Shelagh Marshall, RD, LDN Eating Disorders Shelagh Marshall, RD, LDN

Outline Case Study Recovery Routes Recovery Realities Refeeding Syndrome Approaches and Counseling Case Study Interventions, Monitoring, etc.

Case Study A 24-year old female admitted to the hospital with syncope and collapse and has a PMHx significant for amenorrhea, depression, and hypotension. During interview, patient informs you that her typical intake is as follows: Breakfast: ½ cup of oatmeal with ½ cup strawberries, black coffee Lunch: raw carrots and celery with 2 Tbs hummus, water Dinner: salad (mixed greens, cucumbers) with 1 Tbs low-fat dressing, water Meds: oral contraceptive (tricylic), Celexa, and ibuprofen prn Height: 5’8” (68”) Weight: 120 lbs (54.54 kg) as of today, 11/16/17 UBW: 145 lbs (65.9 kg) as of 7/02/17 Nutrition-focused physical assessment: moderate temporal wasting, moderate orbital fat pad loss, lanugo hair.

Recovery Routes Inpatient level of care Residential Programs Closely monitored by medical professionals Blood work, medicating, enteral feeds, etc. Residential Programs Group work, therapy, coping skills, meal plans, etc. Partial Hospitalization Programs Multiple visits per week to medical professionals/ ED specialists Meal plans, groups, real-life trials, etc. Outpatient level of care Typically weekly or bi-weekly visits with multiple providers: RD, therapist, psychiatrist, PCP/pediatrician, etc. Coping skills, meal plans, goal setting, etc.

Recovery Realities: Anorexia Nervosa Energy Intake: Initially: 130% REE (adjusted Harris-Benedict) Start feeding slowly in malnourished patients on their first day, up-titrating Gradually increase amount of carbohydrates in diet Focus on protein and fats Weight Changes: 2-3 lb/week inpatient 0.5-1 lb/week outpatient Lifestyle Modifications: Coping mechanisms Limiting exercise Eating in public/with others

Recovering Realities: Bulimia Nervosa Energy Intake: 100% REE needs (Harris-Benedict or Mifflin-St. Joer) Consistency of calorie distribution Well-balanced meals Weight Changes: Maintain weight 0.5-1 lb/week Lifestyle Modifications: No compensatory behaviors: no laxatives or diuretics, limiting physical activity, no vomitus purging Coping mechanisms

Recovery Realities: Binge Eating Disorder Energy Intake: 100% REE needs (Harris-Benedict or Mifflin-St. Joer) Consistency of calorie distribution Well-balanced meals Weight Changes: Maintain weight Long-term, gradual weight loss (if obese, overweight) or 0.5-1 lb per week Lifestyle Modifications: Coping mechanisms

Recovery Realities: Eating Disorder Not Otherwise Specified Energy Intake: Initially: 130% REE (adjusted Harris-Benedict) Start feeding slowly in malnourished patients on their first day, up-titrating Gradually increase amount of carbohydrates in diet Focus on protein and fats Weight Changes: 2-3 lb/week inpatient 0.5-1 lb/week outpatient Lifestyle Modifications: Coping mechanisms Limiting exercise

Refeeding Syndrome Occurs when under-nourished/NPO (x >5 days) patients/people re-feed their body Caused by the increased uptake of phosphorus, magnesium, and potassium into cells Uncomfortable: can cause abdominal distension and abdominal pain Dangerous: AMS, AMI, cardiac failure, arrhythmias, neuromuscular complications, etc.

Phosphorus in Refeeding Hypophosphatemia: low level of phosphorus Phos is drawn into cells followed by water in refeeding, resulting in decreased serum levels Function(s): Component of nucleic acids that make up RNA and DNA Bonds in ATP Structural integrity of cell membranes Renal acid-base buffering system Weakness, cardiac arrhythmia, respiratory failure, rhabdomyolsis, confusion Easily missed: non-specific signs and symptoms, Phos levels not included in a basic metabolic panel

Potassium in Refeeding Hypopotassemia/hypokalemia – low levels of K+ Caused by increased uptake of K+ into cell (after being stimulated by insulin) by Na+/K+ pump, resulting in decreased serum levels Function: electrochemical membrane potential issues (think Na+/K+ pumps) Weakness, muscle cramps, numbness, tingling, nausea, vomiting, cardiac arrest

Magnesium in Refeeding Hypomagnesemia: low levels of magnesium Drawn into cell followed by water, resulting in decreased serum levels Function(s): Cofactor in enzyme functions (oxidative phosphorylation, ATP production) Structural integrity of: DNA, RNA, ribosomes Regulation of PTH secretion Helps lower blood pressure

Interventions & Monitoring for Refeeding Initiation of nutrition: PO diet: increase gradually, limit carbohydrates EN Support: increase gradually, limit carbohydrates Incretin effect: greater insulin secretion with oral glucose compared to intravenous Phos in EN solutions need to be digested (can be difficult) Lower concentration of phos in EN forumlas PN Support: increase gradually, limit dextrose, repletion in-bag prn High levels of glucose in PN solutions lead to increased risk of refeeding IV Fluids: consider switching to NS rather than D5 to avoid excess glucose provision Daily metabolic panel (K+), phos, and mag. Replete prn Monitor for signs of GI distress: abdominal distension, nausea, vomiting, etc. Cardiac/telemetry monitoring Coordination of Care: referral to outpt RD, therapist, psychiatrist, etc.

Approaches and Counseling Body image and body dysmorphia Counseling Motivations and triggers Meal plans Goal setting

Case Study A 24-year old female admitted to the hospital with syncope and collapse and has a PMHx significant for amenorrhea, depression, and hypotension. During interview, patient informs you that her typical intake is as follows: Breakfast: ½ cup of oatmeal with ½ cup strawberries, black coffee Lunch: raw carrots and celery with 2 Tbs hummus, water Dinner: salad (mixed greens, cucumbers) with 1 Tbs low-fat dressing, water Meds: oral contraceptive (tricylic), Celexa, and ibuprofen prn Height: 5’8” (68”) Weight: 120 lbs (54.54 kg) as of today, 11/16/17 UBW: 145 lbs (65.9 kg) as of 7/02/17 Nutrition-focused physical assessment: moderate temporal wasting, moderate orbital fat pad loss, lanugo hair. PES Statement Interventions Monitoring/Evaluation