Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
+ 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