
Role of the Registered Dietitian (RD)
 Main
Goals:

Weight restoration

Determine target weight

Determine energy needs

Customize a healthy eating plan

Correct disordered thoughts about food and eating

Well supported as an essential component of treatment

Collaborate with multi-disciplinary team
+
Where to start
Take focus away from calorie counting
All nutrition prescriptions are individualized
Educate
Identify possible barriers
Motivational Interviewing
Encourage and applaud minute accomplishments
+
+
Nutrition Screening
 Clinical indicators for





ED risk
Unintentional weight loss
 ≥5% in one month
 ≥10% in 1-6 months
Unintentional weight change ≥ 10% in the past 3 months
Decreased appetite
< Half usual food intake in past 7 days
Mini Nutritional Assessment to assess for malnutrition
+
Assessment
Patient History







Reason for seeking care

Socioeconomic status

Living situation

Social and medical support

History of recent crisis

Activity level

Meal preparation.

Religious or cultural dietary
practices

Alcohol or drug use/abuse
Medications
Supplement or vitamins
Menstrual history
ED related treatment history
Chronic disease states
Family health history

Oral health history,

Psychiatric history
+
Assessment
Food and Nutrition-Related History

Food habits (rituals,
preoccupations)

Eating patterns

Restrictions and “fear foods”

Preferences

Intolerances/allergies

Obtained by:
 24-hour recall, food
frequencies, or food
records
+ Assessment
Laboratory Data and Procedures
Mandatory:



Electrolytes
Optional

Cholesterol

Thyroid function tests

Chest or abdominal X-rays

Electromyography (EMG)

Examination of muscle enzymes (CPK)

Computed tomography (CT)
EKG
Complete blood count with differential

Blood urea nitrogen (BUN) and creatinine

Blood glucose

Calcium

GI endoscopy

Liver function tests

Magnetic resonance imaging (MRI)
scans of the head
.

Body Composition
+
Nutrition-Focused Physical
Assessment
+
Anthropometric Data
 Weight
 Height
 BMI
+
Diagnosis

Sample PES statement

Inadequate oral intake related to limited food acceptance due to
psychological issues as evidenced by weight less than 75% ideal body
weight and food recall consumption meeting less than 25% calorie needs

Diagnosis may be hard to accept for many patients
+
Intervention

Should target the problem decided upon from diagnosis

Nutritional intervention should be timely and appropriate

Immediate interventions:

Determining target weight

Developing nutrition prescription
+
Intervention
Determining Target Weight
 Adolescents

CDC growth curve charts
BMI
 McLaren method
 Moore method
Use previous height/weight percentiles
IBW calculation





Resumption of menses
Highest pre-ED weight
Weight goal for adolescents is often a moving target!
+
Intervention
Nutrition Prescription

Calories:





REE x AF (1.2-2.0)
40-50 calories per kilogram + 500 calories for anabolic energy
needs
Begin with:
 600-1,000 calories per day
Advance by:
 300-400 calories every three to four days
May need up to 4,000-5,000 calories per day
+
Nutrition Prescription
Macronutrients

Protein:


Carbohydrate:


15-20% total daily caloric intake
50-60%
Fat:

30%
+
Nutrition Prescription
Weight & Fluid

2-3 pounds weight gain per week

Fluid:




30-40 mL per kilogram per day
Measure fluid intake and output
Monitor weights for fluid retention or “water loading”
EN or PN

Most severe circumstances
+
Sample Meal Plans
Meal
Plan
Calories
Meat/Pro
tein
Milk
Fat
Starch
Fruit
Veg
Dessert
(weekly)
A
1700
5
2
4
6
2
2
3
B
2000
6
3
5
7
2
2
4
C
2200
6
3
6
8
3
2
4
*Fluid: ≥8 cups per day
+
Other Nutritional Issues

Constipation


Avoid bulky foods, increase fiber, and maintain adequate hydration
Low bone density/osteopenia/osteoporosis

Calcium: 1,000-1,500 mg per day

Vitamin D: 600-1,000 IU

Weight gain
+
General Meal Guidelines

Earn privilege to choose food

Cannot bring anything that could be used to hide food

Prohibited behaviors include: overuse of condiments, using the
restroom during meals, using food rituals

Fill out a food diary of their meals along with portion sizes and
exchanges

Write how they are feeling before or after each meal
+
Monitoring and Evaluation

Utilization of ATP
Refeeding syndrome

Monitor associated labs for appropriate amount of time


Refeeding
Daily or every other day for the first 7-10 days, then biweekly
Be aware of symptoms such as altered mental status
Intracellular shift of
phosphorus,
Weight/Growth
magnesium,chart
and trends
potassium
Food intake- meet 100% estimated needs
Sodium
and fluid
retention

Glucose
 Insulin
Glucagon
+ Presentation of G.V.
Anorexia Nervosa
+
Presentation of G.V.
Social history

15-year-old white female

Home-schooled

Lives at home with parents and 6 siblings

Does not feel sense of autonomy

No structure to meals

Poor relationship with father and older sister
+
ED Onset & Diagnosis

Onset: 11 years old

Started with older sister wanting GV to diet with her

GV: “I couldn’t diet as good as her”  began restricting and exercising

3 hours a day of exercising + 400-1,000 calories per day

Diagnosis: Anorexia Nervosa (Age 12)

Also diagnosed with Obsessive-Compulsive Disorder

Height: 57.5”
+
+
+
January 2012
• First inpatient treatment for ED
January-March 2012
• Continuing outpatient treatment of ED
July 2012
• Inpatient hospitalization for attempted suicide
July-August 2012
• First admission to The Renfrew Center
• 77 pounds
August 2012
• The Renfrew Center DTP
+
The Renfrew Center
5.29.2013
+
Medication/
Supplement
Indication
Luvox
OCD
Abilify
Major Depressive Disorder, Bipolar
Ativan
Anxiety
Multivitamin
Nutrient deficiencies
Calcium carbonate
Osteopenia
+
Admitting Diagnoses
AN
 OCD
 Malnutrition
 Dental enamel erosion
 Osteopenia
 Orthostatic
 Bradycardic
+
Day One
Assessment






57.5”
85.5 pounds (90% goal)
Goal weight = 95 pounds
BMI: 18.2
Lost 6.5 pounds in 6 months
Abnormal Labs: Chol 223 H, AST
34 H, ALT 27 H, T4 0.7 L
+
Day One
Diagnosis
Inadequate energy intake (NI-1.2) related to
anorexia nervosa as evidenced by estimated
energy intake meeting only 25-43% of estimated
calorie needs
+
Day One
Intervention

Start at “Meal Plan A” – 1,700 calories

Increase to “Meal Plan B” in 5 days – 2,000 calorie

Goals:

48 ounces of Gatorade daily until blood pressure within normal range

Complete 100% of meals for six consecutive days

Weight gain of 1-2 pounds per week
+
Day One
Monitoring & Evaluation
Monitor weight, labs, eating patterns, meal intake,
and behavioral symptoms
+
Day Five
Assessment

85.9 pounds (+0.4 pounds since admission)

“Meal Plan B” = 2,000 calories

Restricted food Day Two; 100% meal compliance since

Caught exercising Day Two

Abnormal labs: BUN/Cr ratio 33 H, BUN 21 H
+
Day Five
Diagnosis
Inadequate energy intake (NI-1.2) related to
anorexia nervosa as evidenced by failure to gain
appropriate weight and restriction of energydense foods from diet
+
Day five
Intervention

Continue with “Meal Plan B” with addition of supplement – 2,350 calories

Advance to “Meal Plan C” with supplement tomorrow = 2,550 calories

Given warning about exercise

Goals:

Weight gain goal increased to 2-4 pounds per week

Complete 100% of meals (ongoing)

Drink 1.5 cups water with each meal
+
Day Five
Monitoring & Evaluation
Monitor weight, labs, eating patterns, meal intake,
and behavioral symptoms
+
Day twelve
Assessment

85.6 pounds (- 0.3 pounds since last assessment)

“Meal Plan C” plus 2 snacks = 2,800 calories

Family visited this weekend; played tag

100% meal and snack completion

Target weight was increased to 105 pounds
+
Day twelve
Diagnosis
Inadequate energy intake (NI-1.2) related to
anorexia nervosa and hypermetabolism as
evidenced by failure to gain appropriate weight
+
Day twelve
Intervention

Continue with “Meal Plan C” with two snacks
 Add one supplement today (3, 150 total calories)
 Increase supplement to BID tomorrow (3,500 calories)

Goals:
 Weight gain of 2-4 pounds per week (ongoing)
 Complete 100% of meals (ongoing)
+
Day twelve
Monitoring & Evaluation
Monitor weight, labs, eating patterns, meal
intake, and behavioral symptoms
+
Day nineteen
Assessment

89.6 pounds (+ 4 pounds since last assessment)

“Meal Plan C” with 2 snacks and 2 supplements = 3,500 calories

“Meal pass” this weekend

Obtained Mom and Dad’s height

Calculated growth potential = 62.5”

IBW for 62.5” = 112 pounds
+
Day nineteen
Diagnosis
Excessive physical activity (NB-2.2) related to
addictive behaviors towards exercise and
increased energy needs as evidenced by
engaging in an hour-long hike
+
Day nineteen
Intervention

Continue with “Meal Plan C” with two snacks and two supplements


Increase supplements to TID = 3,850 total calories
Goals include:

“Meal pass” with older sister

Complete 100% of meals (ongoing)

Weight gain of 2-3 pounds per week
+
Day nineteen
Monitoring & Evaluation
Monitor weight, labs, eating patterns, meal intake,
and behavioral symptoms
+
Day twenty-one
Treatment Team Meeting


Goals from admission re-visited

No longer orthostatic

Still with signs of restriction and anxiety
GV caught exercising again


Locked bathroom + spontaneous room checks
Weight goal of 112 pounds not agreed upon

105-107 pounds is new target
+
Day thirty-five
Assessment

Discharged today

96.2 pounds (+ 10.7 pounds since admission)

Goal weight: 105-107 pounds (90-92%)

Height: 57.5”

BMI: 20.4
+
Day thirty-five
Diagnosis
No nutritional diagnosis at this time
+
Day thirty-five
Intervention


Nutrition Prescription:

4,100 calories

2 supplements, 2 snacks daily

Exchanges: 6 meat/protein, 3 dairy, 6 fats, 8 starches, 3 fruits, 2
vegetables
Goals:

Continued weight gain to 105-107 pounds

Bone-age study to assess growth potential

Weekly outpatient nutrition appointments
+
Day thirty-five
Monitoring & Evaluation

Weight

Food journals

Vital signs

Labs per protocol

Psychological/Body disturbances
+
Critical Comments

Stable with acceptable weight for discharge

Goal weight

Bone-age study

DEXA scan

Family therapy
+
+
+
+
References
1) Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM-IV.
Fairburn Christopher G., Bohn Kristin. "Editorial Board/Publication Information." Behaviour Research and Therapy 43.6
(2005): 691-701. Web. May 2013
2) "Feeding and Eating Disorders." DSM-5 Development. APA, May 2013. Web.
3) Ries Merikangas Kathleen, Jian-ping He, Burstein Marcy, et al. "Lifetime Prevalence of Mental Disorders in US
Adolescents: Results from the National Comorbidity Study-adolescent Supplement (NCS-A)." J Am Acad Child Adolesc
Psych (2010): pag. 31 July 2010. Web.
4) Whitney E. N., C. B. Cataldo, S. R. Rolfes. "Eating Disorders." Understanding Normal and Clinical Nutrition. 8th ed.
Australia: Wadsworth Thomson Learning, 2002. 270. Print.
5) Escott-Stump Sylvia. "Eating Disorders." Nutrition and Diagnosis-related Care. 7th ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins, 2008. Print.
6) Lock J., D. Le Grange, W. S. Agras, A. Moye, S. W. Bryson, and B. Jo. "Randomized Clinical Trial Comparing Family-Based
Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa." Archives of General
Psychiatry 67.10 (2010): 1025-032. Print.
7) Murphy Rebecca, Suzanne Straebler, Zafra Cooper, and Christpher G. Fairburn. "Cognitive Behavioral Therapy for Eating
Disorders." Psychiatr Clin North Am 33.3 (2012): 611-27. Print.
8) "National Eating Disorders Association." National Eating Disorders Association. Web. 19 May 2013.
9) Ozier, AD, and BW Henry. "Position of the American Dietetic Association: Nutrition Intervention in the Treatment of
Eating Disorders." Academy of Nutrition and Dietetics. J Am Diet Assoc, 2011. Web. 19 May 2013.
+
10) Setnick, Jessica. "ADA Pocket Guide to Eating Disorders." Academy of Nutrition and Dietetics. N.p., Aug. 2011. Web. 19
June 2013.
11) Barberio, Judith A. Nurse’s Pocket Drug Guide. 2012. Print.
12) "Eating Disorders Statistics." National Association of Anorexia Nervosa and Associated Disorders. Web. 19 June 2013.
13) "Diagnosis of Eating Disorders in Primary Care." American Family Physician -- AAFP. Web. 19 June 2013.
14) "Anorexia Nervosa Fact Sheet. Anorexia Affects Your Whole Body." Womenshealth.gov. Web. 19 June 2013.
15) "Bulimia Nervosa Fact Sheet. Bulimia Affects Your Whole Body." Womenshealth.gov. Web. 19 June 2013.
16) "Eating Disorders." American Psychological Association (APA). Web. 19 June 2013.
17) Barausky, Amy L. "PEDIATRIC NUTIRION –A BUILDING BLOCK FOR LIFE A Publication of the Pediatric Nutrition
Practice Group . Update on Eating Disorders and Multi-disciplinary Treatment Teams." Academy of Nutrition and
Dietetics. A.I. DuPont Hospital for Children, 2008. Web. 19 June 2013.
18) Morgan, John F., J. Hubert Lacey, and Fiona Reid. "The SCOFF Questionnaire a New Screening Tool for Eating Disorders."
West J Med. (n.d.): 164-65. Www.ncbi.nlm.nih.gov. Web. June 2013.
19) Mehler, Philip S., Amy B. Winkelman, Debbie M. Andersen, and Jennifer L. Gaudiani. "Nutritional Rehabilitation: Practical
Guidelines for Refeeding the Anorectic Patient." Journal of Nutrition and Metabolism 2010 (2010): 1-8. Print.
20) Lund, Brian C., Elsa R. Hernandez, William R. Yates, Jeff R. Mitchell, Patrick A. McKee, and Craig L. Johnson. "Rate of
Inpatient Weight Restoration Predicts Outcome in Anorexia Nervosa." International Journal of Eating Disorders 42.4
(2009): 301-05. Print.
21) Golden, Neville H., Marc S. Jacobson, Wendy Meyer Sterling, and Stanley Hertz. "Treatment Goal Weight in Adolescents
with Anorexia Nervosa: Use of BMI Percentiles." International Journal of Eating Disorders 41.4 (2008): 301-06. Print.
+
22) Butryn, Meghan L., Adrienne Juarascio, and Michael R. Lowe. "The Relation of Weight Suppression and BMI to Bulimic Symptoms." International Journal
of Eating Disorders (2010): N/a. Print.
23) Oldershaw, A., D. Hambrook, K. Tchanturia, J. Treasure, and U. Schmidt. "Emotional Theory of Mind and Emotional Awareness in Recovered Anorexia
Nervosa Patients." Psychosomatic Medicine 72.1 (2010): 73-79. Print.
24) DeSocio, Janeice E. "The Neurobiology of Risk and Pre-Emptive Interventions for Anorexia Nervosa." Journal of Child and Adolescent Psychiatric Nursing
26.1 (n.d.): 16-22. Feb. 2013. Web. June 2013.
25) "What Are Eating Disorders." Alliance for Eating Disorder Awareness. Web. 19 June 2013.
26) Fairburn, C., and Z. Cooper. "Eating Disorders, DSM–5 and Clinical Reality." The British Journal of Psychiatry (2011): n. pag. Web. June 2013.
27) Lock, J Le Grange. "Treatment Manual for Anorexia Nervosa, Second Edition: A Family-Based Approach." (2013): 2. Web. June 2013.
28)Loeb, K., and D. Le Grange. "Family-Based Treatment for Adolescent Eating Disorders: Current Status, New Applications and Future Directions." Int J
Child Adolesc Health (n.d.): 243-54. Jan.-Feb. 2009. Web.
30) Warren, Michael. "Endocrine Manifestations of Eating Disorders." The Journal of Clinical Endocrinology & Metabolism 96.2 (n.d.): 333-43. 1 Feb. 2011.
Web.
31) Takakazu, Yagi, Ueda Hirotaka, Amitani Haruka, Asakawa Akihiro, Miyawaki Shouichi, and Inui Akio. "The Role of Ghrelin, Salivary Secretions, and
Dental Care in Eating Disorders." Nutrients 2.4 (2012): 967-89. Web. June 2013.
32) Arcelus, Jon, Alex J. Mitchell, Jackie Wales, and Søren Nielson. "Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Metaanalysis of 36 Studies." JAMA Psychiatry 68.7 (n.d.): n. pag. July 2011. Web. June 2013.
33) "Nutrition Care Process." Evidence Analysis Library. Web. 20 June 2013.
34) Rome, E. S., S. Ammerman, D. S. Rosen, R. J. Keller, J. Lock, K. A. Mammel, J. O'Toole, J. M. Rees, M. J. Sanders, S. M. Sawyer, M. Schneider, E. Sigel, and T. J.
Silber. "Children and Adolescents With Eating Disorders: The State of the Art." Pediatrics 111.1 (2003): E98-108. Print.
35) Sim, Leslie A., Donald E. McAlpine, Karen B. Grothe, Susan M. Hines, Richard G. Cockerill, and Matthew M. Clark. "Identification and Treatment of Eating
Disorders in the Primary Care Setting." Mayo Clinic Proceedings 85.8 (2010): 746-51. Aug. 2010. Web. June 2013.
+
36) Birmingham, C. Laird, and Janet Treasure. Medical Management of Eating Disorders. Cambridge: Cambridge UP, 2010. Print.
37) Naab, Silke, Sandra Shlegl, Alexander Korte, Joerg Heuser, Markus Fumi, Manfred Fichter, Ulrich Kuntz, and Ulrich Vonderholzer. "Effectiveness of
a Multimodal Inpatient Treatment for Adolescents with Anorexia Nervosa in Comparison with Adults: An Analysis of a Specialized Inpatient
Setting." Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity 18.2 (n.d.): 167-73. June 2013. Web. June 2013.
38) Schaffner, Angela D., and Linda Paulk Buchanon. "Evidence-Based Practices in Outpatient Treatment for Eating Disorders." IJBCT 6.1 (n.d.): n. pag.
Web. June 2013.
39) Yager, Joel, Michael J. Devlin, Katherine A. Halmi, David B. Herzog, James E. Mitchell, Pauline S. Powers, and Kathryn K. Zerbe. "Practice Guideline
for the Treatment of Patients with Eating Disorders." Guideline Watch (n.d.): n. pag. Aug. 2012. Web. June 2013.
41) Mehler, Philip S., Amy B. Winkelman, Debbie M. Andersen, and Jennifer L. Gaudiani. "Nutritional Rehabilitation: Practical Guidelines for Refeeding
the Anorectic Patient." Journal of Nutrition and Metabolism 2010 (2010): 1-8. Print.
42) Goodheart, Kristin, James R. Clopton, and Jacalyn J. Robert-McComb. "Chapter 17: Nutritional Evaluation and Treatment of Eating Disorders."
Eating Disorders in Women and Children Prevention, Stress Management, and Treatment. Bosa Roca: CRC, 2011. N. pag. Print.
43) Reel, Justine J. "Dialectical Behavior Therapy." Eating Disorders: An Encyclopedia of Causes, Treatment, and Prevention. Santa Barbara, Calif:
Greenwood, 2013. N. pag. Print.
44) Katzman, Debra K., and Madhusmita Misra. "Bone Health in Adolescent Females with Anorexia Nervosa: What Is a Clinician to Do?" International
Journal of Eating Disorders (n.d.): n. pag. 9 May 2013. Web. June 2013.
45) Mehler, Philip S., and Arnold E. Andersen. Eating Disorders: A Guide to Medical Care and Complications. 2nd ed. Baltimore: Johns Hopkins UP,
2010. Print.
46) The Renfrew Center. Nutrition Handbook and Standards of Care.
47) "Pediatric Nutrition Care Manual." Behavioral Health – Eating Disorders (n.d.): n. pag. American Dietetic Association, 2012. Web. June 2013.
48) ADA Pocket Guide to Nutrition Assessment. Second Edition. P Charney, A Malone. 2009.
49) Le Grange, Daniel, Peter M. Doyle, Sonja A. Swanson, Kali Ludwig, Catherine Glunz, and Richard E. Kreipe. "Calculation of Expected Body Weight
in Adolescents With Eating Disorders." Official Journal of the American Academy of Pediatrics 129.2 (n.d.): n. pag. Pediatrics, 4 Jan. 2012. Web.
June 2013.
+
15 year old Female
Height: 62.5”
Moore
Method
McLaren Method 
IBW: 112 lbs
IBW: 104 lbs