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Transcript of + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July...
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MNT in a Residential Eating Disorder Treatment Facility
Aly BrownSodexo 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
I. Eating Disorders 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:
+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
Perfectionist
Dependent
Obsessive-compulsive
Meticulous Fear of growing up
Introverted
Trust issues
Overly rigid thinker
Socially insecureSelf denying
Characteristics of AN
+Warning Signs
Dramatic weight loss
Preoccupation with weight or food
Refusal to eat certain foods
Excessive exercise
Withdrawal from friends and activities
Development of food rituals
+
Physical
Lanugo
Brittle nails
Thinning hair, falls out easily
Muscle wasting
Blotchy, yellow skin
Consequences
Internal
Cardiac complications
Reduced bone density
Growth retardation
Amenorrhea
Digestive dysfunction
Psychological
Anxiety
Depression
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 TherapyIn 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
+AssessmentPatient History Reason for seeking care
Medications
Supplement or vitamins
Menstrual history
ED related treatment history
Chronic disease states
Family health history
Oral health history,
Psychiatric history
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
+AssessmentFood 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
+ AssessmentLaboratory Data and Procedures
Mandatory:
Electrolytes
EKG
Complete blood count with differential
Blood urea nitrogen (BUN) and creatinine
Blood glucose
Calcium
Liver function tests
.
Optional Cholesterol
Thyroid function tests
Chest or abdominal X-rays
Electromyography (EMG)
Examination of muscle enzymes (CPK)
Computed tomography (CT)
GI endoscopy
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
+InterventionDetermining 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!
+InterventionNutrition 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 PrescriptionMacronutrients
Protein: 15-20% total daily caloric intake
Carbohydrate: 50-60%
Fat: 30%
+Nutrition PrescriptionWeight & 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/Protein
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
Refeeding syndrome Monitor associated labs for appropriate amount of time
Daily or every other day for the first 7-10 days, then biweekly Be aware of symptoms such as altered mental status
Weight/Growth chart trends
Food intake- meet 100% estimated needs
+ 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”
+
+
+
+
The Renfrew Center5.29.2013
+
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 OneDiagnosis
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 FiveDiagnosis
Inadequate energy intake (NI-1.2) related to
anorexia nervosa as evidenced by failure to gain
appropriate weight and restriction of energy-
dense 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 twelveAssessment
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 twelveIntervention
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
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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.
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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.
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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.
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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.
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+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.
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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.
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+15 year old FemaleHeight: 62.5”
IBW: 104 lbs
IBW: 112 lbs
McLaren Method
Moore Method