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What is healthy eating?
- Mindful: know the difference between physical and emotional cues and needs. Eat when you are hungry; stop when you are full/meet your body needs
- Enjoyable: eat pleasurable foods without guilt or anxiety
- Flexible: be able to eat needed amount in available time. No calorie counting. Eat a variety of foods. Don't avoid any food group. Try new things without knowing all ingredients
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What are some statistics about anorexia and bulimia? BED?
- anorexia: incidence rates have increased over past 25 years, affects 1% of adolescent females, rates for men on 10% of those for women; seen in clients as young as 6
- Bulimia: occurs in 1-5% of high school girls
- as high as 19% in college women
- BED: occurs more commonly in women; can vary from 3-30% of women
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When is onset most likely?
- eating disorders ave onset most commonly in teen and young adult years, but may occur at other ages ( BN slightly later onset then AN)
- <10% have onset prior to puberty
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What is the etiology?
- no consensus on precise cause
- Combination of psychological, biological, family, gene ti, environmental and social factors
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What are the associated factors?
- hx of dieting in adolescent children
- Childhood preoccupation with a thin body and social pressure about weight
- Sports and artistic endeavors in which leanness is emphasized
- Women whose first degree relatives have eating disorders-6 to 10 fold increased risk for developing an eating disorder
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What is the female athlete's triad? Whose at risk? What should you look for?
- The triad: eating disorders, stress fractures, amenorrhea
- At risk: appearance related sports, high performance sports
- What to look for: Weight, HR 40-50, hypotension, hypothermia, parotid swelling, poor dentition, overuse injuries especially stress fractures
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What are the associated psychiatric conditions?
- affective disorders
- anxiety disorders
- OCD
- Personality disorders
- substance abuse
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What is the DSM-5 criteria for anorexia nervosa?
- refusal to maintain weight within a normal ramge for height and age (more tan 15% below ideal body weight)
- Fear of weight gain*
- Severe body image disturbance in which body image is the predominant measure of self-worth with denial of the seriousness of the illness
- In post-menarchal females, absence of the menstrual cycle, or amenorrhea (greater than three cycles)
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What are the fears?***
- Anorexia nervosa is not a disorder of appetite
- Clients may report decreased appetite
- Others Fear appetite
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What is the assessment, diagnosis and plan for anorexia nervosa
- Assessment: general assessment, self assessment
- Plan: refeeding syndrome
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What are the signs and symptoms of anorexia nervosa?
- Dry skin, blue hands and feet
- cold intolerance
- constipation, bloating
- delayed puberty, primary or secondary amenorrhea
- nerve compression
- fainting
- ortho hypo
- lanugo
- scalp hair loss
- early satiety
- weakness, fatigue
- short stature
- osteopenia
- breast atrophy
- atrophic vaginitis
- pitting edema
- cardiac murmurs
- sinus brady
- hypothermia
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What questions should you ask as a screening tool? (Esp)
- Are you satisfied with your eating patterns?: no is abnormal
- Do you ever in secret?: yes is abnormal
- Does your weight affect the you feel about yourself?: yes is abnormal
- Have any members of your family suffered with an eating disorder?: Yes is abnormal
- Do you currently suffer with or have you suffered in the past with an eating disorder?
- (2 or more abnormal is bad????)
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What lab assessment is necessary?
- CBC: anemia
- Electrolytes, BUN/Cr
- Mg, PO4, Calcium
- Albumin, serum protein
- B-HCG
- UA: Specific gravity
- thyroid function tests
- Serum prolactin
- FSH
- Bone density
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What diseases should you rule out first?
- New onset DM
- Adrenal insufficiency
- Primary depression with anorexia
- Inflam. bowel disease
- Abdominal masses
- Central nervous system lesions
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What interventions are done for AN in acute care?
- psychosocial interventions
- Pharm interventions
- integrative medicine
- Health teaching and promotion
- Safety and teamwork
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Why is cognitive behavioral therapy used for AN? Who is part of the interdisciplinary team?
- Cognitive behavioral: emphasizes the relationship of thoughts and feelings to behavior; limited efficacy
- Care team: medical provider, dietitian with experience in ED, mental health professional
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What medications are used for AN?
- disappointing results, effective only for comorbid conditions of depression and ocd
- Anxiolytics may be helpful before meals to supress the anxiety associated with eating
- Case reports in the literature supporting the use of olanzapine
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What kind of complications cause hospitalization in AN?
- Severe malnutrition (<75% IBW)
- Dehydration
- Electrolyte disturbance
- cardiac dysrhythmia
- Arrested growth and development
- physiologic instability
- Failure of outpatient treatment
- Acute psychiatric emergencies
- Comorbid conditions that interfere with the treatment of the ED
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What is the goal for nutrition in AN?
- Goal: regain to goal of 90-92% if IBW; inpatient treatment varies by facility
- this is done by:
- Oral liquid nutrition
- Nasogastric tube feedings
- gradual caloric increase wit regular food
- parenteral nutrition rarely indicated
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How does amenorrhea relate to AN?
- Scondary amenorrhea affects more than 90% of clients with anorexia
- Caused by low levels of FSH and LH
- Menses resumes with 6 months of achieving 90% IBW
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What kind of cardiac changes do you see with AN?
- MVP: occurs in 32-60% of clients with anorexia
- Long QT: as many as 33% of patients ( independent marker for arrhythmia, immediate attention if client is bradycardic and underweight as well
- Risk of heart failre is greates in the first 2 weeks of refeeding: reduced cardiac contractility and refeeding edema ( slow refeeding, repletion of PO4, avoidance of sodium intake)
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What is the DSM-5 criteria for bulimia
- episodes of binge eating with a sense of loss of control
- binge eating is followed by compensatory behavior of the purging type (self induced vomiting, lax abuse, diuretic abuse) or non-purging ( excessive exercise, fasting, or stric diets)
- Binges and the resulting compensatory behavior must occur a minimum of two times per week for 3 months
- Dissatisfaction with body shape and weight
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What are the signs and symptoms of BN?
- Mouth sores
- Pharyngeal trauma
- Dental caries
- Esophageal rupture
- Impulsivity (stealing, alcohol abuse, drugs/tobacco)
- Muscle cramps
- weakness
- bloody diarrhea
- bleeding or easy bruising
- irregular periods
- fainting
- swollen parotid glands
- hypotension
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What will you find with BN on Physical exam?
- all elements of anorexia plus
- parotid gland swelling and erosion of the teeth enamel; calluses on hands
- *Weight may be normal
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What are the complications of BN?
- Hypokalemia
- hyponatremia
- elevated BUN
- inability to concentrate urine
- Decreased GFR
- ketonuria
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What is one of the most severe complications of BN?
- Osteopenia
- Difficult to reverse
- Treatment: weight gain, 1200-1500mg/day of elemental calcium
- multivitamin wit 400 IU vitamin D
- Consider estrogen/progesterone replacement
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What are the interventions for BN in acute care?
- Teamwork and safety
- Pharmacological interventions
- Counseling
- Health teaching and health promotion
- Advanced practice interventions: psychotherapy
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What type of therapy is effective for BN? What about pharmtherapy?
- Therapy: cognitive behavioral therapy is effective
- Pharm: high success rate; fluoxetine-studies reveal up to 67% reduction in vomiting
- TCAs
- Topiramate-reduced binge eating by 94% and average wt loss of 6.2kg
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What is refeeding syndrome?
- Severe hypophosphatemia: cardiovascular collapse, rhabdomyolysis, seizures, delirium, starte refeeding at 20kcals/kg and increase by 100-200kcals/day
- Wernicke's encephalopathy: Daily MVI with thiamine
- Constipation: metoclopromide
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What is the most common eating disorder in the US?
BED
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What is the criteria for binge eating disorder?
- eating in a discrete period of time an amount of food that is larger than most people would eat in a similar period
- Occurs 2 days per week for six month duration
- Associated with a lack of control and with distress over the binge eating
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BED must have 3 of which 5 criteria?
- eating much more rapidly than normal
- eating until uncomfortably fool
- eating large amounts of food when not feeling physically hungry
- eating alone because of the embarrassment
- feeling very disgusted, depressed or very guilty over overeating
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What are some statistics for BED?
- occurs more commonly in women
- depending on population surveyed, can vary from 3-30%
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What is the treatment for BED?
- Cognitive therapy
- group/family therapy
- nutrition counseling
- pharmacotherapy-SSRI
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What are the common feeding and elimination disorders?
- feeding: Pica (craving food with no nutritious value) Rumination ( throwing food then re-chewing it), Avoidant/restrictive food intake disorder
- Elimination: enuresis, encopresis
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What is voluntary encopresis?
- person has control over where and when bowel movements occur
- Once a month for at least 3 months
- developmentally at least 4 years old
- power struggle, oppositional deviant disorder, conduct disorder, sexual abuse
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