1. MARSIPAN Medical assessment Alastair Forbes Norwich Medical School University of East Anglia

2. England

4. Starvation Humans well adapted Intermittent food consumption Continuous energy expenditure

5. Starvation Stores of Carbohydrate Fat (and protein) Reduced expenditure

6. Starvation Survival ?

7. Marasmus vs Kwashiorkor

8. Starvation Stores of Carbohydrate and fat Calorific value Muscle sparing

9. Starvation Insulin lower Glucagon & catecholamines higher Glycogenolysis & lipolysis Free fatty acids & ketones

10. Starvation <72h Energy mainly from glycogenolysis for ~24h at rest Thereafter from gluconeogenesis Brain adapts to ketones Effects on appetite

11. Starvation >72h No glycogen Glucose from gluconeogenesis Never from free fatty acids Amino acids become glucose source Negative nitrogen balance 200g muscle/day

12. Starvation >72h Ketones support brain & muscle Some muscle sparing effect

13. Starvation >72h Change in body composition Classic Keys study 1950 50% diet for 24 weeks

14. The Minnesota experiment

15. Starvation 24 weeks 23% loss of weight 71% loss of fat 24% cell mass loss Basal Metabolic Rate 60% of baseline Various mechanisms

16. Common Still 30-40% on admission Worsens during admission Malnutrition in hospitals

17. Several tools What do they do ? Are they feasible in practice ? Are they valuable ? Are they relevant to eating disorders ? Nutrition screening

20. Albumin and nutritional status Highly relevant to prognosis Many different clinical contexts Unrelated to nutritional status??

21. Albumin and nutritional status David Blaine 2003 Starved for 44 days – water only

22. Albumin and nutritional status David Blaine 2003 Starved for 44 days – water only Weight 96.0 to 71.5kg = -25.5%; BMI 28.3 to 18.9 Jackson JM ‘06

23. Albumin and nutritional status Albumin at 44 days ……

24. Albumin and nutritional status Albumin at 44 days …… 52.9 !

25. Special aspects in Eating Disorders (ED) Usually thought of as simple (!) starvation Probably not actually true

26. Special aspects in ED Usually thought of as simple (!) starvation Probably not actually true Metabolic aspects from pharmacological manipulation – especially laxatives and diuretics Inflammatory aspects from immunosuppression and element of infection

27. Special aspects in ED Usually thought of as simple (!) starvation Probably not actually true Deception in Anorexia Nervosa (AN) – Water-loading before weighing – Extra weights concealed in clothing

28. Special aspects in ED Usually thought of as simple (!) starvation Probably not actually true Deception in AN – Water-loading before weighing – Extra weights concealed in clothing Exercise in AN – Overt – Microexercise

29. Special aspects in ED Bulimia also complex Nutrition risk may be under-recognised

30. Assessment in ED Simple anthropometry Weight and BMI – challenge/threat Nutrition screening tools – depend on former Do other tests contribute?

31. Assessment in ED – other tests When BMI >16 no special concerns Similar to other malnourished patients No special tests needed But important to agree assessment strategy

32. Assessment in ED – other tests When BMI >16 no special concerns Similar to other malnourished patients No special tests needed But important to agree assessment strategy For example – weekly weighing

33. Assessment in ED – other tests When BMI <16 concerns increase Cardiovascular instability Significant immunosuppression Possibility of added self-induced metabolic upset

34. Assessment in ED – other tests When BMI <16 - and increasingly critically as it falls lower Must assess cardiac and electrolyte status Postural hypotension (Wikipedia emphasis) Should assess muscle function but often refused Assume high risk if refused

35. Assessment in ED with BMI <<16 ECG/EKG - and preferably echo Serum electrolytes Magnesium Phosphate Liver function tests Micronutrients (but assume abnormal)

36. Assessment in ED with BMI <<16 ECG/EKG and preferably echo Bradycardia Long QTc >450ms

37. Assessment in ED with BMI <<16 Look ! - QTC 477

38. Assessment in ED with BMI <<16 Long QTc >450ms

39. Assessment in ED with BMI <<16 Other functional tests Spirometry Stand from crouch Sit Up Squat Stand (SUSS) test

40. SUSS Scoring (Sit-up and Squat-Stand tests separately) 0: Unable 1: Able only using hands to help 2: Able with noticeable difficulty 3: Able with no difficulty

41. MARSIPAN Medical treatment in adults

42. Assessment in ED Simple anthropometry Weight and BMI Nutrition screening tools Laboratory tests Psychological status

43. “Non-assessment” in ED Emergency admission Unplanned transfer Additional problems

44. “Non-assessment” in ED Emergency admission Unplanned transfer Additional problems Liaison with EDU and team May need to be initiated – Previously unknown – Deliberate geographical displacement

45. Planning management in ED Decisions needed on strategy Life-saving Part of continuing care plan Mixture

46. Planning management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion …

47. Planning management in ED What will the treatment be ? … Nutrition evidently but …

48. Planning management in ED “Food is not the issue”

49. Planning management in ED “Food is not the issue” Multidisciplinary approach crucial Remember “peripheral players”

50. The hospital cleaner

52. Planning management in ED What will the treatment be ? Food Oral supplements Tube feed Parenteral feed

53. Planning management in ED How much ? Enough Harris-Benedict equation (etc) Unreliable when low BMI Indirect calorimetry

55. Planning management in ED How much ? Enough Harris-Benedict equation (etc) Unreliable when low BMI Indirect calorimetry Calories as basis for other nutrients

56. Planning management in ED Which constituents ? Complete balanced regimen Obvious – but ….

57. Planning management in ED Which constituents ? Complete balanced regimen Obvious – but …. Easier to achieve with artificial feed

58. Planning management in ED Micronutrients Critical and potentially life-saving / losing

59. Planning management in ED Micronutrients Critical and potentially life-saving / losing Especially thiamine = vitamin B1 Deficiency likely Demands increased Risk of permanent damage

60. Ophthalmoplegia Thiamine deficiency

61. Scurvy Vitamin C deficiency

62. Acrodermatitis enteropathica Zinc deficiency Dermatol On Line

63. Planning management in ED How quickly ? Difficult decision Practical and influenced by risk of refeeding syndrome Multidisciplinary approach Influenced by severity of starting position

64. Planning management in ED Which route ? If the gut works use it

65. Planning management in ED Which route ? If the gut works use it If the mouth works use it

66. Planning management in ED Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues

67. Planning management in ED Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues Nasogastric tube feed often needed Gastrostomy very rarely appropriate

68. Planning management in ED Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues Nasogastric tube feed often needed Gastrostomy very rarely appropriate Parenteral nutrition – “never”

69. Planning management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion …

70. Planning management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion …

71. Active management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion with the patient

72. Active management in ED What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion with the patient Negotiation

73. Active management in ED Start

74. Active management in ED Start Careful monitoring Good initial progress

75. Active management in ED Start Careful monitoring Good initial progress Stop – all sorts of reasons

76. Active management in ED Start Careful monitoring Good initial progress Stop – all sorts of reasons Renegotiate

77. Targets in ED management Needed to some extent Always contentious Weight / BMI not ideal

78. Targets in ED management Needed to some extent Always contentious Weight / BMI not ideal Rule of engagement ! Never punitive

79. Discharge planning in severe ED Starts at admission Close and frequent liaison with psychological (EDU) team In-patient review

80. Discharge planning in severe ED Starts at admission Close and frequent liaison with psychological (EDU team In-patient review Often can and should be staged Use of day-care facility In-patient transfer not always needed

81. Medical withdrawal in ED When will the treatment be stopped ? How much has to be done first ? Which constituents can be omitted ? Micronutrients still important ? How quickly can this happen ? Which route can be avoided ? Discussion with the patient Negotiation

82. PatientDoctor

83. Active management in ED This is not an easy area!

84. Aitäh

85. Lõunasöök ?